The Importance of Patient Sex in the Outcomes of Anterior Cruciate Ligament Reconstructions: A Systematic Review and Meta-analysis

The influence of patient gender on exercise prescription in ACL reconstruction rehabilitation

OBJECTIVE

To assess differences in physical therapists' exercise prescription and confidence in return-to-sport readiness between girl and boy patients undergoing rehabilitation post-ACLR.

DESIGN

Cross-sectional survey.

METHODS

115 physical therapist responses were collected in an electronic survey. Demographics were captured and therapists were asked to assess the appropriateness of exercises and intensity of prescription for case vignettes of an adolescent boy and girl at four different phases of post-ACLR rehabilitation. Wilcoxon signed-rank tests were performed for paired comparisons among physical therapists' responses to the boy and girl vignettes.

RESULTS

Physical therapists' exercise prescription and confidence in return-to-sport readiness differed for the boy and girl vignettes post-ACLR, specifically during the return-to-sport phase. When exercise was performed with perceived ideal form, physical therapists indicated it was more appropriate to maintain or progress the exercise for girls and had more confidence in girls' ability to return-to-sport. When the exercise was performed with perceived poor form, physical therapists indicated it was more appropriate to maintain or progress the exercise for boys and had more confidence in boys' ability to return-to-sport.

CONCLUSION

A patient's gender may influence exercise prescription and return-to-sport expectations of physical therapists, which may contribute to disparities in patient outcomes between genders post-ACLR.

Anterior Cruciate Ligament Allograft Reconstruction in Females Can Produce Outcomes Comparable to Those of Autografts in Male Counterparts

There are unique anatomical and geometric risk factors that contribute to higher injury rates of the anterior cruciate ligament (ACL) in women. Allografts are an important alternative option for female patients.Patients who underwent primary ACL reconstruction were retrospectively evaluated. The case group comprised female patients with ACL allograft reconstruction, and the control group comprised male patients with ACL reconstruction. Functional and clinical evaluations were based on the pre- and postoperative Cybex test, Lysholm score, International Knee Documentation Committee subjective and objective measurement criteria, and Tegner Activity Scale questionnaires. Radiological comparisons were performed using the femorotibial angle (FTA), posterior tibial slope (PTS), and intercondylar notch width (INW). The roof inclination angle (RIA) was assessed using magnetic resonance imaging.The two groups (female [44] and male [88]) had an average follow-up period of 57.9 ± 19.3 months and average ages of 36.5 ± 10.9 and 35.2 ± 11.7 years, respectively. Functional and clinical outcomes showed no differences between the groups, except that the return to the preinjury activity level was higher in the female group (95% vs. 77%, p < 0.001). The female group showed larger FTA and PTS and smaller INW and RIA than those of the male group (p < 0.001, 0.008, <0.001, and 0.035, respectively).Female ACL allograft reconstruction showed comparable outcomes to those of their male counterparts, and the return to preinjury activity levels was significantly higher in women. However, women showed lower activity levels and were more vulnerable to geometric risk factors than their male counterparts.

What Do Women (With Serious Knee Injury) Want to Know About Knee Health? Identifying Research Priorities With a Consumer Advisory Group

OBJECTIVES: To (1) establish a women's knee health consumer advisory group (CAG) via an evidence-informed process and (2) identify the CAG's research priorities to inform future projects. DESIGN: Mixed-methods priority-setting study. METHODS: The CAG was established, grounded in a participatory action research approach and using the Patient Engagement in Research Framework, to inform a 4-phase process: (1) understand, (2) plan, (3) undertake, and (4) evaluate. We identified the CAG's priorities for knee health research via a mixed-methods approach using the nominal group technique (NGT). We adopted a constructivist epistemology, using reflexive thematic analysis to construct codes and themes inductively. RESULTS: Six women (mean age of 35 years) joined the CAG, generating, reviewing, and discussing 70 ideas during NGT phases 1 to 3. We constructed 14 codes, grouped into 3 key themes: (1) best practice management and support for serious knee injury and rehabilitation, (2) social and gendered factors; and (3) physical, psychological, and personal factors. Voting and ranking (NGT phases 3-6) revealed the CAG's highest priority for future research was "Knowledge of, and access to specialised knee rehabilitation and practitioners." CONCLUSION: Establishing a CAG was an achievable and novel approach to identifying consumer priorities to enhance women's knee health outcomes. Women wanted improved access to information and best-practice care via genuine therapeutic relationships with practitioners who understand the gendered-social rehabilitation environment. J Orthop Sports Phys Ther 2025;55(2):1-14. Epub 15 January 2025. doi:10.2519/jospt.2025.12869.

Impact of Functional Training on Injuries After Anterior Cruciate Ligament Reconstruction for Return-to-Duty Status in U.S. Naval Academy Midshipmen: A Retrospective Analysis

INTRODUCTION

Acute anterior cruciate ligament (ACL) injuries can be disabling because of prolonged rehabilitation process following surgical reconstructions. Rates of ACL injuries among military service members are close to 10 times greater than the general civilian population, likely because of the operation tempo and the unique physical requirements. Studies debated functional testing requirements for return to sports, but no study investigated the impact of functional training and re-injury rates following ACL reconstruction and their association with functional testing outcomes and time to return to full duty in United States Naval Academy (USNA) Midshipmen. Therefore, the purpose of this study was to review all ACL reconstructions with and without meniscal injury at USNA, the functional training and testing, timing of return to military training, and associations with postoperative re-injury rates.

MATERIALS AND METHODS

A retrospective chart review of all Midshipmen who sustained ACL reconstructions between 2015 and 2019 was performed. Demographic variables, type of surgeries, functional training/testing outcomes, timing to return to full duty and postoperative re-injury rates were recorded up to January 1, 2022.

RESULTS

Of 204 ACL reconstructions, 87 were excluded, resulting in a sample size of 117 including 76 (65%) men and 41 (35%) women aged 20.4 ± 1.4 years. Fifty-one (44%) Midshipmen sustained a re-injury to the postoperative knee or complication. Thirty-three out of 76 (43%) men and 18 out of 41 (35%) women sustained complication or re-injury to the surgical knee. Of those re-injuries or complications, 12 Midshipmen (10%) sustained graft failures,12 (10%) anterior arthrofibrosis, 7 (6%) meniscus tears, 17 (15%) patella tendinopathy, and 3% other ligament injuries (MCL, PCL, etc.). Fifty participants (43%) followed a functional training program while 67 (57%) lacked documented functional training. There was a significant difference in Midshipmen who participated in functional training, displaying fewer postoperative anterior cruciate ligament reconstruction (ACLR) re-injuries or complications to the surgical knee as compared to those who did not (0.027). Nineteen Midshipmen (16%) performed functional testing while 98 did not. Of the 98 Midshipmen who did not perform functional testing, 57 (58%) had re-injury or complications to the surgical knee postoperatively compared to 9 (48%) who performed functional testing sustained a re-injury or complication. The average return to full duty was 37.1 ± 25.8 weeks versus 63.8 ± 35.8 weeks for Midshipmen who sustained postoperative injuries. Within 1 year of return to duty, 6 of 12 (50%) ACL graft failures occurred.

DISCUSSION-CONCLUSION

Postoperative injuries and complications following ACLR can delay the ability to return to duty by twice as long, consequently effecting military manpower capability. A functional training and testing program resembling both an athletic and military/operational environment can reduce re-injury and complication rates, resulting in faster return-to-duty rates. Future studies should assess the impact of military rehabilitation participation following ACLR and functional testing protocols to assess physical readiness of Midshipmen to return to full duty. Additionally, methods to assess psychological readiness to return to duty should be further investigated.

Males have higher psychological readiness to return to sports than females after anterior cruciate ligament reconstruction: a systematic review and meta-analysis

Objectives

To examine sex differences in psychological readiness to return to sport following anterior cruciate ligament (ACL) reconstruction as well as to determine whether males and females separately fulfilled cut-off values (≥65) of psychological readiness necessary to return to sport.

Information sources

Web of Science, Scopus and PubMed were comprehensively searched from inception to January 2024 to identify relevant studies.

Eligibility criteria

Observational investigations that compared males and females with a history of ACL reconstruction concerning psychological readiness to return to sport.

Risk of bias

Studies were rated using the Methodological Index for Non-Randomised Studies.

Included studies

Only 11 reports fulfilled the eligibility criteria and were included in the quantitative analysis. A total of 2618 participants were subjected to the primary ACL reconstruction, out of 1631 males and 987 females. Psychological readiness to return to sport was evaluated approximately 9±2.9 months following surgery.

Synthesis of results

The main findings demonstrated that males had slightly higher psychological readiness to return to the sport than females (standardised mean difference 0.33; 95% CI 0.14 to 0.52; p=0.0007; I2=77%) after ACL surgery. In addition, the mean psychological readiness to return to the sport of males was 70.1±8.8 points and of females 65.1±8.8 points, indicating that both sexes exceeded recommendations necessary to return to sport.

Conclusion

Males had slightly higher psychological readiness to return to sport than females approximately 9±2.9 months after ACL reconstruction and both sexes exceeded the highlighted recommendations necessary to return to sport.

PROSPERO registration number

CRD42024497769: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024497769.

Sex specific considerations in anterior cruciate ligament injuries in the female athlete: State of the art

The increased participation of females in sports has been accompanied by an increase in the rate of anterior cruciate ligament (ACL) injuries. The literature has identified risk factors for noncontact ACL injuries in female athletes, including anatomic, hormonal, biomechanical, neuromuscular, and environmental factors. This review will provide an overview of sex-specific considerations when managing female athletes with ACL injuries. A discussion of sex-specific surgical and rehabilitative treatment strategies with the goal of optimizing return to sport after ACL reconstruction will be emphasized.

Graft Failure in Pediatric Patients After Bone-Patellar Tendon-Bone, Hamstring Tendon, or Quadriceps Tendon Autograft ACLR: A Systematic Review and Meta-analysis

Background

Anterior cruciate ligament (ACL) reinjury risk is high in young athletes, with graft failure rates as high as 23%. The optimal autograft choice to minimize reinjury risk in this population is unclear.

Purpose

To compare graft failure rates between bone-patellar tendon-bone (BPTB), hamstring tendon (HT), and quadriceps tendon (QT) autografts in patients aged ≤18 years with a minimum follow-up (FU) of 24 months.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review of the literature between database inception and March 2022 encompassed PubMed/MEDLINE, Cochrane CENTRAL, Embase, and Web of Science Core Collection databases. Studies on autograft ACL reconstruction (ACLR) using HT, QT, or BPTB autograft in patients ≤18 years old with a minimum FU of 2 years were included. Graft failure rates were pooled and estimated using random-effects models via the inverse variance method and logit transformations. Meta-analyses were used to estimate failure rates and pairwise comparisons were conducted by autograft type when appropriate.

Results

A total of 24 studies comprising 2299 patients (HT: n = 1237, 44.8% female, 59.1-month mean FU; BPTB: n = 913, 67.3% female, 79.9-month mean FU; QT: n = 149, 36.4% female, 35.3-month mean FU) were included. HT exhibited the highest failure rate at 11.8% (95% CI, 9.0%-15.4%); failure rates for BPTB and QT were 7.9% (95% CI, 6.2%-10.0%) and 2.7% (95% CI, 1.0%-7.5%), respectively. HT had a significantly higher failure rate than both BPTB (Q = 5.01; P = .025) and QT (Q = 7.70; P = .006); BPTB had a significantly higher failure rate than QT (Q = 4.01; P = .045). Male patients were less likely than their female counterparts to experience graft failure after HT ACLR (odds ratio, 0.48; 95% CI, 0.25-0.95).

Conclusion

While the HT remains a common choice for ACLR, the current aggregate data indicate that BPTB and QT demonstrated significantly lower failure rates than HT ACLR in adolescent athletes ≤18 years old. The QT demonstrated the lowest failure rate in adolescents but also the lowest proportion of patients represented due to a paucity of published QT data, indicating a need for future studies with larger sample sizes that include QT autografts, reduced risk of bias, and consistent reporting on skeletal maturity and surgical technique to better determine the ideal autograft for active athletic populations ≤18 years old.

Meniscal allograft transplantation: A matched-pair analysis reveals worse sport activity level but similar clinical improvement and survival in women compared to men

PURPOSE

The aim of this study was to assess how gender might affect the clinical outcome and survival of meniscal allograft transplantation (MAT).

METHODS

A total of 358 patients (23.2% women, 76.8% men) were treated with fresh-frozen nonirradiated allografts implantated arthroscopically using a single- or double-tunnel technique without bone plugs and peripheral suture to the capsule with 'all-inside' stitches.

RESULTS

Patients were evaluated at baseline and 2-year follow-up with the Lysholm score, visual analogue scale (VAS) pain, the Knee Osteoarthritis Outcome Score (KOOS) subscales and Tegner score. Women presented higher body mass index (p < 0.0005), poorer baseline VAS (p = 0.012), Lysholm score (p = 0.005), KOOS symptom (p = 0.034) and KOOS pain (p = 0.030),  Tegner score (preinjury and basal, p < 0.0001 and p = 0.002, respectively), a lower number of previous (p = 0.039) and concurrent (p = 0.001) anterior cruciate ligament reconstructions and a higher number of concurrent procedures (p = 0.032) and distal femoral osteotomies (p = 0.024). Worse results were documented in women at 2 years, with lower Lysholm score (p = 0.024) and Tegner score (p = 0.007) and a lower clinical survival rate (p = 0.03) (67.5% vs. 82.2%) in the overall patient cohort. However, the matched-pair analysis only confirmed a lower Tegner score value at 2 years (p = 0.016), while underlying the interplay of sex, age and concomitant cartilage lesions in determining the clinical outcome. The analysis of this large series of patients affected by postmeniscectomy syndrome and treated with MAT revealed gender differences.

CONCLUSION

While both genders benefited from a significant improvement, the female population presents more often with older age, concomitant cartilage lesions and a lower activity level, all factors contributing towards a lower clinical success after MAT.

LEVEL OF EVIDENCE

Level III, comparative study.

Females demonstrate lower levels of activity, psychological readiness and strength symmetry after anterior cruciate ligament reconstruction than males, and also recovery of quadriceps strength and hop symmetry is delayed in females undergoing reconstruction with a quadriceps tendon autograft

PURPOSE

To investigate sex-based recovery differences in patients undergoing anterior cruciate ligament reconstruction (ACLR) with a hamstring (HT) or quadriceps (QT) tendon autograft.

METHODS

This study included 97 patients, including 50 females (HT = 25, QT = 25) and 47 males (HT = 24, QT = 23), assessed presurgery and at 12- and 24-month postoperatively via surveys, laxity, isokinetic knee extensor and flexor torque and a 6-hop performance battery. Limb symmetry indices (LSIs) were calculated. Outcomes were compared between males and females, as well as within each graft type.

RESULTS

Males reported significantly higher Tegner scores at 12 (p = 0.029) and 24 (p = 0.031) months, Anterior Cruciate Ligament Return to Sport after Injury scores at 12 (p = 0.009) and 24 (p = 0.010) months, and a significantly higher lateral hop LSI at 12 (p = 0.045) months, knee extensor torque LSI at 12 (p = 0.020) months, and knee flexor torque LSI at 12 (p = 0.001) and 24 (p = 0.039) months. Females undergoing ACLR with a QT (vs. HT) graft demonstrated a lower knee extensor torque LSI at 12 (p = 0.006) months, a lower lateral hop LSI at 12 (p = 0.038) months, and a lower medial hop LSI at 12 (p = 0.042) months.

CONCLUSIONS

Females reported less activity and psychological readiness, as well as strength symmetry. Furthermore, the recovery of quadriceps strength and hop symmetry was delayed in females (vs. males) undergoing ACLR with a QT graft. A better understanding of these differences will assist in counselling on expectations, determining the most appropriate graft construct and permitting more targeted rehabilitation.

LEVEL OF EVIDENCE

Level IV.

Sex-differences in psychological readiness for return-to-sport following anterior cruciate ligament reconstruction

Females are at greatest risk for reinjury after return to sport (RTS) following anterior cruciate ligament (ACL) reconstruction (ACLR). The reasons for these sex differences, however, remain unclear. Psychological factors such as kinesiophobia have been identified as a potential predictor for reinjury following RTS. Studies investigating kinesiophobia have identified sex differences, yet whether this holds in the ACLR population remains unknown. The purpose of this study was to examine whether there are sex differences in kinesiophobia and other psychological factors, such as readiness to RTS and self-reported pain in the ACLR population. A total of 20 participants, eleven males (23.0 ± 8.4 years, 178.9 ± 7.6 cm, 76.8 ± 10.4 kg) and 9 females (19.6 ± 5.3 years, 165.1 ± 4.0 cm, 73.2 ± 25.0 kg) voluntarily participated in this study. The Tampa Scale for Kinesiophobia (TSK-11), Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) scale, and self-reported pain using a visual analog scale (VAS) were administered after clearance for RTS (10.5 ± 2.3 months post-ACLR). Statistical significance was set a priori at p<0.05. A significant difference between sexes was observed for the ACL-RSI with males reporting a significantly higher score (92.82±16.16) compared to females (77.0±15.54; p = 0.040). There were no significant differences between sexes for VAS for pain (males = 4.55 ± 6.50; females = 1.22 ± 3.31; p = 0.228) and TSK-11 (males = 18.73 ± 3.17; females = 19.67 ± 4.61; p = 0.596). The results of this study demonstrated males had significantly higher ACL-RSI scores than females, suggesting males may have higher psychological readiness following clearance for RTS. This study did not demonstrate significant differences between sexes for kinesiophobia or pain level. Caution in interpretation of results is warranted due to the small sample size, highlighting the need for further research in this area.

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

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

Arthroscopic Reconstruction of an Anterior Cruciate Ligament Tear Using the Anatomic Single-Bundle Technique: A Clinical and Functional Outcome Evaluation

BACKGROUND

The anterior cruciate ligament (ACL) consists of an anteromedial bundle and a posterolateral bundle giving anteroposterior and rotational stability to the knee. An ACL tear might lead to secondary changes in the knee joint if not operated in time. The aim of the study was to evaluate the clinical and functional results in patients with ACL tears treated by arthroscopic reconstruction using the anatomic single-bundle technique.

METHODS

This was a prospective study conducted between June 2015 and December2017 at a teaching institute in Kolkata, India, on patients who underwent single-bundle arthroscopic reconstruction of an ACL tear. A minimum follow-up of nine months was considered for all patients. The functional outcome was assessed via the Lysholm knee score.

RESULTS

A total of 45 patients were included in this study, of which 34 (75.56%) and eight (17.78%) patients showed excellent and good results, respectively, at the final follow-up. The mean age in this study was 29.88±9.02 years. No complication was seen in 95.6% of patients. The mean Lysholm score by the end of nine months was 95.31±6.55. At the time of the final follow-up, all the patients returned to their same activity status prior to injury.

CONCLUSION

Arthroscopic anatomic single-bundle ACL reconstruction using hamstring autograft is an effective treatment modality for ACL injuries. It restores the stability of the knee and is associated with good recovery of joint function with an early return to active lifestyle and sports activities. This procedure achieves excellent clinical and functional outcomes without any long-term disability.

Anterior Cruciate Ligament Injuries in Female Athletes

This JAMA Insights discusses anterior cruciate ligament (ACL) injuries in female athletes, including modifiable and nonmodifiable sex-based risk factors and the implementation of ACL injury prevention programs.

10-Year Survival and Clinical Improvement of Meniscal Allograft Transplantation in Early to Moderate Knee Osteoarthritis

BACKGROUND

Meniscal allograft transplantation (MAT) is a viable option for patients experiencing unicompartmental knee pain after total or subtotal meniscectomy. Nonetheless, caution is recommended when suggesting this procedure in the presence of knee osteoarthritis (OA) because of the higher risk of poor survival and outcomes.

PURPOSE/HYPOTHESIS

The purpose was to document the long-term survival of MAT performed as a salvage procedure in patients with knee OA. The hypothesis was that MAT would significantly reduce pain and increase the function of the affected joint at a long-term follow-up compared with the preoperative condition, with a low number of failures and knee replacement surgeries.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 47 patients (37 men and 10 women) with symptomatic knee OA (Kellgren-Lawrence grades 2 or 3) treated with MAT were evaluated at baseline, 5 years, and a minimum 10-year final follow-up (11.1 ± 1 years) using the Lysholm score, the visual analog scale for pain, the Knee injury and Osteoarthritis Outcome Score subscales, and the Tegner score. A total of 44 patients had undergone previous surgeries. Patient satisfaction, revision surgeries, and failures were also recorded.

RESULTS

A statistically significant improvement was observed in all clinical scores from the baseline assessment to the final follow-up. The Lysholm score improved significantly from 46.4 ± 17.2 at the preoperative assessment to 77.7 ± 20.4 at the intermediate follow-up (P < .001), with a significant decrease at the final follow-up (71 ± 23.3; P = .018). A similar trend was reported for the visual analog scale scale for pain, Knee injury and Osteoarthritis Outcome Score, and Tegner score, with no complete recovery to the previous sports activity level. A total of 33 patients required concurrent procedures, such as anterior cruciate ligament reconstructions, osteotomies, and cartilage procedures. Five patients underwent reoperation and were considered surgical failures, while 15 patients presented a clinical condition of <65 of the Lysholm score and were considered clinical failures. Among these, 4 patients were considered both surgical and clinical failures.

CONCLUSION

MAT surgery has proven to be a valid option for improving pain and function even in OA joints (Kellgren-Lawrence grades 2 or 3), yielding satisfactory results despite a worsening clinical outcome in the long-term follow-up. Therefore, based on the data from this study, orthopaedic surgeons may consider recommending MAT as a salvage procedure even in knees affected by early to moderate OA, while advising patients that the need for combined interventions could potentially reduce graft survival.

A Pilot Survey Study of Anterior Cruciate Ligament Injuries in Female University Athletes

Introduction Female sports players are at increased risk of soft tissue knee injuries (STKIs) compared to their male counterparts. Injury prevention programs effectively reduce the incidence of anterior cruciate ligament (ACL) knee injuries. This pilot study, therefore, aimed to examine the prevalence, type, and management of STKIs within a population of female university sports players at the University of Cambridge. Additionally, this study aimed to examine the perceived risk of ACL injuries and knowledge of long-term complications, alongside participation and attitudes towards injury prevention programs. Methodology A survey was distributed to women's university sports teams at the University of Cambridge. Information was gathered on participant demographics and sporting history. Relevant medical history, including joint laxity, connective tissue disorders, and previous knee injuries, was also collected. Participant involvement in and attitudes towards injury prevention programs were evaluated. Results Data from eighty-five participants (n = 85) were collected, all of whom were female. Forty-two percent of participants had sustained a previous knee injury, of which the majority (44%) were ACL injuries. In the ACL-injured group, 38% (n=6) had undergone ACL reconstructive surgery, 44% (n=7) had received only physiotherapy, and 19% (n=3) had received no form of treatment. Only 44% of these participants sustaining an ACL injury reported a return to the same level of post-injury sport. Seventy-two percent of respondents felt they were at increased risk of ACL injury compared to males. Most participants (87%) did not follow an injury prevention program, but 95% expressed a willingness to enroll in one. Conclusions This pilot study indicates that most knee injuries in female university athletes in this cohort at Cambridge University are ACL injuries, with a considerable number being managed conservatively. The low rate of return to pre-injury sporting levels highlights the significant impact of ACL injuries on athletic careers. This study demonstrates results similar to previous studies on the broader population. However, due to the pilot nature of the research and limited statistical power, the results should be interpreted with caution before transposing to the wider population. Further investigation is required into why many of these ACL-injured female athletes were managed conservatively and whether this finding is mirrored in their male counterparts. Despite recognizing their higher risk than males, participants displayed low engagement in injury prevention programs, indicating a gap between awareness and action. The willingness to participate in prevention programs suggests the potential for improved engagement through targeted interventions. Future research should focus on identifying and addressing specific barriers to participation in injury prevention programs and exploring the reasons behind the preference for conservative management of ACL injuries. Additionally, expanding the sample size and including a more diverse athletic population would enhance the generalizability of the findings.

Return to sports in female athletes after anterior cruciate ligament reconstruction: A systematic review and metanalysis

IMPORTANCE

Return to sport (RTS) is considered an indicator of successful recovery after anterior cruciate ligament reconstruction (ACLR). In recent years, there has been major interest in documenting RTS following anterior cruciate ligament (ACL) injury. Despite women being at increased risk for ACL injuries and a global increase in women's participation in sports, research has not adequately focused on female athletes.

OBJECTIVE

The purpose of this study is to conduct a systematic review and meta-analysis evaluating the RTS rate in female athletes after ACLR. We hypothesize that most of the female athletes can RTS.

EVIDENCE REVIEW

A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Electronic databases (PubMed, Embase, and Epistemonikos) were searched for articles reporting RTS rates and contextual data in female athletes. The following search terms were used: "anterior cruciate ligament reconstruction" OR "ACL reconstruction" AND "female" OR "women" AND "return to sports" OR "return to play" to retrieve all relevant articles published between 2003 and 2023. A quality assessment of the included studies was conducted.

FINDINGS

Fifteen articles were included, reporting on 1456 female athletes participating in pivoting sports. The included studies comprised 9 cohorts, 1 case-control study, 2 case series, 2 descriptive epidemiology studies, and 1 observational study. Eight out of fifteen studies focused solely on elite-level athletes. The participants had a mean age of 23.13 years. Soccer was the most prevalent sport among the participants, accounting for 49.7% of all athletes included. All 15 studies reported an RTS rate, yielding a meta-proportion of 69% [95% CI, 58-80%] for RTS. Nine articles reported the average time to RTS, which was 10.8 months [95% CI, 8.7-12.8 months].

CONCLUSIONS

This systematic review demonstrates that a majority of female athletes (69 ​%) can RTS participation at an average of 10.8 months, however, the available information is insufficient, and quantitative data and reasons for not returning to play are lacking. Future studies should establish return-to-play criteria in this population and determine reasons for not returning to play.

LEVEL OF EVIDENCE

III.

Correlation between higher lateral tibial slope and inferior long term subjective outcomes following single bundle anterior cruciate ligament reconstruction

BACKGROUND

The impact of anatomical factors, such as the lateral tibial slope (LTS), on outcomes following anterior cruciate ligament (ACL) reconstruction is an area of growing interest. This study was led by the observation that patients with a higher LTS may have different recovery trajectories.

HYPOTHESIS/PURPOSE

The purpose of this study was to investigate the correlation between a higher LTS and long term subjective outcomes following single-bundle ACL reconstruction.

STUDY DESIGN

This study was designed as a retrospective cohort study.

METHODS

The study comprised 138 patients who underwent single-bundle ACL reconstruction. The LTS was measured on preoperative radiographs. Patient-reported outcome measures (PROMs) were collected, which included the Lysholm Knee Score, UCLA Activity Score, IKDC Score, and Tegner Activity Score, over a mean follow-up duration of 137 months.

RESULTS

A significant negative correlation was found between LTS and all measured PROMs (p < 0.001). The established cut-off value of LTS distinguishing between "Good" and "Fair" Lysholm scores was 8.35 degrees. Female patients have statistically significant higher LTS and lower PROMs scores than male. Patients with LTS greater than or equal to 8.35 had significantly lower PROMs, indicative of poorer functional and subjective outcomes.

CONCLUSION

Our findings suggest that a higher LTS is associated with inferior subjective outcomes following single-bundle ACL reconstruction in long term. The LTS cut-off value of 8.35 degrees could potentially be used as a reference in preoperative planning and patient counseling.

CLINICAL RELEVANCE

Understanding the relationship between LTS and ACL reconstruction outcomes could inform surgical planning and postoperative management. These findings highlight the need to consider anatomical variances, such as LTS, when assessing patient-specific risks and recovery expectations, contributing to the advancement of personalized care in sports medicine.

Patient-Reported Outcome Measurement Information System Depression and Anxiety in Elective Knee Surgery Patients

Mental health has been shown to play an important role in patient-reported outcomes (PRO); however, there is a general lack of literature describing patient-reported outcome measurement information system (PROMIS) depression and anxiety computer adaptive tests in elective knee surgery patients. The purpose of our study was to assess the prevalence of depression and anxiety symptoms before and after elective knee surgery and to determine whether these symptoms influence postoperative functional outcomes. An institutional review board-approved prospective orthopaedic registry was retrospectively queried for patients undergoing elective knee surgery from June 2015 to November 2018. Electronic surveys collecting patient demographic information and PROs were administered pre- and postoperatively. Of the 663 patients that completed baseline questionnaires, 466 completed 2-year follow-up (70.3%). PROs included PROMIS depression, PROMIS anxiety, International Knee Documentation Committee Subjective Knee Form (IKDC), and PROMIS physical function (PF). Wilcoxon rank sum and Spearman's rank order correlation were utilized to determine associations between variables. Multivariable analysis was used to control for confounding variables. Average PROMIS depression and anxiety scores significantly improved 2 years after surgery. PROMIS depression and anxiety scores significantly correlated with each other. PROMIS depression and anxiety scores significantly correlated with PROMIS PF and IKDC scores. After controlling for confounders on multivariable analysis, worse 2-year PROMIS anxiety was predictive of less functional improvement and worse 2-year PF and IKDC, while worse 2-year PROMIS depression was predictive of less improvement in IKDC. This study confirms the important relationship between mental health and functional outcomes. Given that psychiatric comorbidities are potentially modifiable with treatment, proper recognition could potentially lead to better orthopaedic outcomes. In addition, the prevalence of depression and anxiety symptoms postoperatively, as documented by PROMIS computer adaptive tests, may act as a barrier to achieving optimal functional outcomes after elective knee surgery. LEVEL OF EVIDENCE:  Level III.

Comparison of physical therapy utilization, timing of return-to-sport test completion, and hop test performance by age and between sexes in youth athletes after anterior cruciate ligament reconstruction

OBJECTIVE

To compare physical therapy (PT) utilization, timing of return-to-sport (RTS) test and hop test performance by age and between sexes in youth after anterior cruciate ligament reconstruction (ACLR).

DESIGN

Multicenter retrospective cohort.

METHODS

A retrospective review of adolescents after primary ACLR was conducted. Participants completed return-to-sport (RTS) tests including single-legged hop testing. PT frequency, average weekly visits, and timing of RTS test were calculated. T-tests assessed the effect of age and sex on average weekly PT visits and multivariable logistic regressions assessed odds of passing hop tests.

RESULTS

289 participants were included (15.7 ± 1.9 years). There was no difference in average weekly PT visits (p = 0.321) or time to RTS test (p = 0.162) by age. There were significant differences in average weekly PT visits (p = 0.047) and mean time from surgery to RTS test (p = 0.048) between sexes with small effect sizes (d = 0.24 and d = 0.21, respectively). Age and sex had no effect on odds of passing hop tests (OR, 1.29; 95% CI, 0.71-2.35 and OR, 0.79; 95%CI, 0.43-1.45, respectively).

CONCLUSION

In a youth cohort, age and sex may have no clinically important effect on PT visit utilization, timing of RTS test or hop test performance.

Sports Medicine Patient Experience: Implicit Bias Mitigation and Communication Strategies

Unconscious bias, also known as implicit bias, is the principal contributor to the perpetuation of discrimination and is a robust determinant of people's decision-making. Unconscious bias occurs despite conscious nonprejudiced intentions and interferes with the actions of the reflective and conscious side. Education and self-awareness about implicit bias and its potentially harmful effects on judgment and behavior may lead individuals to pursue corrective action and follow implicit bias mitigation communication strategies. Team physicians must follow existing communication strategies and guidelines to mitigate unconscious bias and begin an evolution toward nonbiased judgment and decision-making to improve athlete care.

Quadriceps Tendon With Bone Autograft Has Better Stability and Magnetic Resonance Imaging Maturation Than Hamstring Tendon Autograft After Anterior Cruciate Ligament Reconstruction in Patients With Knee Hyperextension

PURPOSE

To compare the clinical outcomes of anterior cruciate ligament (ACL) reconstruction between methods using quadriceps tendon with bone (QTB) and hamstring tendon (HT) in patients with hyperextension of the knee.

METHODS

The medical records of patients with knee hyperextension greater than 8° who underwent arthroscopic ACL reconstruction between October 2010 and October 2020 with follow-up for at least 2 years (median, 3 years; interquartile range [IQR], 2.0-4.6 years) were retrospectively reviewed. Side-to-side difference in anterior translation, pivot-shift test grade, Lysholm score, and graft intensity using the Howell grade on magnetic resonance imaging at final follow-up were compared between the QTB and HT groups.

RESULTS

The HT and QTB groups consisted of 42 patients and 21 patients, respectively. The overall mean age was 21.5 years (range, 14-48 years), and the median Tegner Activity Scale score was 6 (range, 3-9). Postoperatively, the median side-to-side difference in anterior translation was 1.75 mm (IQR, 1-3 mm) in the HT group and 1.0 mm (IQR, 0-1.75 mm) in the QTB group (P = .01). Pivot-shift testing showed grade 0 in 74.7%, grade 1 in 18.7%, and grade 2 in 6.6% of patients in the HT group and grade 0 in 85.7% and grade 1 in 14.3% of those in the QTB group (P = .03). The median postoperative Lysholm score was 99 in both groups. Graft signal intensity showed a significant between-group difference: grade I in 52%, grade II in 36%, and grade III in 12% of patients in the HT group versus grade I in 85.7%, grade II in 9.5%, and grade III in 4.8% of those in the QTB group (P = .03).

CONCLUSIONS

In patients who underwent ACL reconstruction for hyperextension of the knee, QTB yielded better clinical outcomes than HT with respect to anterior stability, rotational stability, and graft signal intensity on median 2-year follow-up magnetic resonance imaging.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Psychological Readiness to Return to Sport (RTS) and RTS Rates Are Similar in Patients After Either Bilateral or Unilateral Anterior Cruciate Ligament Reconstruction

Purpose

To compare psychological readiness to return to sport (RTS), RTS rate, level of return, and time to return between patients who underwent bilateral anterior cruciate ligament reconstruction (ACLR) and those who underwent unilateral ACLR.

Methods

The electronic medical record at a single academic medical center was queried for patients who underwent ACLR from January 2012 to May 2020. The inclusion criteria were skeletally mature patients who underwent either single or sequential bilateral ACLR and who had undergone either the primary ACLR or second contralateral ACLR at least 2 years earlier. Bilateral ACLRs were matched 1:3 to unilateral reconstructions based on age, sex, and body mass index. Psychological readiness to RTS was assessed using the validated ACL Return to Sport After Injury (ACL-RSI) scale. This, along with time to return and level of RTS, was compared between the 2 cohorts.

Results

In total, 170 patients were included, of whom 44 underwent bilateral ACLR and 132 underwent unilateral ACLR. At the time of the first surgical procedure, patients in the unilateral cohort were aged 28.8 ± 9.4 years and those in the bilateral cohort were aged 25.7 ± 9.8 years (P = .06). The average time difference between the first and second surgical procedures was 28.4 ± 22.3 months. There was no difference in psychological readiness to RTS (50.5 in bilateral cohort vs 48.1 in unilateral cohort, P = .66), RTS rate (78.0% in unilateral cohort vs 65.9% in bilateral cohort, P = .16), percentage of return to preinjury sport level (61.2% in unilateral cohort vs 69.0% in bilateral cohort, P = .21), or time to return (41.2 ± 29.3 weeks in unilateral cohort vs 35.2 ± 23.7 weeks in bilateral cohort, P = .31) between the 2 cohorts.

Conclusions

Compared with patients who undergo unilateral ACLR, patients who undergo bilateral ACLR are equally as psychologically ready to RTS, showing equal rates of RTS, time to return, and level of return.

Level of Evidence

Level III, retrospective cohort study.

Anterior cruciate ligament injury occurrence, return to sport and subsequent injury in the Australian High Performance Sports System: A 5-year retrospective analysis

OBJECTIVES

To report anterior cruciate ligament (ACL) injury occurrence, return to sport (RTS) timeframes and ACL subsequent injuries recorded in the Australian High Performance Sports System according to athlete sex.

METHODS

ACL injury data of injured athletes were prospectively collected by the treating sports and exercise physicians and physiotherapists within the Australian High Performance Sports System between January 1, 2015 and May 31, 2020. RTS time frames for ACL injuries and the proportion of subsequent ACL injuries were calculated. The RTS time was compared between sexes, age groups and ACL injury categories using the Mann-Whitney U test and the Kruskal-Wallis test.

RESULTS

A total of 132 ACL injuries were reported in 108 athletes (77 female, 31 male). ACL injuries accounted for 6.4% of all reported knee injuries, with almost half (48.5%) of the ACL injuries reported to occur during training. Median RTS time was 369 days (IQR = 273-487), with RTS times reducing with increasing age (X2 (Zbrojkiewicz et al., 2018) = 11.781, p = 0.008). The presence of concurrent knee pathology did not significantly affect the RTS timeframes. ACL injuries were most frequently reported in netball, winter sports, basketball, field hockey and gymnastics. One quarter of the ACL reported (n = 34, 25.8%) were subsequent to a prior ACL injury, with the majority of these injuries occurring to the ipsilateral knee (n = 26) as opposed to contralateral knee (n = 6).

CONCLUSIONS

Despite ACL injuries accounting for a small proportion of all knee injuries reported in the Australian High Performance Sports System, more than a quarter are subsequent to a previous ACL injury. Shorter RTS times were observed in older athletes; however, considerable periods of time-loss occur as a consequence of ACL injuries. Effective primary prevention, rehabilitation processes, and ongoing tertiary prevention strategies are warranted in this population.

Higher Rates of Residual Postoperative Instability after Anterior Cruciate Ligament Reconstruction in Female Patients: A Systematic Review of Level II Studies

PURPOSE

To compare revision rates and residual postoperative instability after anterior cruciate ligament (ACL) reconstruction based on biological sex.

METHODS

A systematic review was conducted according to the 2020 PRISMA guidelines. PubMed, Embase, MEDLINE, and Cochrane library databases were queried from database inception through October 2022. Level I and II prospectively-enrolling human clinical studies that compared revision rates and physical examination of postoperative stability after ACL reconstruction between male and female patients were included. Outcomes were stratified by patient sex and quantitatively compared using a χ2 test. Study quality was assessed using the MINORS criteria.

RESULTS

Four studies consisting of 406 patients (50% males) with a mean age of 25 years (range, 13.9-62 years) were identified. Mean follow-up time was 34.4 months (range, 22-60 months). Hamstring tendon autografts were used in 62% of ACL reconstructions in males and in 65% of ACL reconstructions in females, whereas bone-patellar tendon-bone autografts were used in 38% and 35% of procedures in males and females, respectively. A residual positive Lachman test result was more frequently reported among females compared to males (5.8% vs 0.6%; P = 0.03). No significant difference in revision rates or residual pivot-shift on examination was observed between males and females (P = 0.38 and P = 0.08, respectively).

CONCLUSION

Female patients undergoing ACL reconstruction have higher reported rates of residual anterior instability with Lachman than male patients. However, no sex-based differences were identified with residual pivot-shift on examination or rate of revision ACL surgery.

LEVEL OF EVIDENCE

II; Systematic Review of level II studies.

Prevalence and Predictors of Postoperative Depression and Anxiety After Anterior Cruciate Ligament Reconstruction

PURPOSE

Preoperative mood disorders influence postoperative outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR), but the prevalence and risk factors associated with postoperative depression/anxiety development remain unknown. The purposes of this study were to quantify the prevalence of postoperative diagnoses of depression or anxiety following ACLR in patients under the age of 25 and assess the interplay between patient sex and ACL reoperation on the prevalence of a depression or anxiety diagnosis following ACLR.

METHODS

ACLR patients under the age of 25 years old were identified in the Truven Healthcare Marketscan database. Patients with incomplete coverage +/- one year of the index surgical procedure were excluded. Patients were categorized by the presence of preoperative, postoperative, or no depression/anxiety using the International Classification of Diseases, Ninth Revision (ICD-9) codes. We compared patient demographics and reoperation rates following the index ACLR between the depression and anxiety categories. Additionally, logistic regression was fit to assess the interaction between sex and either ipsilateral or contralateral ACL surgery on postoperative depression/anxiety diagnosis.

RESULTS

Of the 42,174 patients, 10.7% had a new depression/anxiety diagnosis after ACLR. Postoperative depression/anxiety was nearly twice as prevalent for females (F: 14.4%, M: 7.6%) despite having similar rates of secondary ACLR (F: 15.5%, M: 13.0%). Those with postoperative depression/anxiety had a considerably greater prevalence of reoperation (18.8%) than those without depression/anxiety (13.7%) and those with pre-existing preoperative depression/anxiety (12.9%). Sex and reoperation were independently associated with postoperative depression/anxiety diagnosis.

CONCLUSION

Female sex and secondary ACL surgery are independently associated with an increased prevalence of postoperative depression/anxiety. Nearly one in seven young females are diagnosed with depression/anxiety after ACLR. Similarly, a greater proportion of patients who suffer a secondary ACL surgery are subsequently diagnosed with depression/anxiety. The orthopedic community must be cognizant of the increased risk of postoperative depression/anxiety for females and those who suffer a secondary ACL surgery, and screening for depression/anxiety in these at-risk populations with referrals to mental health professionals may be warranted.

Risk Factors for Revision or Rerupture After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

The rerupture or need for revision after anterior cruciate ligament reconstruction (ACLR) is a serious complication. Preventive strategies that target the early identification of risk factors are important to reduce the incidence of additional surgery.

PURPOSE

To perform a systematic review and meta-analysis to investigate risk factors for revision or rerupture after ACLR.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

Literature searches were performed in PubMed, Embase, and Web of Science from database inception to November 2021 and updated in January 2022. Quantitative, original studies reporting potential adjusted risk factors were included. Odds ratios (ORs) were calculated for potential risk factors.

RESULTS

A total of 71 studies across 13 countries with a total sample size of 629,120 met the inclusion criteria. Fifteen factors were associated with an increase in the risk of revision or rerupture after ACLR: male sex (OR, 1.27; 95% CI, 1.14-1.41), younger age (OR, 1.07; 95% CI, 1.05-1.08), lower body mass index (BMI) (OR, 1.03; 95% CI, 1.00-1.06), family history (OR, 2.47; 95% CI, 1.50-4.08), White race (OR, 1.32; 95% CI, 1.08-1.60), higher posterolateral tibial slope (OR, 1.15; 95% CI, 1.05-1.26), preoperative high-grade anterior knee laxity (OR, 2.30; 95% CI, 1.46-3.64), higher baseline Marx activity level (OR, 1.07; 95% CI, 1.02-1.13), return to a high activity level/sport (OR, 2.03; 95% CI, 1.15-3.57), an ACLR within less than a year after injury (OR, 2.05; 95% CI, 1.81-2.32), a concomitant medial collateral ligament (MCL) injury (OR, 1.62; 95% CI, 1.31-2.00), an anteromedial portal or transportal technique (OR, 1.36; 95% CI, 1.22-1.51), hamstring tendon (HT) autografts (vs bone-patellar tendon-bone [BPTB] autografts) (OR, 1.60; 95% CI, 1.40-1.82), allografts (OR, 2.63; 95% CI, 1.65-4.19), and smaller graft diameter (OR, 1.21; 95% CI, 1.05-1.38). The other factors failed to show an association with an increased risk of revision or rerupture after ACLR.

CONCLUSION

Male sex, younger age, lower BMI, family history, White race, higher posterolateral tibial slope, preoperative high-grade anterior knee laxity, higher baseline Marx activity level, return to a high activity level/sport, an ACLR within less than a year from injury, a concomitant MCL injury, an anteromedial portal or transportal technique, HT autografts (vs BPTB autografts), allografts, and smaller graft diameter may increase the risk of revision or rerupture after ACLR. Raising awareness and implementing effective preventions/interventions for risk factors are priorities for clinical practitioners to reduce the incidence of revision or rerupture after ACLR.

Comparison of ACL and Anterolateral Ligament Reconstruction With Isolated ACL Reconstruction Using Hamstring Autograft: Outcomes in Young Female Patients With High-Grade Pivot Shift

Background

Inferior return to sports (RTS) and functional outcomes have been reported in women after anterior cruciate ligament reconstruction (ACLR).

Purpose/Hypothesis

The purpose was to evaluate the results of combined ACLR and anterolateral ligament reconstruction (ALLR) in young women with a high-grade pivot shift (grade ≥2). It was hypothesized that combined ACLR and ALLR would result in better RTS and rotational stability than isolated ACLR.

Study Design

Cohort study; Level of evidence, 3.

Methods

Two groups were retrospectively evaluated and compared. Group I (n = 39; mean age, 31.1 ± 5.7 years) underwent isolated ACLR using hamstring autografts; group C (n = 39; mean age, 30.4 ± 6.1 years) underwent combined ACLR and ALLR. Subjective outcome measures included the International Knee Documentation Committee subjective form, Lysholm, Tegner, and ACL-Return to Sport after Injury (ACL-RSI). Objective tests included a KT-2000 arthrometer stress test, a pivot-shift test, an isokinetic strength test, a Y-balance test, and a single-leg hop test. A postoperative questionnaire was administered to determine the rates and types of RTS, quality of sports performance, and reinjury and satisfaction rates. Subjective scores and clinical tests were performed at 2 years. Magnetic resonance imaging and second-look arthroscopy were conducted during the 1- and 2-year follow-ups, respectively.

Results

The mean follow-up for groups I and C were 30.4 ± 3.9 and 29.3 ± 3.5 months, respectively (P = .194). Patients in group C had better anteroposterior (P = .001) and rotational (P = .005) stability and higher ACL-RSI scores (P = .025) than those in group I. Group C had higher composite and posteromedial reach scores on the Y-balance test than group I (P = .014 and P = .010, respectively). A total of 26 (66.7%) patients in group C and 17 (43.6%) in group I returned to their prior level of sports (P = .040). Rerupture of the ACL graft and contralateral ACL rupture occurred in 2 (5.1%) and 2 (5.1%) patients in group I, respectively, compared with no rerupture or contralateral ACL rupture in group C.

Conclusion

Combined ACLR and ALLR in young women with a high-grade pivot shift was associated with better knee stability parameters, dynamic postural stability, and psychological readiness to RTS than isolated ACLR.

Return to active duty after anterior cruciate ligament reconstruction (ACLR) in Chinese male military aircrews

Background

Surgically treated anterior cruciate ligament (ACL) injuries may be a waivable condition and allow return to full flight status, but waivers are based on expert opinion rather than recent published data. The purpose of this study was to evaluate return to flight after anterior cruciate ligament reconstruction (ACLR) in male military aircrews with ACL injuries and to identify factors that affect flight clearance.

Method

A single-center retrospective review was conducted by the authors for all active-duty aircrew who underwent ACLR at an authorized military medical center from January 2010 to December 2019. Demographic characteristics, occupational information, surgical data, and flight readiness evaluation outcomes were collected. Based on the final medical evaluation, subjects were divided into a qualified group (N = 64) and a disqualified group (N = 9), and the difference in data collected between the two groups was then analyzed to identify factors affecting flight clearance.

Results

A total of 73 patients underwent successful ACLR with a mean age of 31.6 ± 5.6 years. Non-contact injury was the main type of ACL injury, accounting for 84.9% of the total injuries. 55 cases (75.3%) occurred during daily sports activities and 18 (24.7%) during military training. 64 of the 73 crewmembers (87.7%) were able to return to flight at their last follow-up evaluation. The preoperative interval time (PIT) was significantly less in the qualified group than in the disqualified group (P = 0.002). Patients who underwent ACLR within three months were more likely to return to flying than those who underwent the procedure three months later (97.4% vs. 76.5%, P = 0.010). The incidence of failure to return to flight duty was significantly higher in aircrews with ACL injuries combined with meniscal injuries than in aircrews with isolated ACL injuries (21.4% vs. 0.0%, P = 0.017).

Conclusion

ACLR appears to be safe for military aircrew suffering ACL injuries with or without meniscal injury, and return to flight status is the most likely outcome for the majority of postoperative pilots. Prolonged PIT, PIT > 3 months, and ACL injury combined with meniscus injury had a negative impact on postoperative flight readiness.

Youth With a Sport-Related Knee Injury Exhibit Significant and Persistent Knee-Related Quality-of-Life Deficits at 12-Month Follow-up Compared to Uninjured Peers

OBJECTIVE: We aimed to compare knee-related quality of life (QOL) between youth with and without an intra-articular, sport-related knee injury at baseline (≤4 months postinjury), 6-month, and 12-month follow-up, and assess the association between clinical outcomes and knee-related QOL. DESIGN: Prospective cohort study. METHODS: We recruited 86 injured and 64 uninjured youth (similar age, sex, sport). Knee-related QOL was assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS) QOL subscale. Linear mixed models (95% confidence interval [CI]; clustered on sex and sport) compared KOOS QOL between study groups over the study period, considering sex-based differences. We also explored the association of injury type (anterior cruciate ligament [ACL]/meniscus injury or other), knee extensor strength (dynamometry), moderate-to-vigorous physical activity (accelerometer), intermittent knee pain (Intermittent and Constant Osteoarthritis Pain [ICOAP] measure), and fear of reinjury (17-item Tampa Scale of Kinesiophobia) with knee-related QOL. RESULTS: Participant median (range) age was 16.4 (10.9-20.1) years, 67% were female, and 56% of injuries were ACL ruptures. Injured participants had lower mean KOOS QOL scores at baseline (-61.05; 95% CI: -67.56, -54.53), 6-month (-41.37; 95% CI: -47.94, -34.80), and 12-month (-33.34; 95% CI: -39.86, -26.82) follow-up, regardless of sex. Knee extensor strength (6- and 12-month follow-up), moderate-to-vigorous physical activity (12-month follow-up), and ICOAP (all time points) were associated with KOOS QOL in injured youth. Additionally, having an ACL/meniscus injury and higher Tampa Scale of Kinesiophobia scores were associated with worse KOOS QOL in injured youth. CONCLUSION: Youth with a sport-related knee injury have significant, persistent knee-related QOL deficits at 12-month follow-up. Knee extensor strength, physical activity, pain, and fear of reinjury may contribute to knee-related QOL. JOSPT 2023;53(8):1-10. Epub: 20 June 2023. doi:10.2519/jospt.2023.11611.

Effect of Age and Sex on Psychological Readiness and Patient-Reported Outcomes 6 Months After Primary ACL Reconstruction

Background

Successful return to sport after anterior cruciate ligament (ACL) reconstruction (ACLR) can be affected by a patient's physical and psychological state throughout the rehabilitation process.

Purpose

To prospectively compare differences in patients at 6 months after primary ACLR with the ACL-Return to Sport after Injury (ACL-RSI), International Knee Documentation Committee (IKDC) or pediatric (Pedi)-IKDC, Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Pedi-FABS), and Patient-Reported Outcomes Measurement Information System-Psychological Stress Experiences (PROMIS-PSE) scores.

Study Design

Prospective cohort study; Level of evidence, 2.

Methods

Patients enrolled were 8 to 35 years old who underwent primary ACLR and had their 6-month follow-up appointments between December 2018 and March 2020. Patients were divided into 3 age groups as follows: (1) preadolescents (10-14 years); (2) adolescents (15-18 years); and (3) adults (>18 years). Outcomes on the ACL-RSI, IKDC/Pedi-IKDC, Pedi-FABS, and PROMIS-PSE were compared according to age group, graft type (hamstring, patellar tendon, quadriceps, or iliotibial band autograft), and sex.

Results

A total of 176 patients (69 male, 107 female), with a mean age of 17.1 ± 3.1 years were included in the study. The mean ACL-RSI scores were significantly different among age groups (preadolescents, 75 ± 18.9; adolescents, 61.5 ± 20.4; and adults, 52.5 ± 19.8 [P < .001]) and graft types (P = .024). The IKDC and PROMIS-PSE scores were also significantly different among age groups (P < .001 and P = .044, respectively) and graft types (P = .034 and P < .001, respectively), with the iliotibial graft and the younger age group performing the best. There was no significant difference in the Pedi-FABS either by age group (P = .127) or graft type (P = .198). Female patients had lower ACL-RSI scores and higher (worse) scores on PROMIS-PSE than their male counterparts (P = .019 and P < .001, respectively), with no sex-based differences on IKDC or Pedi-FABS scores. The ACL-RSI and IKDC were positively correlated (Spearman r = 0.57; P < .001), while the ACL-RSI and PROMIS-PSE were negatively correlated (Pearson r = -0.34; P < .001).

Conclusion

This study suggests that psychological profiles and subjective perceptions of knee function 6 months after ACLR may vary in patients of different ages and between the sexes. Preadolescent patients had better scores on a majority of patient-reported outcomes compared with adolescent and adult patients.

Comparison of Return-to-Sports Rates Between Male and Female Australian Athletes After ACL Reconstruction

Background

Return to sports (RTS) is a goal for most patients who undergo anterior cruciate ligament reconstruction (ACLR). Although it has been reported that women RTS at a significantly lower rate compared with men, demographic and contextual factors that may be associated with this have not been investigated.

Purpose

To compare RTS rates between men and women and investigate factors that may be associated with different rates of RTS in an Australian context.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 1338 patients who underwent primary ACLR between January 2014 and December 2017 were invited to complete a detailed sports participation questionnaire 2 to 7 years after surgery. RTS rates were calculated and compared between men and women overall and after stratifying by age at surgery (<20, 20-29, 30-39, or ≥40 years) and geographical location (metropolitan or rural). Contingency analysis was performed to compare factors associated with rates of RTS.

Results

The survey completion rate was 81% (1080/1338). Overall, women had a significantly lower RTS rate compared with men (65.4% vs 74.9%; P = .001). However, when patients were grouped by age, the lower rate of RTS for women was significant only in the 20- to 29-year age group (P = .01). For athletes who returned to sports, there was no sex-based difference when comparing the levels of RTS. When grouping patients based on geographical location, there was a significantly lower rate of RTS in metropolitan-based women compared with metropolitan-based men (P < .001) and rural-based women (P = .042).

Conclusion

Although women returned to sports at a lower rate than men overall, this difference was predominantly seen in the 20- to 29-year age bracket and in those who lived in metropolitan areas. There was no difference between men and women regarding the RTS level.

Improvement Trajectories in Patient-Reported Outcomes Between Males and Females After Anterior Cruciate Ligament Reconstruction

CONTEXT

Patient-reported outcomes (PROs) are used to track recovery and inform clinical decision-making after anterior cruciate ligament reconstruction (ACLR). Whether sex influences the trajectory of improvements in PROs over time post-ACLR remains unclear.

OBJECTIVES

To (1) examine the effect of sex on the association between months post-ACLR and Knee injury and Osteoarthritis Outcome Score (KOOS) Quality of Life (QOL) scores in individuals with ACLR and (2) assess sex differences in the KOOS QOL score at selected timepoints post-ACLR.

DESIGN

Cross-sectional study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 133 females (20± 3 years) and 85 males (22 ± 4 years) within 6 to 60 months of primary, unilateral ACLR.

MAIN OUTCOME MEASURE(S)

The KOOS QOL was completed at a single follow-up timepoint post-ACLR. A multivariate linear regression model was calculated to assess the interaction of sex on the association between months post-ACLR and KOOS QOL score. Sex-specific linear regression models were then used to predict KOOS QOL estimated marginal means at each clinical timepoint (6, 12, 24, 36, 48, and 60 months post-ACLR) and compare the sexes.

RESULTS

In the primary model (R2 = 0.16, P < .0001), a significant interaction existed between sex and time post-ACLR (β = -0.46, P < .01). Greater months post-ACLR were associated with better KOOS QOL scores for males (R2 = 0.29, β = 0.69, P < .001); months post-ACLR was a weaker predictor of KOOS QOL scores for females (R2 = 0.04, β = 0.23, P < .02). Estimated marginal means for KOOS QOL scores were greater for males than females at 36 months (t210 = 2.76, P < .01), 48 months (t210 = 3.02, P < .01), and 60 months (t210 = 3.09, P = .02) post-ACLR.

CONCLUSIONS

Males exhibited PRO improvement post-ACLR as the months post-ACLR increased, whereas females did not demonstrate the same magnitude of linear increase in KOOS QOL score. Females may require extended intervention to improve clinical outcomes post-ACLR and address a plateau in QOL score.

Let's talk about sex (and gender) after ACL injury: a systematic review and meta-analysis of self-reported activity and knee-related outcomes

OBJECTIVE

Investigate sex/gender differences in self-reported activity and knee-related outcomes after anterior cruciate ligament (ACL) injury.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Seven databases were searched in December 2021.

ELIGIBILITY CRITERIA

Observational or interventional studies with self-reported activity (including return to sport) or knee-related outcomes after ACL injury.

RESULTS

We included 242 studies (n=123 687, 43% females/women/girls, mean age 26 years at surgery). One hundred and six studies contributed to 1 of 35 meta-analyses (n=59 552). After ACL injury/reconstruction, very low-certainty evidence suggests females/women/girls had inferior self-reported activity (ie, return to sport, Tegner Activity Score, Marx Activity Scale) compared with males/men/boys on most (88%, 7/8) meta-analyses. Females/women/girls had 23%-25% reduced odds of returning to sport within 1-year post-ACL injury/reconstruction (12 studies, OR 0.76 95% CI 0.63 to 0.92), 1-5 years (45 studies, OR 0.75 95% CI 0.69 to 0.82) and 5-10 years (9 studies, OR 0.77 95% CI 0.57 to 1.04). Age-stratified analysis (<19 years) suggests female athletes/girls had 32% reduced odds of returning to sport compared with male athletes/boys (OR 0.68, 95% CI 0.41 to 1.13, I² 0.0%). Very low-certainty evidence suggests females/women/girls experienced inferior knee-related outcomes (eg, function, quality of life) on many (70%, 19/27) meta-analyses: standardised mean difference ranging from -0.02 (Knee injury and Osteoarthritis Outcome Score, KOOS-activities of daily living, 9 studies, 95% CI -0.05 to 0.02) to -0.31 (KOOS-sport and recreation, 7 studies, 95% CI -0.36 to -0.26).

CONCLUSIONS

Very low-certainty evidence suggests inferior self-reported activity and knee-related outcomes for females/women/girls compared with males/men/boys after an ACL injury. Future studies should explore factors and design targeted interventions to improve outcomes for females/women/girls.

PROSPERO REGISTRATION NUMBER

CRD42021205998.

Anterior Cruciate Ligament Reconstruction Using a 4-Strand Semitendinosus Tendon Graft or a Doubled Semitendinosus and Gracilis Tendon Graft: A 4.5-Year Prospective, Randomized, Double-Blind, Parallel-Group Study

BACKGROUND

Hamstring tendon grafts are the most common choice for anterior cruciate ligament (ACL) reconstruction (ACLR). Previous studies have provided evidence that offers conflicting opinions concerning the most favorable graft choice.

PURPOSE

To identify whether the use of a quadrupled semitendinosus tendon (ST) or doubled semitendinosus tendon and gracilis tendon (ST/G) graft provides comparable anterior tibial translation (ATT) with similar functional results and similar donor site morbidity.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

This was a prospective, patient- and surgeon-blinded, randomized trial set in a busy orthopaedic and traumatology department at a university hospital. Between 2015 and 2017, a total of 162 patients with ACL lesions were randomized to undergo ACLR with either a quadrupled ST or doubled ST/G graft. The primary endpoint was ATT assessed with the KT-1000 arthrometer. Clinical outcomes were assessed using the patient-reported outcome measures (PROMs) of the visual analog scale (VAS), International Knee Documentation Committee (IKDC) subjective evaluation form, Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner activity scale, and Lysholm knee scoring scale.

RESULTS

Preoperative demographic data, ATT, and PROM scores showed no significant differences. At 4.5 years, no significant differences were found between the ST and ST/G groups with respect to PROM scores and KT-1000 arthrometer, Lachman test, and pivot-shift test findings. Differences in functional results between groups were significant (muscle strength). Subgroup analysis revealed significantly increased ATT in female patients undergoing ACLR with a quadrupled ST graft during the 4.5-year observation period, as assessed by the KT-1000 arthrometer, as well as inferior KOOS, IKDC, Lysholm, and VAS scores.

CONCLUSION

This study showed a significant increase in ATT as well as inferior results on PROMs during a 4.5-year observation period in female patients undergoing ACLR with a quadrupled ST graft. In male patients, the study provided evidence of the noninferiority of ACLR with an ST graft, with no influence on donor site morbidity.

TRIAL REGISTRATION

clinicaltrials.gov: NCT03626883.

A comparison of the outcomes of anterior curciate ligament reconstruction with large-size graft versus reconstruction with average-size graft combined with extraarticular tenodesis

INTRODUCTION

Many patients who have had anterior cruciate ligament (ACL) reconstruction (R) complain of instability, inability to return to previous levels of sports activity, and possible ACL graft failure. Graft size was discovered to be an important factor in lowering ACL failure rates. Also, extraarticular tenodesis decreases recurrent instability, A comparative study was done to compare the effect of graft size and lateral external tenodesis on the recurrence of instability after ACL-R.

PATIENTS AND METHODS

A Prospective Blinded Randomized Controlled study included 100 consecutive patients who underwent ACL-R with hamstring tendon grafts in our Hospital. The patients were allocated into two groups (Group A and B) with randomization; group A received ACL-R with a large-size ACL-graft diameter of 6 strands, and group B received ACL-R of 4 strands combined with lateral extraarticular tenodesis (LET) (Modified Lemaire). Each group had fifty patients. The follow-up time was two years. They were examined for graft failure, anterolateral rotatory instability with the pivot shift test, and clinical outcomes, which were evaluated with the International Knee Documentation Committee score (IKDC) both subjective and objective.

RESULTS

In this study; group A, graft failure occurred in three (6.3%) patients, a positive pivot shift test grade I was detected in eight (17.8%) patients, grade II in three (6.7%) patients, and grade III in one (2.2%) patient. The subjective IKDC score was 87.9 (± 7.19) points. The objective IKDC score was normal or nearly normal in 43 (93.4%) patients. In group B, one (2.1%) patient had graft failure, five (10.9%) had a positive pivot shift test grade I, one (2.1%) had a grade II, and no patient had a grade III. The subjective IKDC score was 91.9 (± 8.9) points. The objective IKDC score was normal or nearly normal in 44 (95.6%) patients. As regard the subjective IKDC score, there was a non-significant difference between both groups (p value = 0.465).

CONCLUSION

Both groups showed a low ACL-graft failure rate, low anterolateral rotatory instability, and a good clinical outcome. Although there was no significant difference in subjective IKDC score between both groups, the failure rate and anterolateral rotatory instability were significantly lower in the ACL-R (4 strands) with LET combination group than in the group with the large-diameter (6 strands) graft.

LEVEL OF EVIDENCE

Level 1; Randomized Comparative Study.

Evaluation of hop performance in children with anterior cruciate ligament reconstruction using healthy reference data: A cross-sectional study

BACKGROUND

Hop performance evaluation in children after anterior cruciate ligament (ACL) reconstruction may benefit from comparison to healthy controls. Thus, the purpose was to investigate the hop performance in children one year after ACL reconstruction with a comparison to healthy controls.

METHODS

Hop performance data from children with ACL reconstruction one year post-surgery and healthy children were compared. Four one-legged hop test data were analyzed: 1) single hop (SH), 2) 6 m timed hop (6 m-timed), 3) triple hop (TH), and 4) cross-over hop (COH). Outcomes were the best result (longest/fastest hop) from each leg and limb asymmetry. Differences in hop performance between-limbs (operated versus non-operated) and between-groups were estimated.

RESULTS

98 children with ACL reconstruction and 290 healthy children were included. Few statistically significant group differences were observed. Girls with ACL reconstruction outperformed healthy controls in two tests on the operated leg SH, COH) and in three tests on the non-operated leg (SH, TH, COH). However, the girls performed 4-5% worse on the operated leg when compared to the non-operated leg in all hop tests. No statistically significant between-group differences in the limb asymmetry were found.

CONCLUSION

The hop performance in children with ACL reconstruction one year post-surgery was largely comparable to the level of healthy controls. Despite this, we cannot exclude that neuromuscular deficits exist among the children with ACL reconstruction. The inclusion of a healthy control group for evaluating hop performance evoked complex findings regarding the ACL reconstructed girls. Thus, they may represent a selected group.

Chronic pain and functional impairment after arthroscopic surgery for a knee injury

Arthroscopic interventions are widely used to treat the consequences of the meniscus and anterior cruciate ligament (ACL) injuries. However, the long-term consequences of these surgeries are not always favorable and not in all cases allow to avoid the development of chronic pain and posttraumatic osteoarthritis.Objective: to evaluate the incidence of persistent postoperative pain and the persistence of functional disorders in patients undergoing arthroscopic interventions on the menisci and ACL.Material and methods. The study group consisted of 147 patients (60 women and 87 men, mean age 38.8±12.5 years) who underwent arthroscopic surgery on the knee joint (KJ) in the traumatology and orthopedic department of V.A. Nasonova Research Institute of Rheumatology in 2018– 2021. The condition of patients was assessed by telephone survey and/or online questionnaire. The pain and fatigue levels were assessed on numerical rating scale (NRS, 0–10), as well as the severity of functional disorders on the Lysholm scale (LS).Results and discussion. Moderate or intense knee pain and increased fatigue (≥4 according to NRS) were noted in 11.3% and 14.7% of respondents, respectively. The state of the KJ according to LS in 35.3% of patients was assessed as excellent (95–100 points), in 29.3% – as good (84–94 points), in 21.3% – as satisfactory (65–83 points) and 14.0% – as unsatisfactory (≤64 points).Conclusion. More than 10% of patients after arthroscopic operations on the knee joint experience moderate or severe pain and fatigue, satisfactory and unsatisfactory functional results are observed in 35.4% of cases.

Surgeon's experience, sports participation and a concomitant MCL injury increase the use of patellar and quadriceps tendon grafts in primary ACL reconstruction: a nationwide registry study of 39,964 surgeries

PURPOSE

To investigate the influence of surgeon-related factors and clinic routines on autograft choice in primary anterior cruciate ligament reconstruction (ACLR).

METHODS

Data from the Swedish National Knee Ligament Registry (SNKLR), 2008-2019, were used to study autograft choice (hamstring; HT, patellar; PT, or quadriceps tendon; QT) in primary ACLR. Patient/injury characteristics (sex, age at surgery, activity at time of injury and associated injuries) and surgeon-/clinic-related factors (operating volume, caseload and graft type use) were analyzed. Surgeon/clinic volume was divided into tertiles (low-, mid- and high-volume categories). Multivariable logistic regression was performed to assess variables influencing autograft choice in 2015-2019, presented as the odds ratio (OR) with a 95% confidence interval (CI).

RESULTS

39,964 primary ACLRs performed by 299 knee surgeons in 91 clinics were included. Most patients received HT (93.7%), followed by PT (4.2%) and QT (2.1%) grafts. Patients were mostly operated on by high-volume (> 28 ACLRs/year) surgeons (68.1%), surgeons with a caseload of ≥ 50 ACLRs (85.1%) and surgeons with the ability to use ≥ two autograft types (85.9%) (all p < 0.001). Most patients underwent ACLR at high-volume (> 55 ACLRs/year) clinics (72.2%) and at clinics capable of using ≥ two autograft types (93.1%) (both p < 0.001). Significantly increased odds of receiving PT/QT autografts were found for ACLR by surgeons with a caseload of ≥ 50 ACLRs (OR 1.41, 95% CI 1.11-1.79), but also for injury during handball (OR 1.31, 95% CI 1.02-1.67), various other pivoting sports (basketball, hockey, rugby and American football) (OR 1.59, 95% CI 1.24-2.03) and a concomitant medial collateral ligament (MCL) injury (OR 4.93, 95% CI 4.18-5.80). In contrast, female sex (OR 0.87, 95% CI 0.77-0.97), injury during floorball (OR 0.71, 95% CI 0.55-0.91) and ACLR by mid-volume relative to high-volume surgeons (OR 0.62, 95% CI 0.53-0.73) had significantly reduced odds of receiving PT/QT autografts.

CONCLUSION

An HT autograft was used in the vast majority of cases, but PT/QT autografts were used more frequently by experienced surgeons. Prior research has demonstrated significant differences in autograft characteristics. For this reason, patients might benefit if surgery is performed by more experienced surgeons.

LEVEL OF EVIDENCE

Level III.

[Translated article] Three years follow-up outcome of 4-strand semitendinous-gracilis anterior ligament reconstruction in women: A matched-cohort study

INTRODUCTION

Women carry out a greater risk of anterior cruciate ligament (ACL) rupture. However, outcomes following ACL reconstruction remain unclear. The aim of this study was to analyse the outcomes in women following ACL reconstruction and compare these outcomes with men.

MATERIAL AND METHODS

Retrospective study of a prospective database of patients treated with ACL reconstruction between January 2017 and December 2018. Outcome measures included Tegner activity scale, Lysholm scale, EVA scale, and IKDC evaluation form. Clinical significance was measured with minimally clinical important difference, and patient acceptable symptom state.

RESULTS

A total of 33 women were matched with 99 men. The mean follow-up was 36 months. Women showed significant improvement from preoperative PROs to the latest follow-up, with no differences between groups. In patients under 25 years old, there was less significant IKDC subjective score in women compared to men. There were no significant differences in frequency of patients achieving MCID and PASS in women compared with men.

CONCLUSIONS

At 3-year following 4-strand semitendinosus-gracilis anterior ligament reconstruction, women showed significant improvements in PROs, with no differences compared to men.

Outcome of 4-strand semitendinosus-gracilis anterior ligament reconstruction in women: A matched-cohort study

INTRODUCTION

Women carry out a greater risk of anterior cruciate ligament (ACL) rupture. However, outcomes following ACL reconstruction remain unclear. The aim of this study was to analyze the outcomes in women following ACL reconstruction and compare these outcomes with men.

MATERIAL AND METHODS

Retrospective study of a prospective database of patients treated with ACL reconstruction between January 2017 and December 2018. Outcome measures included Tegner activity scale, Lysholm scale, EVA scale, and IKDC evaluation form. Clinical significance was measured with minimally clinical important difference, and patient acceptable symptom state.

RESULTS

A total of 33 women were matched with 99 men. The mean follow-up was 36 months. Women showed significant improvement from preoperative PROs to the latest follow-up, with no differences between groups. In patients under 25 years old, there was less significant IKDC subjective score in women compared to men. There were no significant differences in frequency of patients achieving MCID and PASS in women compared with men.

CONCLUSIONS

At 3-year following 4-strand semitendinosus-gracilis anterior ligament reconstruction, women showed significant improvements in PROs, with no differences compared to men.

Limb and sex-related differences in knee muscle co-contraction exist 3 months after anterior cruciate ligament reconstruction

Interlimb and sex-based differences in gait mechanics and neuromuscular control are common after anterior cruciate ligament reconstruction (ACLR). Following ACLR, individuals typically exhibit elevated co-contraction of knee muscles, which may accelerate knee osteoarthritis (OA) onset. While directed (medial/lateral) co-contractions influence tibiofemoral loading in healthy people, it is unknown if directed co-contractions are present early after ACLR and if they differ across limbs and sexes. The purpose of this study was to compare directed co-contraction indices (CCIs) of knee muscles in both limbs between men and women after ACLR. Forty-five participants (27 men) completed overground walking at a self-selected speed 3 months after ACLR during which quadriceps, hamstrings, and gastrocnemii muscle activities were collected bilaterally using surface electromyography. CCIs of six muscle pairs were calculated during the weight acceptance interval. The CCIs of the vastus lateralis/biceps femoris muscle pair (lateral musculature) was greater in the involved limb (vs uninvolved; p = 0.02). Compared to men, women exhibited greater CCIs in the vastus medialis/lateral gastrocnemius and vastus lateralis/lateral gastrocnemius muscle pairs (p < 0.01 and p = 0.01, respectively). Limb- and sex-based differences in knee muscle co-contractions are detectable 3 months after ACLR and may be responsible for altered gait mechanics.

Returning Athletes to Sports Following Anterior Cruciate Ligament Tears

PURPOSE OF REVIEW

The purpose of this review is to discuss treatment options, rehabilitation protocols, return-to-play criteria, and expected outcomes after non-operative and operative treatment of anterior cruciate ligament (ACL) tears among an athletic population.

RECENT FINDINGS

Non-operative treatment may be a viable option for some athletes with an ACL tears but can be difficult to predict "copers," and those that resume to sports return at lower performance level and/or less intense activities. Most studies assessing function after ACL reconstruction demonstrate favorable outcomes using patient-reported outcome studies. However, return-to-play and graft re-rupture rates vary substantially based on patient characteristics and level and type of athletic activity. Grafts used to reconstruct ACL produce similar objective outcomes and favorable patient-reported outcomes but have variable re-rupture rates depending on study and differ largely on morbidity associated with graft harvest. Various treatment methods including non-operative and operative techniques have been demonstrated to be efficacious in returning athletes to athletic activity depending on patient age and level of activity. Adherence to fundamental rehabilitation principles and accepted return-to-play guidelines can optimize outcomes and limit re-injury to the injured or contralateral limb.

Young men are at higher risk of failure after ACL hamstring reconstructions: a retrospective multivariate analysis

Background

Results of ACL reconstruction are influenced by both patient and surgical variables. Until now a significant amount of studies have focused on the influence of surgical technique on primary outcome, often leaving patient variables untouched. This study investigates the combined influence of patient and surgical variables through multivariate analysis.

Methods

Single-center retrospective cohort study. All patients who underwent primary ACL hamstring reconstruction within a 5-year period were included. Patient characteristics (gender, age, height, weight, BMI at time of surgery) and surgical variables (surgical technique, concomitant knee injury, graft diameter, type of femoral and tibial fixation) were collected. Patients were asked about Tegner Activity Scale (TAS), complications and revision surgery. Multivariate logistic regression was used to study risk factors. First graft failure and potential risk factors (patient and surgical) were univariately assessed. Risk factors with a p-value ≤ 0.05 were included in the multivariate model.

Results

Six hundred forty-seven primary ACL hamstring reconstructions were included. There were 41 graft failures (failure rate 6.3%). Patient gender, age, height and preoperative TAS had a significant influence on the risk of failure in the univariate analysis. The multivariate analyses showed that age and sex remained significant independent risk factors. Patients with a failed ACL reconstruction were younger (24.3 vs 29.4 years, OR 0.937), with women at a lower risk for failure of their ACL reconstruction (90.2% males vs 9.8% females, female OR 0.123). ACL graft diameter and other surgical variables aren’t confounders for graft failure.

Conclusion

This study shows that patient variables seem to have a larger influence on the failure rate of ACL hamstring reconstructive surgery than surgical variables. Identification of the right patient variables can help us make more informed decisions for our patients and create patient-specific treatment protocols. Young men’s higher risk of failure suggests that these patients may benefit from a different reconstruction technique, such as use of a patellar tendon or combined ligament augmentation.

Level of evidence

Retrospective cohort III.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05547-8.

Tibial slope, remnant preservation, and graft size are the most important factors affecting graft healing after ACL reconstruction

PURPOSE

The aim of this study was to determine the anatomic, operative and biological factors that influenced graft healing after single-bundle anterior cruciate ligament (ACL) reconstruction.

METHODS

One hundred fourteen consecutive patients who underwent anatomic single-bundle ACL reconstruction with quadrupled hamstring tendon autografts between 2016 and 2019 were retrospectively analyzed. Ninety-four patients met the inclusion criteria with minimum follow-up of 12 months. Patients were evaluated with multiple clinical measurements, including International Knee Documentation Committee Subjective Knee Form (IKDC-SKF), Lyshom Scores, and Marx activity scale. To evaluate graft healing, the signal-to-noise quotient (SNQ) was measured at intra-articular graft and intra-tunnel integration were evaluated on magnetic resonance imaging (MRI) at one year after surgery. Potential factors affecting graft healing, including age, sex, body mass index, time from injury to surgery, posterior tibial slope, lateral femoral condyle ratio, notch width index, meniscal injury, remnant preservation, tunnel aperture locations, graft size, graft bending angle, graft/remaining notch volume ratio were evaluated for their association with graft SNQ value by stepwise regression analysis.

RESULTS

A total of 94 patients were evaluated with mean follow-up 28.5 ± 9 months. Univariate regression analysis showed that posterior tibial slope, notch width index, remnant preserving procedure, high femoral tunnel, anterior tibial tunnel, graft bending angle, and graft/remaining notch volume ratio significantly associated with graft SNQ values. Multivariate regression analysis showed that lateral tibial slope, remnant preservation, and graft/remaining notch volume ratio were independent factors correlated with graft SNQ values. Also, the graft SNQ values was weakly correlated with femoral tunnel integration and Marx activity scale at one year. There was no correlation between graft SNQ values and IKDC-SKF and Lysholm scores. There was no correlation between graft SNQ values and International Knee Documentation Committee and Lysholm scores.

CONCLUSIONS

Tibial slope, remnant preservation and graft/remaining notch volume ratio were significant independent associated factors of graft SNQ value at one year. The graft SNQ values were also weakly correlated with femoral tunnel integration and the Marx activity scale. These factors should be taken into account for ensuring the ideal graft healing and for the return to sport decision-making.

LEVEL OF EVIDENCE

Level IV.

Graft Choice for Anterior Cruciate Ligament Reconstruction in Women Aged 25 Years and Younger: A Systematic Review

CONTEXT

Although anterior cruciate ligament (ACL) tears are relatively common in athletic populations, few studies have systematically reviewed graft choice in young women.

OBJECTIVE

To quantitatively and qualitatively examine reported outcomes for graft choice in women aged 25 years and younger undergoing primary ACL reconstruction.

DATA SOURCE

A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. An electronic search in the PubMed (includes MEDLINE) and EMBASE databases was completed using a combination of key terms.

STUDY SELECTION

Studies were included if they reported graft choice outcomes in women aged 25 years and younger.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

The following information was extracted: title, author, year of publication, number of female patients and age, graft type, follow-up, and patient-reported outcome measures. The following outcome scores were identified as being reported or not reported by each study: graft failure, contralateral ACL (CACL) rupture, IKDC (International Knee Documentation Committee), graft survival (Kaplan-Meier), Lysholm, Tegner, KT-1000, kneeling pain, return to sport, and Lachman.

RESULTS

Of 1170 identified articles, 16 met inclusion criteria, reporting on 1385 female patients aged 25 years and younger. Comparison of 655 bone-patellar tendon-bone (BPTB) versus 525 hamstring tendon (HT) autografts showed significant differences in mean failure rate between BPTB autografts (6.13% ± 2.58%) and HT autografts (17.35% ± 8.19%), P = 0.001. No statistically significant differences in CACL failure rates were found between BPTB autografts and HT autografts (P = 0.25). Pooled results for IKDC were possible in 3 of the HT autograft studies, showing a mean score of 88.31 (95% CI 83.53-93.08). Pooled Lysholm score results were possible in 2 of the HT autograft studies, showing a mean score of 93.46 (95% CI 91.90-95.01).

CONCLUSION

In female patients aged 25 years and younger, BPTB autografts showed significantly less graft failure compared with HT autografts. However, BPTB autografts had comparable patient-reported outcomes compared with HT autografts with the available data. The overall state of evidence for graft choice in female patients aged 25 years and younger is low. Future studies should report statistics by age and sex to allow for further analysis of graft choice for this specific population that is known to be more vulnerable to ACL injury.

Minimizing the risk of graft failure after anterior cruciate ligament reconstruction in athletes. A narrative review of the current evidence

Anterior cruciate ligament (ACL) tear is one of the most common sport-related injuries and the request for ACL reconstructions is increasing nowadays. Unfortunately, ACL graft failures are reported in up to 34.2% in athletes, representing a traumatic and career-threatening event. It can be convenient to understand the various risk factors for ACL failure, in order to properly inform the patients about the expected outcomes and to minimize the chance of poor results. In literature, a multitude of studies have been performed on the failure risks after ACL reconstruction, but the huge amount of data may generate much confusion.The aim of this review is to resume the data collected from literature on the risk of graft failure after ACL reconstruction in athletes, focusing on the following three key points: individuate the predisposing factors to ACL reconstruction failure, analyze surgical aspects which may have significant impact on outcomes, highlight the current criteria regarding safe return to sport after ACL reconstruction.

Bench to Bedside: A Multidisciplinary Approach toward the Unknowns after ACL Injuries to Drive Individual Success

ACL injury and surgery are increasing in prevalence. Several challenges exist that can be obstacles to an individual achieving success after ACL surgery. A knowledge of these risk factors alongside a multidisciplinary collaborative team approach can result in a greater likelihood of achieving individual success after ACL surgery.

Sex-Specific Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Background:

Despite the significant difference between men and women in incidence of anterior cruciate ligament (ACL) injuries, there is a paucity of consistent information on the influence of patient sex on outcomes after ACL reconstruction. A previous meta-analysis has demonstrated that female patients have worse outcomes with regard to laxity, revision rate, Lysholm score, and Tegner activity score and are less likely to return to sports (RTS).

Purpose:

To conduct a systematic review and meta-analysis to evaluate and compare sex-specific outcomes after ACL reconstruction.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review was performed using PubMed, PubMed Central, Embase, OVID, and Cochrane databases per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The following search terms were used: “anterior cruciate ligament reconstruction” OR “ACL reconstruction” OR “anterior cruciate ligament” OR “ACL” AND “gender” OR “sex” OR “male” OR “female” AND “outcome” AND “2015-Present” to gather all relevant articles between 2015 and 2020. A risk-of-bias assessment and quality assessment was conducted on included studies.

Results:

Of 9594 studies initially identified, 20 studies with 35,935 male and 21,455 female patients were included for analysis. The 7 studies reporting International Knee Documentation Committee (IKDC) scores showed that male patients had statistically significantly higher postoperative scores (mean difference, 3.02 [95% CI, 1.19-4.84]; P< .01; I² = 66%), and 7 studies that reported the rate of ACL revision showed there was no significant difference between male and female patients (odds ratio, 0.85 [95% CI, 0.45-1.60]; P = .61; I² = 94%). The 7 studies that reported rates of rerupture showed that males were significantly more likely than females to have a graft rerupture (odds ratio, 1.35 [95% CI, 1.22-1.50]; P < .01; I² = 0%). Male patients reported a higher RTS rate than did their female counterparts (59.82% compared with 42.89%); however, no formal statistical analysis could be done because of the variability in reporting techniques.

Conclusion:

Male and female patients with ACL injuries demonstrated similar outcomes regarding their rates of revision; however, male patients were found to have statistically significantly higher postoperative IKDC scores but at the same time higher rerupture rates. Our findings suggest that sex-based differences in outcomes after ACL reconstruction vary based on which metric is used. These results must be considered when counseling patients with ACL injuries.

Disparities in ACL Reconstruction: the Influence of Gender and Race on Incidence, Treatment, and Outcomes

PURPOSE OF REVIEW

Anterior cruciate ligament (ACL) rupture is a common injury that has important clinical and economic implications. We aimed to review the literature to identify gender, racial and ethnic disparities in incidence, treatment, and outcomes of ACL injury.

RECENT FINDINGS

Females are at increased risk for ACL injury compared to males. Intrinsic differences such as increased quadriceps angle and increased posterior tibial slope may be contributing factors. Despite lower rates of injury, males undergo ACL reconstruction (ACLR) more frequently. There is conflicting evidence regarding gender differences in graft failure and ACL revision rates, but males demonstrate higher return to sport (RTS) rates. Females report worse functional outcome scores and have worse biomechanical metrics following ACLR. Direct evidence of racial and ethnic disparities is limited, but present. White athletes have greater risk of ACL injury compared to Black athletes. Non-White and Spanish-speaking patients are less likely to undergo ACLR after ACL tear. Black and Hispanic youth have greater surgical delay to ACLR, increased risk for loss to clinical follow-up, and less physical therapy sessions, thereby leading to greater deficits in knee extensor strength during rehabilitation. Hispanic and Black patients also have greater risk for hospital admission after ACLR, though this disparity is improving. Females have higher rates of ACL injury with inconclusive evidence on anatomic predisposition and ACL failure rate differences between genders. Recent literature has suggested inferior RTS and functional outcomes following ACLR in females. Though there is limited and mixed data on incidence and outcome differences between races and ethnic groups, recent studies suggest there may be disparities in those who undergo ACLR and time to treatment.