Return to Play and Long-term Participation in Pivoting Sports After Anterior Cruciate Ligament Reconstruction

Imaging of soccer injuries in adolescent female athletes

Soccer participation is increasing among female adolescents with a concomitant rise of injuries in this group. Age- and sex-related factors, such as the transition from skeletal immaturity to skeletal maturity as well as anatomic, physiologic, neuromuscular, and behavioral differences between females and males, all play a role in injury patterns for these athletes. Anterior cruciate ligament (ACL) tears in this group have received a great deal of attention in the medical literature and the media in recent years with increasing knowledge about causative factors, surgical management, and injury prevention. There have been fewer studies specifically focused on female adolescent soccer players in relation to other types of injuries, such as patellar dislocation/instability; other knee and ankle ligament tears; hip labral tears; muscle strains and tears; and overuse injuries such as apophysitis, patellofemoral pain syndrome, and bone stress injuries. Because imaging plays a critical role in diagnosis of soccer-related injuries in female adolescents, knowledge of the mechanisms of injury, imaging findings, and clinical considerations are essential for radiologists involved in the care of these patients.

Primary Anterior Cruciate Ligament Reconstruction in Level 1 Athletes: Factors Associated With Return to Play, Reinjury, and Knee Function at 5 Years of Follow-up

BACKGROUND

Favorable outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR) are often gauged by successful return to play (RTP), a low incidence of subsequent ACL injury, and positive patient-reported outcomes. Level 1 sports place the highest demands on the knee by requiring frequent pivoting, changes in direction, and jumping.

PURPOSE

To analyze the outcomes of primary ACLR in level 1 athletes and identify pre- and intraoperative factors associated with RTP, ipsilateral ACL reinjury, contralateral ACL injury, and International Knee Documentation Committee (IKDC) score at 5 years postoperatively.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A consecutive cohort of 1432 patients who underwent primary ACLR by 2 orthopaedic surgeons were prospectively evaluated. The RTP rate, incidence of ipsilateral/contralateral ACL injury, and IKDC score were analyzed at 5 years. Comparative analysis of clinical variables was performed between those who achieved favorable outcomes and those who did not. Outcomes at 5 and 2 years were also compared.

RESULTS

The mean age was 24.3 ± 7.3 years (males: 75%, females: 25%). Gaelic football was the predominant sport (40%), followed by soccer (19%). The RTP rate was 87.4%, with 59.8% of athletes still playing at an equivalent or higher level at 5 years. The incidence of ipsilateral reinjury for athletes who resumed level 1 sport was 4.3% for bone-patellar tendon-bone (BPTB) autografts with screw fixation and 19.7% for hamstring tendon (HT) autografts with EndoButton and screw fixation. The incidence of contralateral ACL injury was 13.7%. The mean IKDC score at 5 years (86.6 ± 10.9) was comparable to that at 2 years (86.8 ± 10.1). Patients were more likely to RTP with each year of decreasing age (OR, 1.06; P < .001), with a higher preoperative Marx score (OR, 1.08; P < .001) or a higher 5-year IKDC score (OR, 1.06; P < .001). The risk of ipsilateral ACL reinjury increased each year of decreasing age (OR, 1.11; P < .001) or when an HT autograft was used (OR, 5.56; P < .001). Younger age was also associated with contralateral ACL injury (OR, 1.1; P < .001). Female sex, older age, concomitant meniscal/chondral injuries, and lower preoperative Anterior Cruciate Ligament Return to Sport after Injury scores were associated with lower IKDC scores at 5 years.

CONCLUSION

Most patients could return to level 1 sports, although their performance level was impacted. Those who returned to sport maintained their performance level over the 5 years. The ipsilateral reinjury rate for BPTB autografts with screws was significantly lower than that for HT autografts with EndoButton and screw fixation. Most ACL reinjuries occurred between 2 and 5 years of follow-up. Younger patients had an increased risk of a subsequent ACL injury to either knee, regardless of graft type. IKDC scores were lower in female patients, older patients, and those with concomitant meniscal/cartilage injuries.

REGISTRATION

NCT02771548 (ClinicalTrials.gov identifier).

Subjective Causes for Failure to Return to Sport After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

CONTEXT

While current literature has explored the outcomes of athletes who return to sport (RTS) after anterior cruciate ligament (ACL) injuries, less is known about the outcomes of those who are unsuccessful in returning to sport.

OBJECTIVE

To determine the rate of athletes who did not RTS after primary ACL reconstruction (ACLR) and to identify the specific subjective reasons for failure to RTS.

DATA SOURCES

A comprehensive search of the PubMed/MEDLINE, Scopus, and Web of Science databases was conducted through April 2021.

STUDY SELECTION

Eligible studies included those explicitly reporting the rate of failure for RTS after ACLR as well as providing details on reasons for athletes' inability to return; 31 studies met the inclusion criteria.

STUDY DESIGN

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

Level 2 to 4.

DATA EXTRACTION

The reasons for failure to RTS referred to in our study are derived from those established previously in the studies included. Data were collected on the number of athletes, mean age, mean follow-up time, type of sport played, failure to RTS rate, and specific reasons for failure to return.

RESULTS

The weighted rate of failure to RTS after ACLR was 25.5% (95% CI, 19.88-31.66). The estimated proportion of psychosocial-related reasons cited for failure to RTS was significantly greater than knee-related reasons for failure RTS (55.4% vs 44.6%, P < 0.01). The most cited reason for failure to RTS was fear of reinjury (33.0%).

CONCLUSION

This study estimates the rate of failure to RTS after ACLR to be 25.5%, with the majority of athletes citing fear of reinjury as the major deterrent for returning to sports. We highlight how factors independent of surgical outcomes may impact an athlete's ability to return to play given that the predominant reason for no RTS after ACLR was unrelated to the knee.

Nonoperative Treatment of Anterior Cruciate Ligament Tears With 5-Year Follow-up

Background

It remains unknown whether anterior cruciate ligament (ACL) reconstruction (ACLR) alters the natural history of degenerative changes or prevents further injury compared with nonoperative treatment.

Purpose/Hypothesis

The purpose of this study was to evaluate the midterm risk of knee surgery in patients who sustained an ACL tear treated with initial nonoperative management. It was hypothesized that the majority of patients who pursue initial nonoperative treatment after ACL rupture will not undergo further surgery within 5 years.

Study Design

Case series; Level of evidence, 4.

Methods

An electronic health record search was performed for all patients aged 12 to 65 years from 2011 to 2012 with magnetic resonance imaging-confirmed ACL tear. Patients who did not undergo ACLR within 6 months after diagnosis comprised our initial cohort. Patients were longitudinally followed until August 31, 2017. The primary outcome was an occurrence of ipsilateral knee surgery, including ACLR and non-ACLR procedures.

Results

A total of 932 patients with a mean age of 36.2 ± 13.6 years were included. The mean follow-up time was 57.9 ± 7.4 months. During the follow-up period, 365 patients (39.2%) had ipsilateral knee surgery, with a mean time from ACL tear diagnosis to the first procedure of 11.9 ± 13.0 months. Overall, 67% of surgeries occurred within 12 months of diagnosis. ACLR was performed in 211 patients (22.6%); 284 patients had non-ACLR knee procedures, with 130 undergoing ACLR and non-ACLR surgery and 154 patients undergoing non-ACLR procedures alone. After adjusting for demographic and clinical factors, younger age remained a significant risk factor for undergoing ACLR: patients aged 12 to 18 years and those aged 19 to 30 years had similar adjusted hazard ratios compared with patients aged 51 to 65 years (5.49 [95% CI, 2.78-10.88] and 5.48 [95% CI, 2.85-10.53], respectively; P < .001 for both).

Conclusion

In this universally insured, contained patient cohort, 39.2% of the patients underwent a subsequent surgical procedure on the ipsilateral knee within 5 years of ACL injury, with 22.6% of patients opting to undergo delayed ACLR. Younger age was an independent risk factor for undergoing ACLR.

Return to Sport and Graft Failure Rates After Primary Anterior Cruciate Ligament Reconstruction With a Bone-Patellar Tendon-Bone Versus Hamstring Tendon Autograft: A Systematic Review and Meta-analysis

BACKGROUND

Anterior cruciate ligament (ACL) tears are frequent injuries in athletes that often require surgical reconstruction so that patients may return to their previous levels of performance. While existing data on patient-reported outcomes are similar between bone-patellar tendon-bone (BTB) and hamstring tendon (HT) autografts, the literature regarding return to sport (RTS), return to previous levels of sport activity, and graft failure rate remains limited.

PURPOSE

To compare rates of RTS, return to previous activity levels, and graft retears among athletes undergoing primary ACL reconstruction using a BTB versus HT autograft.

STUDY DESIGN

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

METHODS

The MEDLINE, Embase, and Cochrane Library databases were queried, and studies reporting on RTS after primary ACL reconstruction using a BTB or HT autograft were included. Exclusion criteria included revision reconstruction, ACL repair, quadriceps tendon autografts, allografts, graft augmentation, or double-bundle autografts. Rates of RTS, return to previous levels of activity, and retears were extracted and analyzed across included studies.

RESULTS

A total of 33 articles met inclusion criteria, with a patient cohort of 4810 athletes. The overall RTS rate for all athletes was 80.4% (95% CI, 75.3%-84.6%) at a mean follow-up of 35.7 months, with 54.6% (95% CI, 48.5%-60.6%) returning to preinjury levels of activity. No significant difference was found between BTB and HT autografts with respect to rates of RTS, return to preinjury activity levels, or reruptures. The overall RTS rate in patients after primary ACL reconstruction with a BTB autograft was 83.3% (95% CI, 77.0%-88.2%), with 56.1% (95% CI, 49.3%-62.7%) returning to preinjury levels of activity. Conversely, the overall RTS rate in patients after primary ACL reconstruction with an HT autograft was 77.9% (95% CI, 70.3%-84.0%), with 53.5% (95% CI, 42.8%-63.9%) returning to preinjury levels of activity. The overall graft rerupture rate for the entire patient cohort was 3.6% (95% CI, 2.5%-5.1%), for patients with BTB grafts was 3.2% (95% CI, 1.9%-5.3%), and for patients with HT grafts was 4.4% (95% CI, 2.8%-6.8%).

CONCLUSION

Primary ACL reconstruction using BTB autografts demonstrated similar rates of RTS, return to previous activity levels, and reruptures compared with reconstruction using HT autografts.

Training Model for Extended Career Athletes: A Narrative Review

CONTEXT

Today's elite and professional sports tend to feature older, more seasoned athletes, who have longer sporting careers. As advancing age can potentially limit peak performance, balancing training load is necessary to maintain an optimal state of performance and extend their sports career.

OBJECTIVE

To describe an appropriate training model for extended career athletes.

DATA SOURCES

Medline (PubMed), SPORTDiscus, ScienceDirect, Web of Science, and Google Scholar.

STUDY SELECTION

A search of the literature between January 1, 2015 and November 22, 2023 was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

STUDY DESIGN

Narrative review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Data were extracted from studies related to the management of training and performance of athletes with extended and long careers.

RESULTS

A total of 21 articles related to extended careers were found. Key themes from these papers included: expertise, biological maturation, and specificity; epidemiology and health; athlete monitoring; strength training; load management and detraining; success management.

CONCLUSION

A training model for extended career athletes should balance the deleterious effects of age with the athletes' knowledge of, and expertise within, the sport. Designing specific training that accommodates previous injuries, training load intolerances, and caters for quality of life after retirement should be key considerations. Load management strategies for athletes with extended careers should include strength training adaptations to minimize pain, load-response monitoring, a broad range of movement, recovery and intensity activities, and the avoidance of large training load peaks and periods of inactivity.

Greater return to sports after anterior cruciate ligament reconstruction combined with anterolateral ligament reconstruction compared with anterior cruciate ligament reconstruction alone: A systematic review and meta-analysis

Purpose

This study aimed to compare the return to sports, return to competition, Tegner score and anterior cruciate ligament-return to sports injury (ACL-RSI) scores between patients who underwent ACL reconstruction (ACLR) combined with anterolateral ligament reconstruction (ALLR) and those who underwent ACLR alone.

Methods

Two independent reviewers conducted a literature search in PubMed (MEDLINE), EMBASE, Google Scholar and the Cochrane Library in July 2024, followed by data extraction and quality assessment. This study followed the Preferred Reporting Items for Systematic Reviews and meta-analysis guidelines. The return to sports rate, return to competition rate, Tegner score and ACL-RSI score were compared between patients who underwent primary ACLR with ALLR and those who underwent isolated primary or revision ACLR. The methodological quality of the included studies was assessed via the Cochrane risk-of-bias tool and methodological items for nonrandomized studies.

Results

In total, 12,139 studies were screened, and 14 (four randomized controlled trials and 10 nonrandomized studies) studies were ultimately evaluated. Compared with isolated ACLR, ACLR combined with ALLR resulted in a higher rate of return to sports and competition. Nevertheless, no significant differences were found in the Tegner score or ACL-RSI score between the two groups.

Conclusion

Patients who underwent ACLR in combination with ALLR had higher rates of return to sports and competition, but their Tegner activity and ACL-RSI scores were similar to those of patients who underwent ACLR alone. This finding may assist surgeons in making decisions when treating patients undergoing ACLR, especially athletes.

Level of Evidence

Level III.

Development and validation of a novel method for assessing physical activity profiles after anterior cruciate ligament reconstruction: The Sports and Physical Activity scale

OBJECTIVES

To describe and evaluate the preliminary validity of a novel scoring system for assessing the physical activity of patients after anterior cruciate ligament (ACL) reconstruction.

METHODS

The Sports and Physical Activity (SPA) scale consists of thirty options of sports and physical activities, followed by four frequency options for each option selected. Factors used to develop the scoring system were frequency of participation and intensity of the sports or physical activities. Possible scores ranged from a low of 0 to a high of 24. The scale was assessed for validity and responsiveness.

RESULTS

The study cohort included 418 primary ACL reconstructed patients 2 years after surgery, and a subgroup of 183 patient 5 years after surgery. The mean and median SPA scores for the cohort were 12.35 ( ​± ​6.95) and 12, respectively. There was no statistically significant difference between the scores of men and women (U ​= ​21,541.0, p ​= ​0.921). The SPA scale had a small but statistically significant inverse correlation with age (rs ​= ​-0.2, p = <0.001), indicating divergent validity. Patients who had returned to sport had a statistically significantly higher score (U ​= ​21593.5, p = <0.001), and there was a statistically significant difference between scores of the three current sports status groups (H ​= ​19.99, p value = <0.001) indicating convergent validity. Construct validity was indicated with a statistically significant correlation with the Marx scale (rs ​= ​0.422, p value= <0.001). In a subgroup (n ​= ​183) of the patient sample, comparison between scores at 2-years (13.27 ​± ​7.02) and 5-years (12.11 ​± ​7.88) found a statistically significant decline (p= <0.001). However, this decline was smaller than the decline seen in the Marx score between 2 and 5 years (11.11 ​± ​4.07 and 9.30 ​± ​4.52 p= <0.001).

CONCLUSION

Preliminary validity was found for the SPA scale. Women and men were found to be participating in a similar amount of activity 2 years post ACL reconstruction, despite return to sport differences between men and women being well documented. The scores of the SPA scale showed a statistically significant decrease over time with a negligible effect size.

LEVEL OF EVIDENCE

III.

Joint Effusion at 3 Months After Anterior Cruciate Ligament Reconstruction: Its Risk Factors and Association With Subsequent Muscle Strength and Graft Remodeling

Background

Joint effusion at 3 months after anterior cruciate ligament (ACL) reconstruction is a risk factor for ACL reinjury. However, factors associated with joint effusion at 3 months postoperatively and the effect of joint effusion on subsequent quadriceps muscle strength and graft remodeling remain unknown.

Purposes

To identify factors associated with joint effusion and investigate the association between joint effusion and quadriceps muscle strength and graft remodeling in the postoperative period.

Study Design

Case-control study; Level of evidence, 3.

Methods

In this retrospective multicenter study, the medical records of patients who underwent single-bundle ACL reconstruction between 2015 and 2021 were reviewed. The study included the data of 174 patients (mean age, 23.5 ± 10.6 years). Demographic data, including sex, age at surgery, time from injury to surgery in months, body mass index, preinjury Tegner activity score, presence of meniscus, and chondral injuries, were collected. Magnetic resonance imaging was performed 3 months postoperatively. Joint effusion was defined as grade 3 (range of grades, 0-3) according to the ACL Osteoarthritis Score. Isokinetic strength testing was performed at 60 deg/s, while the limb symmetry index (LSI) of quadriceps strength was evaluated at 6 months postoperatively. Moreover, graft remodeling was evaluated using magnetic resonance imaging-derived signal intensity ratio (SIR) measures at 1 year postoperatively. The authors used multivariate logistic and linear regression analyses to identify the factors influencing joint effusion at 3 months and those associated with postoperative quadriceps strength LSI and SIR values, respectively.

Results

Greater preinjury Tegner activity scores (odds ratio, 1.59; 95% CI, 1.08 to 2.34; P = .02) increased the odds of joint effusion at 3 months postoperatively. Multivariable linear regression analysis revealed that joint effusion (β = -23.8; 95% CI, -36.0 to -11.7; P < .001) was an independent factor associated with LSI of the quadriceps. Furthermore, joint effusion (β = 1.33; 95% CI, 0.53 to 2.14; P = .001) was associated with a higher SIR value of the reconstructed graft.

Conclusion

The preinjury Tegner activity score was a factor associated with joint effusion at 3 months postoperatively, and joint effusion was associated with subsequent muscle weakness and delayed graft remodeling.

Evaluation of the Relative Frequency of Preinjury Activity Recovery in Anterior Cruciate Ligament Replacement Patients: A Cohort Study

Background

Anterior cruciate ligament (ACL) injury has an incidence of 0.05-0.08 per thousand. An inappropriate treatment plan could lead to articular cartilage damage and early knee osteoarthritis. Some surgical reconstruction techniques use different graft types; all of them try to restore the patient's preinjury activity levels. The current study aims to evaluate the efficacy of ACL reconstruction (ACLR) using an autologous hamstring tendon.

Materials and Methods

This is a retrospective one-center cohort study performed on consecutive patients with an ACL injury who underwent ACLR using semitendinosus and gracilis autograft. The postsurgical activity and fear were measured using Marx scale and Tampa scale of kinesophobia, respectively, during a follow-up of 18 months.

Results

From a total of 76 patients included in our study, 40.8% were female. The mean age of the participants was 26.25-year-old. Five patients from those with kinesophobia (12.5%) and 34 patients from those with no-kinesophobia (94%) returned to the preinjury activity level (P value < 0.001). Marx scale six months after the surgery was significantly lower than the score before the surgery, but as expected, it improved during the 18-month follow-up.

Conclusion

The current study showed that kinesophobia reduces the rate of return to preinjury levels. Maybe, overcoming this fear will help these patients to reach better results. However, we suggest implementing further trials in larger sample sizes before reaching a solid conclusion.

Association of suture augmentation with graft failure and clinical outcomes following anterior cruciate ligament reconstruction: A systematic review and meta-analysis of comparative studies with a minimum 2-year follow-up

PURPOSE

To compare graft failure, nonrevision reoperation, complication, patient-reported outcome measures (PROMs) and return to sports (RTS) between patients who underwent anterior cruciate ligament reconstruction (ACLR) with and without suture augmentation (SA).

METHODS

A systematic search was performed on PubMed, Cochrane, Embase and Web of Science databases from the inception of databases to 18 April 2024, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies comparing clinical outcomes of SA- and standard ACLR with a minimum 2-year follow-up were included. Data extraction and quality appraisal were performed by two researchers independently.

RESULTS

Eight retrospective cohort studies were included, with a total of 408 patients receiving SA-ACLR and 443 patients receiving standard ACLR. A meta-analysis of graft failure demonstrated a 62% relative risk reduction (RR [risk ratio], 0.38 [95% confidence interval {CI}, 0.19-0.73]; p = .004) in those receiving SA-ACLR compared with standard ACLR. An age-related heterogeneity in graft failure reduction was detected in the subgroup analysis, which was more pronounced in studies with mean ages of <20 years compared with ≥20 years (p = .05; I2 = 73.9%). No significant difference was observed in nonrevision reoperation or complication rates. No clinically relevant difference was observed in PROMs. SA-ACLR was associated with a significantly higher RTS rate compared with the standard ACLR (RR, 1.12 [95% CI, 1.00-1.24]; p = .04), whereas no significant difference was observed in time to RTS.

CONCLUSION

SA-ACLR is associated with a reduced graft failure rate and increased RTS rate compared with standard ACLR without additional reoperations or complications. However, confidence in the evidence is limited by substantial heterogeneity. Future studies with a higher level of evidence are warranted to validate the benefit of SA and to determine the indication for different risk populations.

LEVEL OF EVIDENCE

Level III.

Anterior cruciate ligament injuries in elite badminton athletes: 84% Return to sport, half return to performance

PURPOSE

Badminton requires fast and pivoting movements, putting athletes at risk of sustaining an anterior cruciate ligament (ACL) injury. The primary purpose is to investigate the return to sport (RTS) and the return to performance (RTP) after an ACL injury in elite badminton athletes. The secondary purpose is to describe ACL injury mechanisms in elite badminton players.

METHODS

Athletes within the top 200 of the Badminton World Federation World Ranking who sustained an ACL injury between January 2001 and December 2021 were retrospectively included. An anonymous online survey was created in eight languages. RTS, RTP and contributing factors were analysed among athletes aiming to RTP. The injury mechanism was analysed in all participants.

RESULTS

Sixty-six athletes from 32 countries were included. Fifty-seven athletes (86.4%) aimed to RTP. Forty-eight out of 57 (84.2%) did RTS. Twenty-nine (50.9%) managed to successfully RTP. Forty-nine (74.2%) of ACL injuries occurred during a competition, 14 (21.2%) occured during training. Thirty-one (49.2%) occurred in the rear court backhand side and 47 (74.6%) occurred during landing after a jump.

CONCLUSION

Forty-eight out of 57 (84.2%) athletes managed to RTS. Half of the athletes managed to successfully RTP. Most of the ACL injuries occurred during competition, in the rear court backhand side and during landing after a jump.

LEVEL OF EVIDENCE

Level III.

Evaluation of the relationship between non-contact anterior cruciate ligament rupture and eminential morphometry: a cross-sectional and MRI based study

BACKGROUND

The literature does not clearly convey the relationship between eminential morphometry and non-contact anterior cruciate ligament (ACL) ruptures. This study attempts to reveal whether there is a relationship between non-contact ACL ruptures and eminential morphometry.

METHODS

Knee magnetic resonance images (MRIs) taken for the various indications between January 2022 and June 2023 were retrospectively scanned. The patients were categorized into 2 groups: those with an ACL rupture and those with an intact ACL. For each patient, eminential angle 1, eminential angle 2, medial eminential height, lateral eminential height, total eminential height, eminential width, and the ratio of tibial plateau width and eminential width to the tibial plateau width were measured by 2 different orthopedists. Patients whose MRIs were used for measurement were evaluated and grouped according to their age, sex, and injury side.

RESULTS

In total, 400 MRIs of 400 patients were included in the study. While 200 patients had an ACL rupture, 200 had an intact ACL. The total eminential height in the ACL rupture group was measured at 16.1 ± 2.6 mm and 15.5 ± 2.7 mm (p = 0.035) in the ACL intact group. Eminental width in the ACL rupture group was measured at 12.1 ± 1.9 mm and 13.0 ± 2.0 mm in the ACL intact group (p = 0.0001). The tibial plateau width was 75.4 ± 15.7 mm in the ACL rupture group and 73.6 ± 5.8 mm in the ACL intact group (p = 0.002). According to the logistic regression analysis, the p-value for males was 0.0001, and for eminential width, the p-value was 0.0001.

CONCLUSIONS

A significant difference was found between the ACL rupture and the ACL intact groups regarding eminential height, eminential width, and tibial plateau width parameters. Being male and having a low eminential width were identified as independent risk factors for non-contact ACL.

TRIAL REGISTRATION

Not applicable.

Limb dominance influences landing mechanics and neuromuscular control during drop vertical jump in patients with ACL reconstruction

Objectives

The purpose of this study was to compare the interlimb biomechanical differences in patients who had undergone anterior cruciate ligament reconstruction (ACLR) in either dominant (ACLR-D) or nondominant (ACLR-ND) limbs and healthy controls (CON) during drop vertical jump (DVJ) task. To investigate whether the dominant or nondominant limb influences the risk of re-injury in ACLR patients.

Methods

Thirty-three ACLR patients were divided into ACLR-D and ACLR-ND groups according to whether the surgical limb was dominant or nondominant. Seventeen healthy individuals were selected as the CON group. Three-dimensional kinematic data, ground reaction force (GRF) data, and surface electromyographic (EMG) data from the bilateral lower limbs of all participants were collected during the DVJ task. Two-way repeated-measures ANOVAs (limb × group) were performed on the variables of interest to examine the main effects of limb (dominant vs. nondominant) and group (ACLR-D, ACLR-ND, and CON), as well as the interaction between limb and group.

Results

The nonsurgical limbs of ACLR group had significantly greater knee valgus angles, knee extension and valgus moments, peak posterior GRF (PPGRF), and peak vertical GRF (PVGRF) compared to the surgical limbs. The nonsurgical limbs of ACLR-ND patients demonstrated significantly greater knee extension and valgus moments, greater PPGRF and PVGRF, and reduced muscle activity in the vastus medialis and vastus lateralis compared to the CON group. The ACLR patients had reduced muscle activity in the quadriceps of the surgical limb and the hamstrings of the bilateral limbs compared to controls.

Conclusion

The nonsurgical limbs of ACLR patients may suffer an increased risk of ACL injury due to altered landing mechanics and neuromuscular control strategies compared to the surgical limbs. Additionally, limb dominance influences movement patterns and neuromuscular control during DVJ task, the nonsurgical limbs of the ACLR-ND might be at higher risk of ACL injury compared to the ACLR-D group.

How Athletic Swiss Patients Experience Their Return to Sports After Anterior Cruciate Ligament Reconstruction: Results from a Retrospective Self-Assessment

Introduction

Anterior cruciate ligament (ACL) ruptures are frequent injuries, especially in athletes. Return to sports after reconstruction of the ligament is a frequently debated topic and of high relevance for these patients. It is mostly achieved at 9-12 months post-surgery. However, the risk of subsequent knee injuries is high and psychological factors play an important role in the process and success of returning to sports. Little is known about patients' perception of their journey returning to sports. This study aims to fill the gap.

Material and Methods

The study aimed to include patients treated surgically for an ACL injury over 5 years at a specialized sports-medicine clinic. Patients were surveyed on the impact of the injury on their lives, their return to sports experience, and medical history.

Results

In total, 100 (of 474) patients aged 35.9 years responded. Within 5 years, 19% experienced a reoperation and 23% a new knee injury. Overall, 83% of patients returned to their main sport, 72% reached their pre-injury level. However, 45% reported at least one distinct or severe consequence of their ACL injury. The ability to return to sports had more impact on the perception of the course of treatment than the experience of new injuries or surgery.

Conclusion

The rate of successful return to sports was comparable to previous reports despite a higher average age in this cohort. A successful return to sports seems to be a major determinant for the perception of impact from the injury and may be more important than the avoidance of repeat trauma.

Return to Physical Activity in Individuals with Surgical Stomas: A Scoping Review

In surgically treated individuals with surgical stomas, the return to physical activity is an indicator of quality of life that reflects their well-being. With the aim of synthesizing the available evidence regarding the return to physical activity in individuals with surgical stomas, a scoping review was developed following the methodological approach of the Joanna Briggs Institute and the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Scoping Reviews criteria. Searches were conducted in Medline (PubMed), Scopus, Web of Science, Cinahl, and Lilacs, as well as the meta-search engines TripDatabase and Epistemonikos, using MeSH terms. Included studies were written in Spanish, English, Portuguese, and German, without any limitation on the year of publication. A total of n = 15 studies was included (n = 2 qualitative; n = 2 case reports; n = 1 case series; n = 1 cohort; n = 8 cross-sectional; and n = 1 randomized clinical trial), which showed variability in the quality of the designs. The qualitative studies explored themes such as motivation, beliefs about physical activity, and other lifestyle factors. The case reports described physiological, psychological, and functional implications of returning to physical activity for specific individuals after ostomy surgery. Quantitative studies evaluated the effects of different types of physical activity on quality of life and tolerance to physical activity in these individuals, employing various measurement instruments. In conclusion, the evidence on returning to sports and physical activity after stoma surgery is limited and varied. While studies highlight the importance of social support and self-confidence, they generally lack rigor and primarily focus on adults and oncology patients. There is a need for more research to establish clear guidelines on physical activity type, frequency, and intensity to ensure safe and beneficial outcomes for individuals with stomas.

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.

Age under 20 years, pre-operative participation in pivoting sports, and steep posterior tibial slope of more than 12° are risk factors for graft failure after double-bundle anterior cruciate ligament reconstruction

Purpose

Younger age and steep posterior tibial slope (PTS) have been reported as risk factors for graft failure after anterior cruciate ligament reconstruction (ACLR). Few studies have evaluated these risk factors simultaneously in a large cohort of patients undergoing double-bundle ACLR (DB-ACLR). Therefore, this retrospective study aimed to simultaneously investigate known risk factors such as PTS and age in DB-ACLR, determine their thresholds and calculate odds ratios (ORs).

Methods

We investigated 482 knees that underwent DB-ACLR with a follow-up period of at least 2 years. Receiver operating characteristic analysis determined cut-off values for age and PTS for graft failure. Subsequently, logistic regression analysis was conducted to evaluate the effects of age, sex, height, weight, laterality, surgical waiting period, pre-operative sport type and level, meniscal injury, hyperextension, general joint laxity and PTS on graft failure.

Results

Graft failure was observed in 33 out of 482 knees (6.8%). Notably, the graft failure group was significantly younger (18.0 ± 5.0 years [standard deviation] vs. 30.4 ± 13.1 years, p < 0.01) and had a steeper PTS (11.9 ± 2.3° [standard deviation] vs. 9.6 ± 2.9°, p < 0.01) than the group with no graft failure. The cut-off values were 20.0 years for age (specificity, 64.6%; sensitivity, 87.9% and area under the curve, 0.808) and 12.0° for PTS (specificity, 70.9%; sensitivity, 69.7% and area under the curve, 0.734). Logistic regression analysis identified an age of <20 years (OR = 10.1; p < 0.01), PTS of ≥12° (OR = 5.6; p < 0.01) and pre-operative participation in pivoting sports (OR = 6.0; p < 0.01) as significant risk factors for graft failure.

Conclusion

We identified an age of <20 years, PTS of ≥12° and pre-operative participation in pivoting sports as significant risk factors for graft failure after DB-ACLR.

Level of Evidence

Level III.

Return to Play and Performance After Anterior Cruciate Ligament Reconstruction in Soccer Players: A Systematic Review of Recent Evidence

BACKGROUND

The available literature referring to the return to play (RTP) and performance after anterior cruciate ligament reconstruction (ACLR) has already been comprehensively summarized in team sports such as basketball or American Football. Therefore, in this sense, it is necessary to synthesize evidence relating to the mentioned parameters in soccer players who underwent ACLR.

OBJECTIVE

The aim of this systematic review was to examine RTP and the performance of soccer players after ACLR.

METHODS

Three electronic databases, Web of Science, Scopus, and PubMed, have been comprehensively searched to identify relevant articles. The following inclusion criteria were applied: (1) the sample of respondents consisted of soccer players irrespective of their age, sex, or level of competition; (2) athletes experienced anterior cruciate ligament injury and underwent ACLR; (3) outcomes estimated referred to the RTP, RTP at the preinjury level of competition, RTP time, performance, and career duration of soccer players; (4) studies were written in the English language. The methodological quality of the research was evaluated using the Methodological Index for Non-Randomized Studies (MINORS).

RESULTS

Databases searched yielded a total of 694 studies, of which 17 fulfilled the eligibility criteria and were included in the final analysis. These included 3657 soccer players, 2845 males and 812 females, who underwent ACLR and most commonly competed at the elite, national, amateur, and recreational levels. The results obtained indicated that 72% of soccer players successfully RTP and 53% RTP at the preinjury level of participation after ACLR. In addition, recent evidence provided in this literature review demonstrated that mean RTP time was 264 days or 8.7 months. Moreover, the majority of the studies unambiguously suggested that performance related to statistical aspects noticeably deteriorated compared with both the preinjury period and noninjured athletes. The mean career length of soccer players following ACL surgery was approximately between 4 and 5 years.

CONCLUSION

Although a high percentage of athletes RTP after a relatively short period of absence from the sports field compared with other sports closely related to soccer, ACLR negatively impacts soccer players' performance and career duration.

Prognostic Factors for Multiligament Knee Injury Treated With Multiligament Reconstruction: Functional and Radiological Outcomes at 2 to 8 Years Postoperatively

Background

Multiligament reconstruction (MLR) has become the standard surgical approach for treating multiligament knee injuries (MLKIs).

Purpose

To identify prognostic factors for patient-reported outcome measures, return to work (RTW), return to sports, and radiographic osteoarthritis (OA) (Kellgren-Lawrence grade ≥2) after MLR for MLKI.

Study Design

Case-control study; Level of evidence 3.

Methods

Included were 52 consecutive patients (age, 35.5 ± 11 years; 75% men), with MLKI sustained between 2013 and 2019 and treated with MLR. At a mean follow-up of 3.8 ± 1.6 years, patient-reported outcome measure scores-including the International Knee Documentation Committee (IKDC), the Knee injury and Osteoarthritis Outcome Score (KOOS), the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI), and the 12-Item Short-Form Health Survey-RTW, return to sports, and weightbearing radiographs were obtained. A total of 20 determinants were hypothesized and tested by univariate logistic regression for binary variables or linear regression for continuous variables. Only factors identified as significant (P < .10) were entered into a multivariate logistic regression model.

Results

The prevalence of injury severity according to the Schenck knee dislocation (KD) classification was as follows: KD I (44%), KD III (36%), KD IV (10%), and KD V (10%). Increased KD grades resulted in decreased IKDC (P = .002) and all 5 KOOS subscales (P≤ .007 for all) scores. Medial meniscectomy (23%) was associated with a worse ACL-RSI score (P = .007) and RTW failure (odds ratio [OR], 36.8; P = .035). Peroneal nerve palsy (6%) was associated with a worse ACL-RSI score (P≤ .001). Radiographic OA was observed in 38%, with distribution predominantly patellofemoral (80%) and medial tibiofemoral (45%). Traumatic cartilage damage (Outerbridge grade >2 [37%]) was associated with secondary patellofemoral (OR, 10; P = .012) and medial tibiofemoral (OR, 10; P = .019) OA. Anterior cruciate ligament reconstruction failure (7%) was a risk factor for medial tibiofemoral OA (OR, 25.8; P = .006).

Conclusion

Increased Schenck KD grade, permanent peroneal nerve palsy, and irreparable medial meniscus lesions were prognostic factors for worse functional outcomes 3.8 years after MLKI was treated with MLR. Traumatic cartilage damage and anterior cruciate ligament failure were associated with the development of early OA.

Observe, Practice, and Improve? Enhancing Sidestep Cutting Execution in Talented Female Soccer Players: A Four-Week Intervention Program With Video Instruction

ABSTRACT

Nijmeijer, EM, Kempe, M, Elferink-Gemser, MT, and Benjaminse A. Observe, practice and improve? Enhancing sidestep cutting (SSC) execution in talented female soccer players: A four-week intervention program with video instruction. J Strength Cond Res 38(8): e430-e439, 2024-Implicit learning has the potential to improve movement execution and reduce injury risk. Previous research showed beneficial effects of short-term interventions with implicit learning in male athletes. However, research on long-term interventions in female athletes is lacking. The aim of this study was to examine the effects of a 4-week intervention with video instruction on movement execution of SSC, a task that is highly related with anterior cruciate ligament (ACL) injury risk, in female athletes. Twenty talented adolescent female soccer players were part of the control (CTRL, n = 10) or video instruction (VIDEO, n = 10) group. All subjects practiced 4 weeks and received general task instructions. In addition, the VIDEO group received expert video instruction during practice. Lower extremity kinematics and kinetics and vertical ground reaction force of SSC were examined during baseline, immediate post, and 1-week retention tests. After nonlinear registration, differences between each subject and the expert she had seen were determined. These differences were analyzed with SPM1D 2-way ANOVA. No interaction effects between time and group were found ( p > 0.05). Main effects of time were found in the frontal plane. In particular, smaller deviations of subjects compared with the seen expert of the knee adduction ( p = 0.005, 97.9-100% stance phase [SP]) and hip abduction ( p = 0.005, 11.5-13.8% SP) and adduction ( p < 0.001, 33.4-87.7% SP) moments were found in immediate post compared with baseline. These frontal plane short-term improvements, replicating earlier findings in both sexes, may lower ACL injury risk. The large observed interindividual differences over time may have concealed the long-term effects of video instruction at the group level.

Fear of Reinjury, Psychological Factors, and Sport Played Have Negative Impact on Return to Sport Following Medial Patellofemoral Ligament Reconstruction for Patellar Instability

PURPOSE

To analyze factors that affect return to sport after medial patellofemoral ligament reconstruction (MPFLR), such as psychological factors, sport played, and a positive apprehension test following surgery, and to determine the average return to sport rates and time to return to sport.

METHODS

A literature search was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included studies met the following criteria: patients underwent MPFLR for patellar instability, return to sport was recorded, and a factor that affected return to sport was mentioned. Search terms included medial patellofemoral ligament, tibial tubercle osteotomy, tibial tubercle transfer, return to play, and return to sport.

RESULTS

Eighteen of 632 identified studies met inclusion criteria, and 1,072 patients who underwent MFPLR were recorded. Return-to-sport rates and mean/median time ranged from 60.0% to 100% and 3 to 10.4 months, respectively. Of the patients, 55.6% to 84.0% returned to sport without decreasing the level of competition. Six of 12 studies (50.0%) reported fear of reinjury as the top reason for patients not returning or returning at a lower level of sport. Volleyball/handball had the lowest return to the same level following surgery (18.2%-50.0%).

CONCLUSIONS

Athletes who underwent MPFLR following recurrent patellar instability returned to sport at a range of 60.0% to 100%. Return to sport at the same level or higher was found to have a lower maximum rate at 55.6% to 84.0%. Fear of reinjury and sport played were found to have a substantial impact on ability to return to sport. Surgeons can use this information to advise patients on expectations following surgery.

LEVEL OF EVIDENCE

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

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.

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.

Role of Lateral Extra-articular Tenodesis in Restraining Internal Tibial Rotation: In Vitro Biomechanical Assessment of Lateral Tissue Engagement

BACKGROUND

The way in which force increases in the anterolateral tissues and the lateral extra-articular tenodesis (LET) tissue to resist internal rotation (IR) of the tibia after anterior cruciate ligament (ACL) reconstruction in isolation and after LET augmentation, respectively, is not well understood.

PURPOSE

(1) To compare in a cadaveric model how force increases (ie, engages) in the anterolateral tissues with IR of the tibia after isolated ACL reconstruction and in the LET tissue after augmentation of the ACL reconstruction with LET and (2) to determine whether IR of the tibia is related to engagement of the LET tissue.

STUDY DESIGN

Controlled laboratory study.

METHODS

IR moments were applied to 9 human cadaveric knees at 0°, 30°, 60°, and 90° of flexion using a robotic manipulator. Each knee was tested in 2 states: (1) after isolated ACL reconstruction with intact anterolateral tissues and (2) after LET was performed using a modified Lemaire technique with the LET tissue fixed at 60° of flexion under 44 N of tension. Resultant forces carried by the anterolateral tissues and the LET tissue were determined via superposition. The way force increased in these tissues was characterized via parameters of tissue engagement, namely in situ slack, in situ stiffness, and tissue force at peak applied IR moment, and then compared (α < .05). IR was related to parameters of engagement of the LET tissue via simple linear regression (α < .05).

RESULTS

The LET tissue exhibited less in situ slack than the anterolateral tissues at 30°, 60°, and 90° of flexion (P≤ .04) and greater in situ stiffness at 30° and 90° of flexion (P≤ .043). The LET tissue carried greater force at the peak applied IR moment at 0° and 30° of flexion (P≤ .01). IR was related to the in situ slack of the LET tissue (R2≥ 0.88; P≤ .0003).

CONCLUSION

LET increased restraint to IR of the tibia compared with the anterolateral tissue, particularly at 30°, 60°, and 90° of flexion. IR of the tibia was positively associated with in situ slack of the LET tissue.

CLINICAL RELEVANCE

Fixing the LET at 60° of flexion still provided IR restraint in the more functionally relevant flexion angle of 30°. Surgeons should pay close attention to the angle of internal and/or external tibial rotation when fixing the LET tissue intraoperatively because this surgical parameter is related to in situ slack of the LET tissue and, therefore, the amount of IR of the tibia.

Editorial Commentary: Time-Zero Biomechanical Studies Show Suture Augmentation of a Soft-Tissue Graft Improves Its Properties, But They Need to Be Interpreted With Caution

There is emerging evidence in biomechanical studies that suture augmentation of a soft-tissue graft can improve its elongation, stiffness, and load to failure. However, all biomechanical studies have the intrinsic drawback of not considering loosening, accommodation, and mainly, healing. In the past, many very strong and stiff synthetic grafts produced poor results for anterior cruciate ligament reconstruction, and synthetic material inside the joint was abandoned for awhile. Recent studies have shown that it is possible to use synthetic material to augment the graft instead of being the graft itself. But the question we need to ask ourselves is: Does it really work in the clinical scenario? Undoubtedly, there is still a way to go to incorporate suture augmentation into soft-tissue grafts in knee reconstruction, and it is mandatory to start high-level clinical studies to prove its real benefit to ligament reconstruction results.

Accelerometer-assessed physical activity patterns during the first two years after a non-surgically treated ACL injury

OBJECTIVES

To describe physical activity patterns and analyze changes during the first two years after a non-surgically treated ACL injury, and to assess correlations between accelerometer-assessed physical activity and self-reported knee function and knee-related quality of life.

DESIGN

Prospective cohort study.

PARTICIPANTS

128 patients (61 females, 25.2 ± 7.1 years) with acute ACL injury.

MAIN OUTCOME MEASURES

Physical activity patterns were measured with accelerometry. Self-reported knee function was assessed using the International Knee Documentation Committee Subjective Knee Form, and knee-related quality of life was assessed using the Anterior Cruciate Ligament Quality of Life questionnaire.

RESULTS

Moderate to vigorous physical activity (MVPA) and steps per day increased from baseline to 3 months (p < .001), with no further increase from 3 to 24 months (p > .05). Time in MVPA did not correlate to patient-reported outcome measures at 3, 6, 12, or 24 months (p > .05).

CONCLUSIONS

Physical activity increased from acute phase to 3 months after non-surgically treated ACL injury, but almost one in four patients did not reach recommended levels of physical activity. Physical activity did not correlate with knee function or quality of life. Patients may need improved support to return to physical activity after ACL injury.

LEVEL OF EVIDENCE

Level II.

TRIAL REGISTRATION

NCT02931084.

Poorer patient-reported knee function and quality of life, but not activity level, after revision ACL reconstruction compared with primary ACL reconstruction: a matched-pair analysis with a minimum 5-year follow-up

BACKGROUND

An appropriate method for comparing knee function and activity level between patients with primary and revision anterior cruciate ligament reconstruction (ACLR) is to perform a matched-group analysis. The aim was to assess and compare knee function, knee-related quality of life and activity level between patients with revision ACLR and primary ACLR at a minimum of 5 years of follow-up.

METHODS

Patients aged ≤ 40 years old who underwent revision ACLR between 2010 and 2015 and a matched control group (primary ACLR) (1:1) with age ± 2 years, year of ACLR, sex, and pre-injury sport and Tegner Activity Scale (TAS) were retrospectively identified in our clinic database. The preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) and surgical data were extracted and analyzed. Patients were mailed KOOS and EQ-5D questionnaires at a minimum of 5-years after revision ACLR. Study-specific questions about knee function, limitation in sport, satisfaction, and activity level according to the TAS (all scales of 1-10, 10 best) were also asked by telephone.

RESULTS

Seventy-eight patients with a revision ACLR (mean age ± SD, 29.9 ± 6.0 years) matched with seventy-eight patients with a primary ACLR (30.2 ± 5.8 years) were included. The follow-up for the revision ACLR group was 7.0 ± 1.5 years and for the primary ACLR group 7.7 ± 1.6 years. The revision ACLR group reported poorer KOOS scores in all subscales (p < 0.05) except the Symptoms subscale, poorer EQ-5D VAS (mean 79.2 ± 20.1 vs 86.0 ± 20.1, p = 0.012), and less satisfaction with current knee function (median 7 (6-8) vs 8 (7-9), p < 0.001). Patients with revision ACLR also experienced greater limitation in sports (median 7 (4-8) vs 8 (6-9), p < 0.001). There were no significant differences in the EQ-5D (mean 0.86 ± 0.17 vs 0.89 ± 0.11, p = 0.427), activity level (median 2 (2-5) vs 4 (2-7), p = 0.229), or satisfaction with activity level (median 8 (5-9) vs 8 (6-10), p = 0.281) between the groups.

CONCLUSIONS

At a minimum 5-year follow-up, the revision ACLR group reported poorer knee function and quality of life, less satisfaction with knee function and a greater limitation in sports but no differences in activity level and satisfaction with activity level compared with the primary ACLR group.

Anterior cruciate ligament injuries in female athletes

The anterior cruciate ligament (ACL) is frequently injured in elite athletes, with females up to eight times more likely to suffer an ACL tear than males. Biomechanical and hormonal factors have been thoroughly investigated; however, there remain unknown factors that need investigation. The mechanism of injury differs between males and females, and anatomical differences contribute significantly to the increased risk in females. Hormonal factors, both endogenous and exogenous, play a role in ACL laxity and may modify the risk of injury. However, data are still limited, and research involving oral contraceptives is potentially associated with methodological and ethical problems. Such characteristics can also influence the outcome after ACL reconstruction, with higher failure rates in females linked to a smaller diameter of the graft, especially in athletes aged < 21 years. The addition of a lateral extra-articular tenodesis can improve the outcomes after ACL reconstruction and reduce the risk of failure, and it should be routinely considered in young elite athletes. Sex-specific environmental differences can also contribute to the increased risk of injury, with more limited access to and availablility of advanced training facilities for female athletes. In addition, football kits are designed for male players, and increased attention should be focused on improving the quality of pitches, as female leagues usually play the day after male leagues. The kit, including boots, the length of studs, and the footballs themselves, should be tailored to the needs and body shapes of female athletes. Specific physiotherapy programmes and training protocols have yielded remarkable results in reducing the risk of injury, and these should be extended to school-age athletes. Finally, psychological factors should not be overlooked, with females' greater fear of re-injury and lack of confidence in their knee compromising their return to sport after ACL injury. Both intrinsic and extrinsic factors should be recognized and addressed to optimize the training programmes which are designed to prevent injury, and improve our understanding of these injuries.

It is time to target psychological readiness (or lack of readiness) in return to sports after Anterior Cruciate Ligament tears

Functional recovery has for long been the focus of rehabilitation after an Anterior Cruciate Ligament (ACL) injury. It is now increasingly recognized that more attention should be given to patients` mental recovery, their psychological readiness for returning to sport, after such an injury. Within this relatively new field of science, clinicians need clarity on when and how psychological factors should be monitored and how inexpedient psychological responses may be addressed during rehabilitation. In this Expert Opinion suggestions on how targeting psychological readiness may improve rehabilitation and return-to-sport evaluations are made based on current evidence-and issues in need of further clarification are addressed.

Evaluating the Use of PROMs in Paediatric Orthopaedic Registries

Patient-reported outcome measures (PROMs) provide structured information on the patient's health experience and facilitate shared clinical decision-making. Registries that collect PROMs generate essential information about the clinical course and efficacy of interventions. Whilst PROMs are increasingly being used in adult orthopaedic registries, their use in paediatric orthopaedic registries is not well known. The purpose of this systematic review was to identify the frequency and scope of registries that collect PROMs in paediatric orthopaedic patient groups. In July 2023, six databases were systematically searched to identify studies that collected PROMs using a registry amongst patients aged under 18 years with orthopaedic diagnoses. Of 3190 identified articles, 128 unique registries were identified. Three were exclusively paediatric, 27 were majority paediatric, and the remainder included a minority of paediatric patients. One hundred and twenty-eight registries collected 72 different PROMs, and 58% of these PROMs were not validated for a paediatric population. The largest group of orthopaedic registries collected PROMs on knee ligament injuries (21%). There are few reported dedicated orthopaedic registries collecting PROMs in paediatric populations. The majority of PROMs collected amongst paediatric populations by orthopaedic registries are not validated for patients under the age of 18 years. The use of non-validated PROMs by registries greatly impedes their utility and impact. Dedicated orthopaedic registries collecting paediatric-validated PROMs are needed to increase health knowledge, improve decision-making between patients and healthcare providers, and optimise orthopaedic management.

Association of Psychological Readiness to Return to Sports With Subjective Level of Return at 12 Months After ACL Reconstruction

Background

Return-to-sports (RTS) rates after anterior cruciate ligament (ACL) reconstruction (ACLR) differ according to the level at which patients return. It is unclear whether the level of RTS is affected by psychological readiness to return.

Purpose

To examine the association between psychological readiness to RTS and subjective RTS level 12 months after ACLR.

Study Design

Case-control study; Level of evidence, 3.

Methods

A total of 47 patients who underwent unilateral primary ACLR surgery were enrolled. Assessments at 6 and 12 months postoperatively consisted of knee strength testing (isokinetic quadriceps and hamstring strength), the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC-SKF), and the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale to measure psychological readiness to RTS. Patients were assigned to 1 of 3 subgroups based on their subjective assessment of RTS level at 12 months postoperatively: RTS at or above preinjury level (RTS≥Pre; n = 19), RTS below preinjury level (RTS

Results

Significant differences were found among the RTS≥Pre, RTS

Conclusion

The ACL-RSI score was significantly different among the study groups, and the ACL-RSI score at 12 months postoperatively and younger age were associated with RTS at or above preinjury level.

Collapse

Key Words

• ACL-RSI
• knee strength
• patient-reported knee function
• performance

Collapse

MESH Headings Collapse

Grants Collapse

Affiliation(s)

Makoto Suzuki Faculty of Health Sciences, Hokkaido University, Sapporo, Japan Department of Rehabilitation, Hokushin Orthopaedic Hospital, Sapporo, Japan
Tomoya Ishida Faculty of Health Sciences, Hokkaido University, Sapporo, Japan Department of Rehabilitation, Hokushin Orthopaedic Hospital, Sapporo, Japan
Hisashi Matsumoto Department of Rehabilitation, Hokushin Orthopaedic Hospital, Sapporo, Japan
Satoru Kaneko Department of Orthopaedic Surgery, Hokushin Orthopaedic Hospital, Sapporo, Japan
Chiharu Inoue Department of Orthopaedic Surgery, Hokushin Orthopaedic Hospital, Sapporo, Japan
Yoshimitsu Aoki Department of Orthopaedic Surgery, Hokushin Orthopaedic Hospital, Sapporo, Japan
Harukazu Tohyama Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
Mina Samukawa Faculty of Health Sciences, Hokkaido University, Sapporo, Japan

Collapse

Acute Bone Loss and Infrapatellar Fat Pad Fibrosis in the Knee After an In Vivo ACL Injury in Adolescent Mice

BACKGROUND

Young patients are 6 times more likely than adults to have a primary anterior cruciate ligament (ACL) graft failure. Biological factors (ie, tunnel osteolysis) may account for up to a third of these failures. Previous evaluations of patient ACL explants indicated significant bone loss within the entheseal regions. However, it remains unknown if the degree of bone loss within the ACL insertion regions, wherein ACL grafts are fixated, exceeds that of the femoral and tibial condylar bone.

HYPOTHESIS

Bone loss in the mineralized matrices of the femoral and tibial ACL entheses is distinct from that clinically reported across the whole knee after injury.

STUDY DESIGN

Controlled laboratory study.

METHODS

We developed a clinically relevant in vivo mouse ACL injury model to cross-sectionally track the morphological and physiological postinjury changes within the ACL, femoral and tibial entheses, synovial joint space, and load-bearing epiphyseal cortical and trabecular bone components of the knee joint. Right ACLs of 10-week-old C57BL/6J female mice (N = 75) were injured in vivo with the contralateral ACLs serving as controls. Mice were euthanized at 1, 3, 7, 14, or 28 days after injury (n = 12/cohort). Downstream analyses included volumetric cortical and trabecular bone analyses and histopathologic assessments of the knee joint after injury. Gait analyses across all time points were also performed (n = 15 mice).

RESULTS

The majority of the ACL injuries in mice were partial tears. The femoral and tibial cortical bone volumes were 39% and 32% lower, respectively, at 28 days after injury than those of the uninjured contralateral knees (P < .01). Trabecular bone measures demonstrated little difference between injured and control knees after injury. Across all bone measures, bone loss was similar between the injured knee condyles and ACL entheses. There was also significant inflammatory activity within the knee after injury. By 7 days after injury, synovitis and fibrosis were sigificantly elevated in the injured knee compared with the controls (P < .01), which corresponded with significantly higher osteoclast activity in bone at this time point compared with the controls. This inflammatory response signficantly persisted throughout the duration of the study (P < .01). The hindlimb gait after injury deviated from normal, but mice habitually loaded their injured knee throughout the study.

CONCLUSION

Bone loss was acute and persisted for 4 weeks after injury in mice. However, the authors' hypothesis was not confirmed, as bone quality was not significantly lower in the entheses compared with the condylar bone regions after injury. With relatively normal hindlimb loading but a significant physiological response after injury, bone loss in this model may be driven by inflammation.

CLINICAL RELEVANCE

There is persistent bone resorption and fibrotic tissue development after injury that is not resolved. Inflammatory and catabolic activity may have a significant role in the postinjury decline of bone quality in the knee.

Return to Sport After Multiligament Knee Injury in Young Athletes

Background

While return to sport (RTS) in young athletes after anterior cruciate ligament (ACL) reconstruction has been well studied, little is known regarding their rate of RTS after multiligament knee injury (MLKI).

Purpose

To assess the level of and factors associated with RTS after MLKI in young athletes.

Study Design

Case series; Level of evidence, 4.

Methods

We retrospectively identified 116 patients aged ≤23 years who had sustained an injury to ≥2 knee ligaments and undergone operative reconstruction or repair of ≥1 ligament. Our primary outcome was self-reported RTS at the preinjury level or higher. We estimated the likelihood of RTS using binomial logistic regression. Secondary variables included the 2000 International Knee Documentation Committee Subjective Knee Form (IKDC-SF), ACL-Return to Sport after Injury (ACL-RSI), and 12-Item Short Form Health Survey (SF-12) physical and mental health summaries.

Results

A total of 30 (25.9%) patients (24 men, 6 women; mean age, 18.1 ± 2.5 years) completed patient-reported outcome surveys at a mean follow-up of 7.8 years (median, 6.6 years [range, 1.1-19.5 years]). A total of 28 patients underwent surgical treatment of ≥2 ligaments. RTS was achieved by 90% of patients, and 43.3% returned to their preinjury level or higher. Patients who had played sports at a higher level before injury were more likely to RTS at their preinjury level or higher (odds ratio [OR], 3.516 [95% CI, 1.034-11.955]; P = .044), while those who played cutting sports were less likely to do so (OR, 0.013 [95% CI, 0.000-0.461; P = .017). Patients who achieved RTS at their preinjury level or higher had significantly higher IKDC-SF and ACL-RSI scores versus patients who did not (P = .001 and P = .002, respectively). The number of ligaments injured, age, mental health diagnosis, and SF-12 scores were not associated with the ability to RTS at the preinjury or higher levels.

Conclusion

Most young athletes who sustained MLKI were able to return to play at some level, but a minority returned to their preinjury level. Patients who did return at preinjury or higher levels had higher IKDC-SF and ACL-RSI scores than those who did not. Performance in cutting and/or pivoting sports was negatively associated with RTS.

"Trends and beliefs in ACL reconstruction surgery: Indian perspectives"

Objectives

The survey aimed to assess trends and beliefs in the management of anterior cruciate ligament reconstruction (ACLR) amongst orthopaedic surgeons in India.

Methods

A survey was created and distributed among the various orthopaedic surgeons from India. The questionnaire included brief details of surgeons and their experience, clinical assessment, management strategies and the rehabilitation protocol.

Results

135 surgeons completed the survey. 35% of them were having experience of more than 12 years. A large number of surgeons were from government academic institutes (35.5%). The most common criteria for deciding about surgery was Clinical evaluation (94.8%). The most common graft choice was hamstring tendon (94%), and suspensory fixation on the femur side and interference screw on the tibial side (80%) is the most common fixation method. Almost two-thirds of surgeons in this survey use bracing to protect ACL graft in the initial phase.

Conclusion

We presented the preferences amongst the group of surgeons on the management of ACL injuries. Hamstring tendon graft remains the most preferred graft for ACL reconstruction. Further, the suspensory loop on the femoral side and interference screw on the tibial side are the preferred fixation method. This group of surgeons is conservative in terms of the timing of surgeries and post-operative bracing. Level of evidence Level V, Expert Opinion.

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 results in better patient reported outcomes but has no advantage for activities of daily living or the subsequent development of osteoarthritis. A systematic review and meta-analysis

BACKGROUND

Surgical reconstruction of ACL injuries is a common strategy but superiority over conservative treatment has not been established. The aim was to perform a systematic review and meta-analysis comparing outcomes between operative and non-operative treatment of ACL injuries.

METHODS

Systematic review of Medline, Embase, Scopus, and Google Scholar, including all level 1-3 studies from 2000 to 2021. Patient reported outcome scores and objective measures for knee stability were included. Risk of bias was assessed using the Cochrane Collaboration's tools. GRADE was used to assess the quality of the body of evidence. Heterogeneity was assessed using χ2 and I² statistics.

RESULTS

Twelve studies were included in the analysis. All studies had a high risk of bias and were of low quality. The pooled estimates for IKDC (p = 0.040) favored surgical treatment. There were significant differences for activities of daily living (p = 0.0001) in favor of conservative treatment. There were significant differences for knee stability (p = 0.016) in favor of surgical treatment. The risk of osteoarthritis was not significantly different between the two treatment modalities (p = 0.219). Patients undergoing surgery had a 57% higher risk of osteoarthritis.

CONCLUSION

ACL reconstruction results in a significantly more stable knee with superior clinical and functional outcomes. However, these advantages over conservative treatment were not observed for routine activities of daily living, and subjective patient perceived outcomes favor nonsurgical treatment. Surgical treatment did not reduce the risk of later developing osteoarthritis. Regardless, due to low study quality and high risk of bias, these findings must be interpreted with caution.

Different patient and activity-related characteristics result in different injury profiles for patients with anterior cruciate ligament and posterior cruciate ligament injuries

PURPOSE

To compare patient characteristics including patient sex, age, body mass index (BMI), activities at the time of injury and injury profiles in patients with anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries.

METHODS

Data were obtained from the Swedish National Knee Ligament Registry. Two study groups were created: (1) index ACL reconstruction (ACL group) and (2) index PCL reconstruction (PCL group). Between-group differences were investigated using Fisher's exact test and Fisher's non-parametric permutation test for dichotomous variables and continuous variables, respectively.

RESULTS

Of 39,010 patients, 38,904 were ACL injuries. A larger proportion of patients with combined injuries to the PCL, meniscus and cartilage were female, aged > 25 years and with a BMI of > 35 kg/m² compared with patients with combined injuries to the ACL, meniscus and cartilage. An isolated ACL injury was more commonly found in males, while all other injury profiles of ACL, including combined injuries with meniscus, cartilage and collateral ligament injuries, were more frequently observed in females. The PCL injuries were sustained either during pivoting sports, non-pivoting sports or were traffic-related.

CONCLUSION

Different patient characteristics (BMI, age and sex), and activities at the time of injury (sport- versus traffic-related activities), resulted in distinct injury profiles for the ACL and PCL groups. These findings provide valuable information of the way specific injury patterns of cruciate ligament injuries occur, and subsequently may help clinicians with the diagnostic process of ACL and PCL injuries.

LEVEL OF EVIDENCE

III.

Reliable ligamentous stability and high return-to-sport rates after arthroscopic reduction and internal fixation of tibial eminence fractures

PURPOSE

To investigate functional and clinical outcomes, and physical activity after arthroscopic suture fixation of tibial eminence fractures with regard to postoperative stability, range of motion (ROM), complications, and return to sports.

METHODS

Patients undergoing arthroscopic reduction and internal fixation (ARIF) of tibial eminence fractures using a suture fixation technique were included. Outcome was evaluated retrospectively after a minimum follow-up of 24 months using KT-1000 arthrometer measurements, clinical examination, outcome scores (Lysholm score, Tegner Activity Scale), and a questionnaire about sport activities.

RESULTS

A total of 23 patients (44% male, 57% female) with a mean age of 25 ± 15 years were included. Mean follow-up was 57 ± 25 months. KT-1000 arthrometer measurements of anterior tibial translation revealed a mean side-to-side difference of 0.9 ± 1.0 mm. Clinical examination showed 100% normal or nearly normal anterior translation of the tibia. Two patients (9%) received an ACL reconstruction due to traumatic ACL re-instability and were, therefore, considered as failures. An extension deficit concerning hyperextension occurred in 29% of patients postoperatively. Further postoperative complications occurred in 14% of patients and included postoperative stiffness with ROM limitations and secondary dislocation of a fragment. Mean postoperative Lysholm score was 89 ± 14. Comparing pre- and postoperative values, no significant change of the Tegner Activity Scale was observed. All patients (failures excluded) returned to high impact sports activities after ARIF.

CONCLUSION

Excellent reliable ligamentous stability and high rates of return to high impact sports can be expected after ARIF using a suture fixation technique for type II-IV tibial eminence fractures. Complications, such as limitations in ROM, commonly occur in up to 30% after ARIF. Therefore, regular follow-up examinations remain important in this usually young patient cohort.

LEVEL OF EVIDENCE

Level IV.

Repeat Anterior Cruciate Ligament Injury and Return to Sport in Australian Soccer Players After Anterior Cruciate Ligament Reconstruction With Hamstring Tendon Autograft

BACKGROUND

Soccer is the most commonly played team sport in the world and a high-risk sport for anterior cruciate ligament (ACL) injury and subsequent ACL reconstruction (ACLR).

PURPOSE

To assess the rate of further ACL injury in patients who have undergone ACLR with hamstring tendon autograft after soccer injuries in Australia and to determine factors associated with repeat ACL injury and return to soccer.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

From a prospectively collected database, a series of 1000 consecutive ACLRs using hamstring autografts performed in soccer players were identified. Patients were surveyed at a minimum 5 years after reconstruction, including details of further ACL injuries to either knee, return to soccer or other sports, and psychological readiness per the Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) scale.

RESULTS

Of the 862 participants reviewed, ACL graft rupture occurred in 85 (10%) and contralateral ACL rupture in 68 (8%) within 5 years after the reconstruction. The 5-year ACL graft survivorship was 94% for females and 88% for males. The survivorship of the contralateral ACL was 92% for males and 90% for females. When compared with those aged >25 years, the odds of ACL graft rupture was increased by 4 to 5 times in those aged 19 to 25 years and 3 to 7 times in those ≤18 years. Further ACL injury to the graft or contralateral knee occurred in 44% of males aged ≤18 years. Risk factors for further ACL injury were younger age at time of surgery, male sex, and return to soccer. Graft diameter did not influence ACL graft rupture rates, and 70% of patients returned to soccer after ACLR. The mean ACL-RSI score was 59, and patients who reported more fear of reinjury on this scale were less likely to have returned to soccer.

CONCLUSION

The prevalence of ACL graft rupture (10%) and contralateral ACL rupture (8%) was near equivalent over 5 years in this large cohort of mostly recreational Australian soccer players. ACLR with hamstring autograft is a reliable procedure, allowing 70% of patients to return to soccer in this high-risk population. Risk factors for further ACL injury are progressively younger age at time of surgery, male sex, and return to soccer. Graft diameter was not a factor in ACL graft rupture, indicating that other factors, particularly age, are of primary importance.

Steep lateral tibial slope measured on magnetic resonance imaging is the best radiological predictor of anterior cruciate ligament reconstruction failure

PURPOSE

To identify the radiological predictive risk factors for anterior cruciate ligament reconstruction (ACLR) failure, compare the diagnostic accuracies of different parameters of conventional radiographs and magnetic resonance imaging (MRI), and determine the cutoff values for patients at higher risk.

METHODS

Twenty-eight patients who were diagnosed as ACLR failure via MRI or arthroscopic examination were included in the study group. They were matched to 56 patients who underwent primary ACLR with the same surgical technique and without graft failure at the minimum 24-month follow-up by age, sex, and body mass index. On true lateral whole-leg radiographs, the posterior tibial slope (PTS) referenced to the tibial mechanical axis (PTS-mechanical), PTS referenced to the tibial proximal anatomical axis (PTS-anatomical), and anterior tibial translation (ATT) were measured. On the sagittal slices of MRI, the medial tibial slope (MTS), medial tibial plateau (MTP) subluxation (MTPsublx), lateral tibial slope (LTS), and lateral tibial plateau (LTP) subluxation (LTPsublx) were obtained. Receiver operator characteristic (ROC) curves were constructed to compare the diagnostic performance and determine the cutoff values of different radiological parameters.

RESULTS

The study group demonstrated higher values of PTS-mechanical (10.7° ± 2.9° vs 8.7° ± 1.9°, p = 0.003), PTS-anatomical (13.2° ± 2.8° vs 10.5° ± 2.5°, p < 0.001), ATT (10.7 ± 3.3 mm vs 8.9 ± 2.2 mm, p = 0.014), LTS (9.4° ± 2.1° vs 5.5° ± 2.5°, p < 0.001), and LTPsublx (8.2 ± 2.8 mm vs 6.8 ± 1.9 mm, p = 0.009) as compared with the control group. The area under the ROC curve of LTS was significantly larger than that of PTS-mechanical (p = 0.006) and PTS-anatomical (p = 0.020). Based on the maximum Youden indexes, the cutoff values of PTS-mechanical, PTS-anatomical, and LTS were 10.1° (sensitivity, 64.3%; specificity, 78.6%), 12.0° (sensitivity, 71.4%; specificity, 71.4%), and 7.7° (sensitivity, 85.7%; specificity, 80.4%), respectively.

CONCLUSION

Due to the morphological asymmetry of the MTP and LTP, steep LTS measured on MRI is the best radiological predictor of ACLR failure. Detailed measurement of the LTS on MRI is recommended to evaluate the risk of ACLR failure prior to the surgery.

LEVEL OF EVIDENCE

III.

Risk Factors for Anterior Cruciate Ligament Graft Failure in Professional Athletes: An Analysis of 342 Patients With a Mean Follow-up of 100 Months From the SANTI Study Group

BACKGROUND

Anterior cruciate ligament (ACL) injuries are among the most common knee injuries sustained in elite sport, and athletes generally undergo ACL reconstruction (ACLR) to facilitate their return to sport. ACL graft rupture is a career-threatening event for elite athletes.

PURPOSE/HYPOTHESIS

The purpose of this study was to determine the risk factors for graft failure in professional athletes undergoing ACLR. It was hypothesized that athletes who underwent combined ACLR with a lateral extra-articular procedure (LEAP) would experience significantly lower rates of graft rupture in comparison with those who underwent isolated ACLR.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Professional athletes who underwent primary ACLR with a minimum follow-up of 2 years were identified from the Santy database. Patients were excluded if they underwent major concomitant procedures, including multiligament reconstruction surgery or osteotomy. Further ipsilateral knee injury, contralateral knee injury, and any other reoperations or complications after the index procedure were identified by interrogation of the database and review of the medical notes.

RESULTS

A total of 342 athletes with a mean follow-up of 100.2 ± 51.9 months (range, 24-215 months) were analyzed. Graft failures totaling 31 (9.1%) were reported, requiring revision surgery because of symptomatic instability. The rate of graft failure was significantly higher when ACLR was not combined with a LEAP (15.5% vs 6.0%; P = .0105) and in athletes aged 21 years or younger (13.8% vs 6.6%; P = .0290). A multivariate analysis was performed using the Cox model and demonstrated that athletes undergoing an isolated ACLR were at >2-fold risk of ACL graft rupture (hazard ratio [HR], 2.678 [1.173; 4.837], P = .0164) when compared with those undergoing a combined ACLR with a LEAP. Additionally, athletes aged ≤21 years were also at >2-fold risk of graft failure (HR, 2.381 [1.313; 5.463]; P = .0068) than those aged >21 years. Sex, sport, and graft type were not found to be significant risk factors for graft failure.

CONCLUSION

Professional athletes undergoing isolated ACLR and aged ≤21 years are at >2-fold greater risk of graft failure. Orthopaedic surgeons treating elite athletes should combine an ACLR with a LEAP to improve ACL graft survivorship.

Twenty-Year Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review of Prospectively Collected Data

BACKGROUND

Several long-term (≥20 years) follow-up studies after anterior cruciate ligament (ACL) reconstruction have been published in recent years, allowing for a systematic evaluation of outcomes.

PURPOSE

To summarize outcomes at ≥20 years after ACL reconstruction and identify patient and surgical factors that affect these results.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Prospective studies of primary ACL reconstructions with hamstring or bone-patellar tendon-bone (BTB) autograft via an arthroscopic or a mini-open technique and with a mean follow-up of ≥20 years were identified. When possible, the mean scores for each outcome measure were calculated. Factors identified in individual studies as predictive of outcomes were described.

RESULTS

Five studies met the inclusion and exclusion criteria with a total of 2012 patients. The pooled mean follow-up for patient-reported outcome measures was 44.2% (range, 29.6%-92.7%) and in-person evaluation was 33.2% (range, 29.6%-48.9%). Four studies (n = 584) reported graft tears at a mean rate of 11.8% (range, 2%-18.5%) and 4 studies (n = 773) reported a contralateral ACL injury rate of 12.2% (range, 5.8%-30%). Repeat non-ACL arthroscopic surgery (4 studies; n = 177) to the ipsilateral knee occurred in 10.4% (range, 9.5%-18.3%) and knee arthroplasty (1 study; n = 217) in 5%. The pooled mean of the International Knee Documentation Committee subjective knee function (IKDC) score was 79.1 (SD, 21.8 [3 studies; n = 644]). In 2 studies (n?= 221), 57.5% of patients continued to participate in strenuous activities. The IKDC-objective score was normal or nearly normal in 82.3% (n = 496; 3 studies), with low rates of clinically significant residual laxity. Moderate-severe radiographic osteoarthritis (OA) (IKDC grade C or D) was present in 25.9% of patients (n = 605; 3 studies). Medial meniscectomy is associated with increased risk of radiographic OA. Radiographic OA severity is associated with worse patient-reported knee function, but the association with knee pain is unclear.

CONCLUSION

Currently available prospective evidence for ACL reconstruction with hamstring or BTB autograft provides several insights into outcomes at 20 years. The rates of follow-up at 20 years range from 30% to 93%. IKDC-objective scores were normal or nearly normal in 82% and the mean IKDC-subjective score was 79 points.

Factors affecting return to play and graft re-rupture after primary ACL reconstruction in professional footballers

PURPOSE

Modern ACL reconstruction (ACL-R) techniques have led to improved outcomes in professional footballers. The aim of this study was to identify and assess patient, surgical and post-operative factors that affected rates and time to return to play (RTP) as well as ACL re-rupture rates.

METHODS

A retrospective review of consecutive ACL-R undertaken in professional footballers between 2005 and 2018.

RESULTS

Two-hundred and thirty-two knees in 215 professional footballers (17 bilateral) were included. 205 (88.9%) were male and average age at surgery was 23.3 ± 4.4 years. Two-hundred and twenty-two (96.1%) returned to professional football, with 209 (90.1%) returning to the same or higher Tegner level. Subgroup analysis revealed three factors that independently affected RTP rate: (1) Players under 25 years had a higher rate of RTP (99.3% vs 90.2%. p = 0.001); (2) a subsequent operation prior to RTP decreased RTP rate from 98.2 to 89.7% (p = 0.009).; (3) undergoing meniscal surgery at ACL-R decreased RTP rate (p = 0.002). The mean time to RTP from surgery was 10.5 ± 3.6 months. Factors found to increase RTP time included age under 25 (11.0 vs 9.7 months, p = 0.005), recurrent effusions (11.4 vs 10.2 months, p = 0.035), and medial meniscal repair at ACL-R compared to meniscectomy (12.5 vs 9.6 months, p = 0.022). The surgical technique varied over the study period in relation to graft type, femoral tunnel position and addition of lateral extra-articular tenodesis (LET). Overall, the re-rupture rate was 8.2% at 2 years. Patella tendon autograft in an anteromedial bundle femoral tunnel position with addition of LET has the lowest re-rupture rate (2.0%).

CONCLUSION

Primary ACL-R in professional footballers yields high rates of RTP (96.1%), with 90.1% at the same level or higher, at a mean 10.5 months. Patients under 25 years not only had a significantly higher RTP rate, but also had a lengthier period of rehabilitation.

LEVEL OF EVIDENCE

Level IV.

PHYSICAL TRAINING TO PREVENT SPORTS INJURIES IN ATHLETES

ABSTRACT Introduction: The purpose of physical training for athletes is to maintain and improve athletes’ coordination, reaction ability, spatial orientation, anti-load ability, endurance, and other abilities. But the problem of injury in sports must be solved. Objective: To investigate the causes of athletes’ injuries during physical training and proposes solutions for them. Methods: A questionnaire was applied to athletes to learn about their injuries in recent sports and their methods to avoid injuries. Results: Insufficient warm-up is the most common cause of injury. Other causes include site factors, fatigue, and excessive load. Sports injuries are the most common in extracurricular activities, while injuries are the least in sports training. The season in which the most damage occurs is winter, followed by autumn, and while spring shows the least injuries. Conclusion: The cause of sports injuries in physical training is related to insufficient warm-up activities. Physical training instructors should continuously improve their teaching level and provide athletes with the correct knowledge and skills to prevent sports injuries and protect themselves. As a result, the probability of sports injuries can be reduced as much as possible. Level of evidence II; Therapeutic studies - investigation of treatment results.

Bone-patellar tendon-bone autograft maturation is superior to double-bundle hamstring tendon autograft maturation following anatomical anterior cruciate ligament reconstruction

PURPOSE

The primary purpose of this study was to evaluate the second-look arthroscopic findings 1 year postoperatively and magnetic resonance imaging (MRI) findings 2 years after anterior cruciate ligament reconstruction (ACLR) using bone-patellar tendon-bone autograft (BTB) or hamstring tendon autograft (HT). Secondary purpose included clinical results from physical examination, including range of motion, Lachman test, pivot shift test, and knee anterior laxity evaluation, and the clinical score for subjective evaluations at 2 years after surgery.

METHODS

Between 2015 and 2018, 75 patients with primary ACL injuries were divided into either the BTB group (n = 30) or HT group (n = 45). When using HT, an anatomical double-bundle ACLR was performed. BTB was indicated for athletes with sufficient motivation to return to sporting activity. Graft maturation on second-look arthroscopy was scored in terms of synovial coverage and revascularization. All participants underwent postoperative MRI evaluation 2 years postoperatively. The signal intensity (SI) characteristics of the reconstructed graft were evaluated using oblique axial proton density-weighted MR imaging (PDWI) perpendicular to the grafts. The signal/noise quotient (SNQ) was calculated to quantitatively determine the normalized SI. For clinical evaluation, the Lachman test, pivot shift test, KT-2000 evaluation, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS) were used.

RESULTS

Arthroscopic findings showed that the graft maturation score in the BTB group (3.6 ± 0.7) was significantly greater than that in the anteromedial bundle (AMB; 2.9 ± 0.2, p = 0.02) and posterolateral bundle (PLB; 2.0 ± 0.9, p = 0.001) in the HT group. The mean MRI-SNQs were as follows: BTB, 2.3 ± 0.5; AMB, 2.9 ± 0.9; and PLB, 4.1 ± 1.1. There were significant differences between BTB, AMB, and PLB (BTB and AMB: p = 0.04, BTB and PLB: p = 0.003, AMB and PLB: p = 0.03). Second-look arthroscopic maturation score and MRI-SNQ value significantly correlated for BTB, AMB, and PLB. No significant differences were detected in clinical scores. There was a significant difference (p = 0.02) in the knee laxity evaluation (BTB: 0.9 ± 1.1 mm; HT: 2.0 ± 1.9 mm).

CONCLUSION

BTB maturation is superior to that of double-bundle HT based on morphological and MRI evaluations following anatomical ACLR, although no significant differences were found in clinical scores. Regarding clinical relevance, the advantages of BTB may help clinicians decide on using the autograft option for athletes with higher motivation to return to sporting activity because significant differences were observed in morphological evaluation, MRI assessment, and knee anterior laxity evaluation between BTB and double-bundle HT.

LEVEL OF EVIDENCE

Level IV.

ACL repair for athletes?

Background

The current gold standard treatment for an anterior cruciate ligament (ACL) tear in an athlete is an arthroscopic ACL reconstruction with autografts. This restores the knee stability but is associated with unique complications like graft re-tear, kinesiophobia and graft donor site morbidity. ACL suture repair (ACLSR) is an attractive alternative method of surgical management of this injury.

Current science of ACLSR

The potential advantages of performing a repair are the preservation of native biology and proprioceptive function of ACL, elimination of a graft and preservation of bone stock. The purported benefits are better stability, reduction of kinesiophobia and faster rehabilitation. ACLSR is now performed only for proximal (femoral-sided) tears in the acute phase, when the tissue quality is good and using high-strength nonabsorbable sutures. There are several techniques for performing ACLSR but broadly speaking are either non-augmented, static augmented with suture tape, dynamic augmented or using bio-scaffolds.

Clinical outcome of ACLSR

There is a lot of literature on ACLSRs including case series, cohort studies and randomized controlled trials. The results from these studies are encouraging but mostly pertain to patient reported outcome measures, are in small numbers and in the short-term. The results are also inconsistent across different studies and not specifically performed for the athletic population. Moreover, most of these studies are from the innovator or designer surgeons and groups and have not been independently validated.

Conclusion

Currently, there is insufficient evidence to recommend ACLSR as a preferred method of managing even acute proximal tears in athletes. Improved rates of return to sports, lower retear rate and lesser kinesiophobia needs to be proven in athletes.

Predictors of Osteoarthritis Development at a Median 25 Years After Anterior Cruciate Ligament Reconstruction Using a Patellar Tendon Autograft

BACKGROUND

Few studies have investigated the outcome ≥20 years after an anterior cruciate ligament reconstruction (ACLR) with a bone-patellar tendon-bone autograft, and there is a wide range in the reported rates of radiographic osteoarthritis (OA).

PURPOSE

To report on radiographic OA development and to assess risk factors of knee OA at a median 25 years after ACLR with a bone-patellar tendon-bone autograft.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Unilateral ACLRs performed at a single center from 1987 to 1994 were included (N = 235). The study population was followed prospectively with clinical testing and questionnaires. Results from the 3-month, 12-month, and median 25-year follow-up are presented. In addition, a radiographic evaluation was performed at the final follow-up. Radiographic OA was defined as Kellgren-Lawrence grade ≥2 or having undergone ipsilateral knee replacement surgery. Possible predictors of OA development included patient age, sex, time from injury to surgery, use of a Kennedy ligament augmentation device, any concomitant meniscal surgery, and return to preinjury sports after surgery.

RESULTS

At long-term follow-up, 60% (141/235) of patients had radiographic OA in the involved knee and 18% (40/227) in the contralateral knee (P < .001). Increased age at surgery, male sex, increased time between injury and surgery, a Kennedy ligament augmentation device, and medial and lateral meniscal surgery were significant predictors of OA development in univariate analyses. Return to preinjury level of sports after surgery was associated with less development of OA. In the multivariate model, medial meniscal surgery and lateral meniscal surgery were independently associated with OA development. The adjusted odds ratio was 1.88 (95% CI, 1.03-3.43; P = .041) for medial meniscal surgery and 1.96 (95% CI, 1.05-3.67; P = .035) for lateral meniscal surgery. Patients who had developed radiographic signs of OA had significantly lower Knee injury and Osteoarthritis Outcome Score and Lysholm scores at long-term follow-up.

CONCLUSION

At 25 years after ACLR, 60% of patients had developed OA in the involved knee, and these patients reported significantly lower subjective outcomes. Medial meniscal surgery and lateral meniscal surgery were independent predictors of OA development at long-term follow-up.

High variability and lack of standardization in the evaluation of return to sport after ACL reconstruction: a systematic review

PURPOSE

Return to sport (RTS) after ACL reconstruction (ACLR) has been recognized as an important outcome, which is associated with success of the surgery. This study aimed to assess the methods used to determine return to sport after ACLR in the published literature, report on variability of methods and evaluate their strength in establishing accurate RTS data.

METHODS

Electronic databases (PubMed, Cochrane Library and Embase) were searched via a defined search strategy with no limits, to identify relevant studies from January 2008 to December 2020 for inclusion in the review. Defined eligibility criteria included studies specifically measuring and reporting on return to sport after ACLR with a clear methodology. Each included study was assessed for the definition of successful RTS, successful return to pre-injury level of sport and for methods used to determine RTS.

RESULTS

One hundred and seventy-one studies were included. Of the included studies, six studies (4%) were level of evidence 1 and seventy-two studies (42%) were level of evidence 4. Forty-one studies (24%) reported on return to a specific sport and 130 studies (76%) reported on return to multiple sports or general sport. Sixteen studies (9%) reported on RTS in the pediatric population, 36 (21%) in the adult population and 119 (70%) reported on a mixed-aged population. The most commonly used definition of successful RTS was return to the same sport (44 of 125 studies, 35%). The most common method used to determine RTS was a non-validated study-specific questionnaire (73 studies, 43%), which was administered in various ways to the patients. Time of RTS assessment was variable and ranged between 6 months and 27 years post-surgery.

CONCLUSION

This review demonstrates high variability in defining, evaluating and reporting RTS following ACLR. The findings of this study reveal low reliability and unproven validity of methods used to evaluate RTS and highlight the challenges in interpreting and using RTS data reported in literature.

LEVEL OF EVIDENCE

IV.