Eighteen- to twenty-four-year follow-up after complete rupture of the anterior cruciate ligament

A Comparative Study of Anterior Cruciate Ligament Reconstruction Versus Conservative Treatment

Background The anterior cruciate ligament (ACL) rupture is a common injury with an incidence of 68.6 in 100,000 patients per year. Despite extensive research on ACL rupture, there are insufficient high-quality studies to determine clear treatment strategies for adults lacking the ACL. This study aims to examine the functional differences between surgical and conservative treatment based on the quality of the surgical process. Methodology In this prospective, comparative study, a total of 136 patients aged between 18 and 35 years were enrolled per inclusion and exclusion criteria. Using the lottery system, patients were divided into the following two groups: group A (n = 71) and group B (n = 65). Group A was treated with arthroscopic ACL reconstruction and rehabilitation, whereas group B was treated conservatively (rehabilitation). Patient data, including age, sex, body mass index, International Knee Documentation Committee (IKDC) score, Knee Injury and Osteoarthritis Outcome Score (KOOS), Tegner Activity Level (TAL) score, and complications were recorded and compared. Results The demographic data were comparable, where males had dominancy in both groups. The mean IKDC and KOOS scores were higher in group A at all follow-ups compared to group B. The scores gradually increased at every follow-up till six months. At the final follow-up, the IKDC and KOOS scores were higher in group A than in group B, and a significant difference was observed among both groups. The TAL score also gradually increased at every follow-up till 6 months. At the final follow-up, the TAL score was higher in group A than in group B, with a significant difference between the two groups (p = 0.0032). Complications in both groups were comparable. Conclusions This study showed that both the conservatively treated group and the rebuilt group had identical outcomes, with the exception of the conservative group having greater objectively quantifiable instability. However, at the final follow-up, patients reported feeling just as satisfied with their knee without surgery, demonstrating no subjective difference in activity levels or functional outcomes. Therefore, non-athletes with an ACL-insufficient knee should still choose conservative treatment.

Prevalence of post-traumatic osteoarthritis after anterior cruciate ligament injury remains high despite advances in surgical techniques

Aims

The aim of this study was to report the pooled prevalence of post-traumatic osteoarthritis (PTOA) and examine whether the risk of developing PTOA after anterior cruciate ligament (ACL) injury has decreased in recent decades.

Methods

The PubMed and Web of Science databases were searched from 1 January 1980 to 11 May 2022. Patient series, observational studies, and clinical trials having reported the prevalence of radiologically confirmed PTOA after ACL injury, with at least a ten-year follow-up, were included. All studies were analyzed simultaneously, and separate analyses of the operative and nonoperative knees were performed. The prevalence of PTOA was calculated separately for each study, and pooled prevalence was reported with 95% confidence intervals (CIs) using either a fixed or random effects model. To examine the effect of the year of injury on the prevalence, a logit transformed meta-regression analysis was used with a maximum-likelihood estimator. Results from meta-regression analyses were reported with the unstandardized coefficient (β).

Results

The pooled prevalence of PTOA was 37.9% (95% CI 32.1 to 44) for operatively treated ACL injuries with a median follow-up of 14.6 years (interquartile range (IQR) 10.6 to 16.7). For nonoperatively treated ACL injuries, the prevalence was 40.5% (95% CI 28.9 to 53.3), with a median of follow-up of 15 years (IQR 11.7 to 20.0). The association between the year of operation and the prevalence of PTOA was weak and imprecise and not related to the choice of treatment (operative β -0.038 (95% CI -0.076 to 0.000) and nonoperative β -0.011 (95% CI -0.101 to 0.079)).

Conclusion

The initial injury, irrespective of management, has, by the balance of probability, resulted in PTOA within 20 years. In addition, the prevalence of PTOA has only slightly decreased during past decades. Therefore, further research is warranted to develop strategies to prevent the development of PTOA after ACL injuries.

Impact of anterior cruciate ligament surgery on the development of knee osteoarthritis: A systematic literature review and meta-analysis comparing non-surgical and surgical treatments

Introduction

Context: The development of knee osteoarthritis (OA) after anterior cruciate ligament (ACL) injury is now widely recognized. The impact of surgical or non-surgical management on the development of post-traumatic osteoarthritis is still debated in the medical community.Here, we present a meta-analysis comparing the impact of surgical or non-surgical management of ACL injuries on the development of knee OA.

Method

A systematic literature review was conducted using data from the PubMed, EMBASE, Medline, and Cochrane libraries from February to May 2019. Only randomized clinical trials published between 2005 and 2019 with a non-surgical group and a surgical group were included to explore the onset or progression of knee OA after ACL injury. Trials had to have at least one radiographic endpoint (Kellgren-Lawrence scoring system). Heterogeneity was assessed using the Cochrane's Q and I2 statistical methods.

Results

Only three randomized controlled trials met the inclusion criteria and were selected for meta-analysis. Of the 343 injured knees included in the studies, 180 underwent ACL reconstruction and 163 underwent non-surgical treatment. The relative risk of knee osteoarthritis was higher after surgery than after non-surgical treatment (RR 1.72, CI 95% [1.18-2.53], I2 ​= ​0%).

Conclusion

The results of this meta-analysis suggest a predisposition to knee osteoarthritis after ACL reconstruction surgery compared with non-surgical management. Due to the small number of good quality studies available, further well-conducted randomised studies are needed to confirm these findings.

Aquatic vs. land-based exercise after arthroscopic partial meniscectomy in middle-aged active patients with a degenerative meniscal tear: A randomized, controlled study

BACKGROUND

Awareness of the value of aquatic exercise (AE) in the postoperative rehabilitation has increased, and several inherent advantages of AE, such as adjustment of both resistance and muscle strengthening parameters makes good rationale for its inclusion in postoperative rehabilitation. This study aimed to determine and compare the benefits of AE and land-based exercise (LBE) on pain, functionality, and quality of life after arthroscopic partial meniscectomy (APM).

METHODS

This randomized controlled study included 30 middle-aged (35-50), physically active patients who were randomized into LBE (n = 15) and AE (n = 15) groups after APM for a degenerative meniscal tear. Visual analogue scale (VAS), Short Form-36 (SF-36), single-leg hop test and Lysholm questionnaire scores in addition to isokinetic muscle strength values were evaluated at baseline, at fourth week immediately after cessation of exercise program and at eighth week follow-up visits. The exercise sessions were conducted in 1-h sessions per day, three days a week for a total of four weeks.

RESULTS

Significant improvement was observed in the VAS, single-leg hop test, Lysholm questionnaire, and most of SF-36 subscale scores in both groups at both fourth and eighth follow-ups. Isokinetic dynamometer revealed significant improvement in the peak torque values for extension at angular velocities of 60° and 180° at both follow-ups in the AE group. LBE group showed significant improvement in the peak torque value for extension only at an angular velocity of 60° only at fourth week follow-up. There was no significant difference between groups for any of these parameters at any of the follow-ups.

CONCLUSION

Both AE and LBE programs had significantly improved pain, function, isokinetic muscle strength, and quality of life in patients after APM. Either type of exercise is essential as part of the rehabilitation protocol for good clinical outcomes after APM and should not be neglected (level II).

CLINICALTRIALS REGISTRATION NUMBER

NCT04925726.

Effects of Lower-limb Muscle Fatigue, Cardiopulmonary Fatigue, and Brain FatigueTasks on One-legged Landing Motion

OBJECTIVE

Anterior cruciate ligament (ACL) injury is one of the most frequent sportsinjuries, and previous studies have shown that fatigue is a risk factor for sports injuries.This study aimed to inform prevention of ACL injury by investigating how exercise and desk tasks affect trunk and lower limb alignment and ground reaction force (GRF) during one-legged landing movements.

METHODS

The study subjects were 12 men who performed a one-legged landing movement from a 30-cm platform before and after fatigue tasks, including lower-limb muscle fatigue, cardiopulmonary fatigue, and brain fatigue tasks. For the measurement of joint angles and moments and GRF, a three-dimensional motion analysis device and a floor reaction-force meter were used. Statistics were performed using Wilcoxon's signed rank sum test as a multiple comparison test with Bonferroni adjustment to compare the difference in effects.

RESULTS

The maximum trunk flexion angle during landing on one leg was significantly lower in the brain fatigue group than in the control group. The time to peak vertical GRF (pGRF) was significantly shorter in the leg-muscle fatigue group than in the control group.

CONCLUSION

Brain fatigue may have altered the postural strategy before and after landing, resulting in a decrease in trunk flexion angle. Time to pVGRF was shortened in the leg muscle fatigue group, suggesting that there may be an increased risk of ACL injury. Time to pVGRF during lower extremity muscle fatigue and trunk flexion angle during brain fatigue may be more pronounced during actual sports activities.

Early development of a polycaprolactone electrospun augment for anterior cruciate ligament reconstruction

Despite the clinical success of Anterior Cruciate Ligament reconstruction (ACLR) in some patients, unsatisfactory clinical outcomes secondary to graft failure are seen, indicating the need to develop new regeneration strategies. The use of degradable and bioactive textiles has the potential to improve the biological repair of soft tissue. Electrospun (ES) filaments are particularly promising as they have the ability to mimic the structure of natural tissues and influence endogenous cell behaviour. In this study, we produced continuous polycaprolactone (PCL) ES filaments using a previously described electrospinning collection method. These filaments were stretched, twisted, and assembled into woven structures. The morphological, tensile, and biological properties of the woven fabric were then assessed. Scanning electron microscopy (SEM) images highlighted the aligned and ACL-like microfibre structure found in the stretched filaments. The tensile properties indicated that the ES fabric reached suitable strengths for a use as an ACLR augmentation device. Human ACL-derived cell cultured on the fabric showed approximately a 3-fold increase in cell number over 2 weeks and this was equivalent to a collagen coated synthetic suture commonly used in ACLR. Cells generally adopted a more elongated cell morphology on the ES fabric compared to the control suture, aligning themselves in the direction of the microfibres. A NRU assay confirmed that the ES fabric was non-cytotoxic according to regulatory standards. Overall, this study supports the development of ES textiles as augmentation devices for ACLR.

Analysis of Different Stop-Jumping Strategies on the Biomechanical Changes in the Lower Limbs

The stop-jumping task is one of the most important technical actions in basketball. A previous study showed 70% probability of non-contact ACL injuries during stop-jumping tasks. Therefore, the present study aimed to investigate the differences in lower extremity biomechanical changes between the rear foot as the initial contact area to terminate the jump (SJR) and the fore foot as the initial contact area to also terminate the jump (SJF) during the horizontal landing during a stop-jumping phase. In total, 25 male amateur Ningbo University basketball athletes from China were recruited for this study. The participants were asked to jump vertically by using two different stop-jumping strategies. Kinematic and kinetics data were amassed during a stop-jumping task. Statistical parametric mapping (SPM) analysis was used to find the differences between SJR and SJF. Our results indicated that the change of different ankle range of motion caused significantly different values for knee angle (p < 0.001), velocity (p = 0.003) (p = 0.023) (p < 0.001), moment (p = 0.04) (p < 0.001), (p = 0.036) and power (p = 0.015) (p < 0.001) during the stop-jumping phase and the horizontal landing phase. The same biomechanical parameters of the hip joint were also significantly different for hip angle (p < 0.001), moment (p = 0.012) (p < 0.001) (p < 0.001), and power (p = 0.01) (p < 0.001) (p < 0.001). These findings indicate that altering the primary contact at the ankle angle might effectively reduce the risk of a knee injury.

Adrenergic signalling in osteoarthritis

Adrenoceptors (ARs) mediate the effects of the sympathetic neurotransmitters norepinephrine (NE) and epinephrine (E) in the human body and play a central role in physiologic and pathologic processes. Therefore, ARs have long been recognized as targets for therapeutic agents, especially in the field of cardiovascular medicine. During the past decades, the contribution of the sympathetic nervous system (SNS) and particularly of its major peripheral catecholamine NE to the pathogenesis of osteoarthritis (OA) attracted growing interest. OA is the most common degenerative joint disorder worldwide and a disease of the whole joint. It is characterized by progressive degradation of articular cartilage, synovial inflammation, osteophyte formation, and subchondral bone sclerosis mostly resulting in chronic pain. The subchondral bone marrow, the periosteum, the synovium, the vascular meniscus and numerous tendons and ligaments are innervated by tyrosine hydroxylase-positive (TH+) sympathetic nerve fibers that release NE into the synovial fluid and cells of all abovementioned joint tissues express at least one out of nine AR subtypes. During the past decades, several in vitro studies explored the AR-mediated effects of NE on different cell types in the joint. So far, only a few studies used animal OA models to investigate the contribution of distinct AR subtypes to OA pathogenesis in vivo. This narrative review shortly summarizes the current background knowledge about ARs and their signalling pathways at first. In the second part, we focus on recent findings in the field of NE-induced AR-mediated signalling in different joint tissues during OA pathogenesis and at the end, we will delineate the potential of targeting the adrenergic signalling for OA prevention or treatment. We used the PubMed bibliographic database to search for keywords such as 'joint' or 'cartilage' or 'synovium' or 'bone' and 'osteoarthritis' and/or 'trauma' and 'sympathetic nerve fibers' and/or 'norepinephrine' and 'adrenergic receptors / adrenoceptors' as well as 'adrenergic therapy'.

Intraarticular Ligament Degeneration Is Interrelated with Cartilage and Bone Destruction in Osteoarthritis

Osteoarthritis (OA) induces inflammation and degeneration of all joint components including cartilage, joint capsule, bone and bone marrow, and ligaments. Particularly intraarticular ligaments, which connect the articulating bones such as the anterior cruciate ligament (ACL) and meniscotibial ligaments, fixing the fibrocartilaginous menisci to the tibial bone, are prone to the inflamed joint milieu in OA. However, the pathogenesis of ligament degeneration on the cellular level, most likely triggered by OA associated inflammation, remains poorly understood. Hence, this review sheds light into the intimate interrelation between ligament degeneration, synovitis, joint cartilage degradation, and dysbalanced subchondral bone remodeling. Various features of ligament degeneration accompanying joint cartilage degradation have been reported including chondroid metaplasia, cyst formation, heterotopic ossification, and mucoid and fatty degenerations. The entheses of ligaments, fixing ligaments to the subchondral bone, possibly influence the localization of subchondral bone lesions. The transforming growth factor (TGF)β/bone morphogenetic (BMP) pathway could present a link between degeneration of the osteochondral unit and ligaments with misrouted stem cell differentiation as one likely reason for ligament degeneration, but less studied pathways such as complement activation could also contribute to inflammation. Facilitation of OA progression by changed biomechanics of degenerated ligaments should be addressed in more detail in the future.

Degeneration in ACL Injured Knees with and without Reconstruction in Relation to Muscle Size and Fat Content-Data from the Osteoarthritis Initiative

Background

Anterior cruciate ligaments (ACL) injuries represent a major risk factor for early osteoarthritis (OA).

Purpose

To evaluate the prevalence and 4-year progression of knee OA measured with 3T MR-imaging in individuals with ruptured, reconstructed or normal ACL and to assess the impact of thigh muscle characteristics.

Methods

A total of 54 knees (23/54 male, 31/54 female) were recruited from the Osteoarthritis Initiative (OAI). At baseline, 15/54 subjects had prevalent ACL ruptures and 15/54 subjects had prevalent ACL reconstruction (24/54 normal ACL). Western Ontario and McMasters Universities Arthritis Index (WOMAC) scores, Physical Activity Scores of the Elderly (PASE) and thigh muscle characteristics including strength, fat infiltration (Goutallier score) and thigh muscle cross-sectional area (CSA) MR measurements were obtained at baseline. Whole-organ MR-imaging Scores (WORMS) were obtained at baseline and at a 4-year follow-up time-point. Multivariate regression models, adjusting for covariates (age, gender, body mass index), were used for statistical analysis.

Results

At baseline, subjects with prevalent ACL ruptures had worse WORMS total scores (mean±SEM, 44.1±3.5) than subjects with ACL reconstruction (30.8±4.0; P = 0.015) and worse than subjects with normal ACL (21.3±3.0; P<0.001). Cartilage scores were worse in both femorotibial compartments in ACL injured knees than in knees with normal ACL (P<0.05). Knees with ACL reconstruction showed an increased degeneration of the medial meniscus (P = 0.036), cartilage degeneration at the medial femoral condyle (P = 0.011). In a multivariate regression model, including both ACL groups and total muscle characteristics as influence parameters, high thigh muscle CSA, high muscle/ fat ratio and low Goutallier scores were associated with less degenerative changes at the knee, independent of ACL status. Knees with ACL reconstruction showed an increased progression of cartilage degeneration at the medial tibia compared to the normal ACL group (P = 0.027).

Conclusions

High thigh muscle CSA is associated with less degenerative changes at the knee, independent of the ACL status and may potentially be advantageous in the prevention of early OA.

Twenty-Year Outcome of a Longitudinal Prospective Evaluation of Isolated Endoscopic Anterior Cruciate Ligament Reconstruction With Patellar Tendon or Hamstring Autograft

BACKGROUND

Long-term prospective studies of isolated endoscopic anterior cruciate ligament (ACL) reconstruction are limited and may include confounding factors.

PURPOSE

This study aimed to compare the outcomes of isolated ACL reconstruction using the patellar tendon (PT) autograft and the hamstring (HT) autograft in 180 patients over 20 years.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 180 participants undergoing isolated ACL reconstruction between 1993 and 1994 were prospectively recruited. Evaluation was performed at 1, 2, 5, 7, 10, 15, and 20 years after surgery and included the International Knee Documentation Committee (IKDC) knee ligament evaluation with radiographic evaluation, KT-1000 arthrometer side-to-side difference, and subjective scores.

RESULTS

Over 20 years, there were 16 patients (18%) and 9 patients (10%) with an ACL graft rupture in the HT and PT groups, respectively (P = .13). ACL graft rupture was associated with male sex (odds ratio [OR], 3.9; P = .007), nonideal tunnel position (OR, 3.6; P = .019), and age <18 years at the time of surgery (OR, 4.6; P = .003). The odds of a contralateral ACL rupture were increased in patients with the PT graft compared with patients with the HT graft (OR, 2.2; P = .02) and those aged <18 years at the time of surgery (OR, 3.4; P = .001). The mean IKDC scores at 20-year follow-up were 86 and 89 for the PT and HT groups, respectively (P = .18). At 20 years, 53% and 57% of the PT and HT groups participated in strenuous or very strenuous activities (P = .55), kneeling pain was present in 63% and 20% of the PT and HT groups (P = .018), and radiographic osteoarthritic change was found in 61% and 41% of the PT and HT groups (P = .008), respectively.

CONCLUSION

Compared with patients who received the HT graft, patients who received the PT graft had significantly worse outcomes with regard to radiologically detectable osteoarthritis, kneeling pain, and contralateral ACL injury. At 20-year follow-up, both HT and PT autografts continued to provide good subjective outcomes and objective stability. However, further ACL injury is common, particularly in male individuals, younger patients, and those with tunnel malposition.

Predictors of Revision Surgery After Anterior Cruciate Ligament Reconstruction

BACKGROUND

Arthroscopically assisted anterior cruciate ligament (ACL) reconstruction is a common orthopaedic procedure. Graft failure after reconstruction remains a devastating complication, often requiring revision surgery and less aggressive or modified rehabilitation. Worse functional and patient-reported outcomes are reported compared with primary reconstruction. Moreover, both rates and risk factors for revision are variable and inconsistent within the literature.

PURPOSE

To determine the rate of revision surgery after ACL reconstruction in a large cohort of patients, to assess the influence of patient characteristics on the odds of revision, and to compare revision rates between active-duty military members and non-active-duty beneficiaries.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Using administrative data from the Military Health System, a retrospective study was designed to characterize the rate of ACL revision surgery among patients treated within a military facility. All patients ≥18 years at the time of ACL reconstruction were identified using the American Medical Association Current Procedural Terminology (CPT) for ACL reconstruction (CPT code 29888) over 7 years (2005-2011). Revision ACL reconstructions were identified as having ≥2 ACL reconstruction procedure codes on the ipsilateral knee at least 90 days apart. Univariate analysis was performed to calculate odds ratios (ORs) for demographic, perioperative medication use, and concomitant procedure-related risk factors. A multivariate logistic regression model determined risk covariates in the active-duty cohort.

RESULTS

The study population consisted of 17,164 ACL reconstructions performed among 16,336 patients, of whom 83.3% were male with a mean ± SD age of 28.9 ± 7.6 years for the nonrevision group, and was predominantly active duty (89.2%). Patients undergoing ACL reconstruction on both knees only contributed their index knee for analyses. There were 587 patients who underwent revision surgery, corresponding to an overall revision rate of 3.6%. The median time from the index surgery to revision surgery was 500 days (interquartile range, 102-2406 days). Revision rates were higher in the active-duty cohort as compared with non-active-duty beneficiaries (3.8% vs 1.8%, respectively; OR, 2.14; 95% CI, 1.49-3.07). Based on multivariate logistic regression in the active-duty cohort, age ≥35 years (OR, 0.44; 95% CI, 0.33-0.58) and concomitant meniscal repair (OR, 0.69; 95% CI, 0.53-0.91) were found to be protective with regard to the odds of revision surgery. Perioperative medication use of nonsteroidal anti-inflammatory drugs (NSAIDs) (OR, 1.33; 95% CI, 1.12-1.58; number needed to harm [NNH], 100) and COX-2 inhibitors (OR, 1.31; 95% CI, 1.04-1.66; NNH, 333) was associated with increased odds of revision surgery. No significant findings were detected among sex, race, nicotine use, body mass index, or other concomitant procedures of interest.

CONCLUSION

In this large cohort study, the rate of revision ACL reconstruction was 3.6%, which is consistent with the existing literature. Increased odds of revision surgery among active-duty personnel were associated with the perioperative use of NSAIDs and COX-2 inhibitors. Age ≥35 years and concomitant meniscal repair were found to be protective against ACL revision.

Injury patterns in patients presenting with a recurrent anterior cruciate ligament tear following primary reconstruction

BACKGROUND

An anterior cruciate ligament (ACL) graft rupture or a primary ACL injury in the contralateral knee is one of the greatest concerns of patients following primary anterior cruciate ligament reconstruction (ACLR). Our study describes the epidemiology and presence of concomitant meniscal injuries of patients with a graft rupture following primary ACLR or a primary rupture of the contralateral ACL following primary ACLR of the ipsilateral knee.

METHODS

We reviewed the medical records of 42 patients who underwent a second ACLR. ACLR was performed using the ipsilateral semitendinosus and gracilis autograft. Variables extracted included the presence of concomitant MM and LM injuries intra-operatively, the patients' level of intensity of sport (light, moderate, strenuous), duration of rehabilitation and mechanism of injury (contact, non-contact).

RESULTS

Twenty-four (57.1%) patients had graft rupture of a previously reconstructed ACL of which 20 (83.3%) were male and 18 (42.9%) patients had a primary ACL tear of the contralateral knee following ACLR of the ipsilateral knee of which 18 (100%) were male. Patient who sustained a graft rupture were younger (29.5 vs. 31.9 years), had a higher body mass index (BMI) (26.42 vs. 25.10 kg/m(2)) and had a longer time before re-injury (6.18 vs. 4.94 years). Concomitant meniscal injury rates were comparable in both groups and the medial meniscus was injured more often.

CONCLUSIONS

This study describes the demographics of 2(nd) ACL injuries in the Asian population. Additional studies that investigate the differences in knee anatomy of Asians and Caucasians and their impact on ACL injuries should be performed.

Twenty-year outcomes of a longitudinal prospective evaluation of isolated endoscopic anterior cruciate ligament reconstruction with patellar tendon autografts

BACKGROUND

Long-term prospective follow-up studies of single-incision endoscopic anterior cruciate ligament (ACL) reconstruction are limited and may include confounding factors.

PURPOSE

This longitudinal prospective study reports the outcomes of isolated ACL reconstruction using middle-third patellar tendon autografts in 90 patients over 20 years.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between January 1993 and April 1994, a total of 90 patients met study inclusion criteria: evaluation at 1, 2, 3, 4, 5, 7, 10, 15, and 20 years after surgery. Exclusion criteria were associated ligamentous injuries requiring surgery, previous meniscectomy or meniscal injuries requiring more than one-third meniscectomy, chondral injuries, and an abnormal contralateral knee.

RESULTS

At 20 years, 32 (36%) patients had sustained another ACL injury: 8 (9%) to the index limb and 27 (30%) to the contralateral limb (3 injuring both knees). The mean International Knee Documentation Committee (IKDC) score was 86. Of the patients, 50% participated in strenuous/very strenuous activities, and kneeling pain was present in 63%. Radiographic degenerative change was found in 61%; 20% had IKDC grade C, and 0% had grade D. The IKDC clinical examination revealed that 95% had a normal/nearly normal knee. Significant sex differences existed: when compared with male patients, female patients were less likely to reinjure the reconstructed ACL (18% vs 2%, respectively; P = .01), reported poorer IKDC subjective scores (90 vs 83, respectively; P = .03), had more activity-related pain (20% vs 57%, respectively; P = .02), and were less likely to participate in strenuous activities (66% vs 35%, respectively; P = .009). ACL graft survival was not related to age. Patients <18 years old had an increased odds ratio (3.2) for rupturing the contralateral ACL. A coronal graft angle <17° increased the risk of failure compared with an angle >17° (77% vs 96% survival, respectively) by a factor of 8.5.

CONCLUSION

Injuries more commonly occurred in the contralateral ACL than in the reconstructed ACL graft, and the most significant predictor of a contralateral ACL injury was age <18 years. The most significant predictor of an ACL graft rupture was a coronal graft angle <17°. Female patients had lower rerupture rates, poorer subjective scores, and decreased participation in strenuous activities, putting the graft at a lower risk of failure. Kneeling pain remained persistent over 20 years. Radiographic osteoarthritis was evident in 61% of patients, but symptomatic osteoarthritic symptoms were rarely reported.

Tibiofemoral Osteoarthritis After Surgical or Nonsurgical Treatment of Anterior Cruciate Ligament Rupture: A Systematic Review

OBJECTIVE

  To determine if surgical or nonsurgical treatment of anterior cruciate ligament rupture affects the prevalence of posttraumatic tibiofemoral osteoarthritis (OA).

DATA SOURCES

  Studies published between 1983 and April 2012 were identified via EBSCOhost and OVID. Reference lists were then screened in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

STUDY SELECTION

  Studies were included if (a) treatment outcomes focused on a direct comparison of surgical versus nonsurgical treatment of anterior cruciate ligament rupture, (b) the prevalence of tibiofemoral OA was reported, and (c) they were written in English. Studies were excluded if (a) the included patients were treated with cast immobilization after surgery, (b) the mean follow-up was less than 10 years, or (c) the patients underwent anterior cruciate ligament revision surgery.

DATA EXTRACTION

  Two independent investigators reviewed the included articles using the Newcastle-Ottawa Scale. Frequency of OA, surgical procedure, nonsurgical treatments, and participant characteristics were extracted and summarized. We calculated prevalence (%) and 95% confidence intervals for treatment groups for each individual study and overall. We developed 2 × 2 contingency tables to assess the association between treatment groups (exposed had surgery, referent was nonsurgical treatment) and the prevalence of OA.

DATA SYNTHESIS

  Four retrospective studies were identified (140 surgical patients, 240 nonsurgical patients). The mean Newcastle-Ottawa Scale score was 5 (range = 4-6 [of 10] points). Average length of follow-up was 11.8 years (range = 10-14 years). The prevalence of OA for surgically treated patients ranged from 32.6% to 51.2% (overall = 41.4%, 95% confidence interval = 35.0%, 48.1%) and for nonsurgical patients ranged from 24.5% to 42.3% (overall = 30.9%, 95% confidence interval = 24.4%, 38.3%).

CONCLUSIONS

  Although OA prevalence was higher in the surgical treatment group at a mean follow-up of 11.8 years, no definitive evidence supports surgical or nonsurgical treatment after anterior cruciate ligament injury to prevent posttraumatic OA. Current studies have been limited by small sample sizes, low methodologic quality, and a lack of data regarding confounding factors.

Anterior cruciate ligament tears: reconstruction and rehabilitation

Tears of the anterior cruciate ligament (ACL) are common knee injuries experienced by athletes and people with active lifestyles. It is important for members of the healthcare team to take an evidence-based approach to the diagnosis, surgical management, and postoperative rehabilitation of patients with an ACL-deficient knee. Mechanism of ACL injury and diagnostic testing is consistent throughout the literature. Patients frequently opt for ACL reconstruction, and many surgical techniques for ACL reconstruction are available with no clear consensus regarding superiority. Surgeon preference dictates the type of reconstruction and graft choice utilized. No standardized pre- and postoperative rehabilitation protocol exists. However, rehabilitation plays an important role in functional outcomes. A comprehensive rehabilitation program is needed pre- and postoperatively to produce positive patient outcomes.

Anterior cruciate ligament- and hamstring tendon-derived cells: in vitro differential properties of cells involved in ACL reconstruction

Anterior cruciate ligament (ACL) reconstruction involves the replacement of the torn ligament with a new graft, often a hamstring tendon (HT). Described as similar, the ACL and HT have intrinsic differences related to their distinct anatomical locations. From a cellular perspective, identifying these differences represents a step forward in the search for new cues that enhance recovery after the reconstruction. The purpose of this study was to characterize the phenotype and multilineage potential of ACL- and HT-derived cells. ACL- and HT-derived cells were isolated from tissue harvest from patients undergoing total knee arthroplasty (TKA) or ACL reconstruction. In total, three ACL and three HT donors were investigated. Cell morphology, self-renewal potential (CFU-F), surface marker profiling, expression of tendon/ligament-related markers (PCR) and multilineage potential were analysed for both cell types; both had fibroblast-like morphology and low self-renewal potential. No differences in the expression of tendon/ligament-related genes or a selected set of surface markers were observed between the two cell types. However, differences in their multilineage potential were observed: while ACL-derived cells showed a high potential to differentiate into chondrocytes and adipocytes, but not osteoblasts, HT-derived cells showed poor potential to form adipocytes, chondrocytes and osteoblasts. Our results demonstrated that HT-derived cells have low multilineage potential compared to ACL-derived cells, further highlighting the need for extrinsic signals to fully restore the function of the ACL upon reconstruction. Copyright © 2015 John Wiley & Sons, Ltd.

Anterior cruciate ligament injury and radiologic progression of knee osteoarthritis: a systematic review and meta-analysis

BACKGROUND

Knee osteoarthritis after anterior cruciate ligament (ACL) injury has previously been reported. However, there has been no meta-analysis reporting the development and progression of osteoarthritis.

PURPOSE

We present the first meta-analysis reporting on the development and progression of osteoarthritis after ACL injury at a minimum mean follow-up of 10 years, using a single and widely accepted radiologic classification, the Kellgren & Lawrence classification.

STUDY DESIGN

Meta-analysis.

METHOD

Articles were included for systematic review if they reported radiologic findings of ACL-injured knees and controls using the Kellgren & Lawrence classification at a minimum mean follow-up period of 10 years. Appropriate studies were then included for meta-analysis.

RESULTS

Nine studies were included for systematic review, of which 6 studies were further included for meta-analysis. One hundred twenty-one of 596 (20.3%) ACL-injured knees had moderate or severe radiologic changes (Kellgren & Lawrence grade III or IV) compared with 23 of 465 (4.9%) uninjured ACL-intact contralateral knees. After ACL injury, irrespective of whether the patients were treated operatively or nonoperatively, the relative risk (RR) of developing even minimal osteoarthritis was 3.89 (P < .00001), while the RR of developing moderate to severe osteoarthritis (grade III and IV) was 3.84 (P < .0004). Nonoperatively treated ACL-injured knees had significantly higher RR (RR, 4.98; P < .00001) of developing any grade of osteoarthritis compared with those treated with reconstructive surgery (RR, 3.62; P < .00001). Investigation of progression to moderate or severe osteoarthritis (grade III or IV only) after 10 years showed that ACL-reconstructed knees had a significantly higher RR (RR, 4.71; P < .00001) compared with nonoperative management (RR, 2.41; P = .54). It was not possible to stratify for return to sports among the patients undergoing ACL reconstruction.

CONCLUSION

Results support the proposition that ACL injury predisposes knees to osteoarthritis, while ACL reconstruction surgery has a role in reducing the risk of developing degenerative changes at 10 years. However, returning to sports activities after ligament reconstruction may exacerbate the development of arthritis.

Anterior cruciate ligament injury after more than 20 years: I. Physical activity level and knee function

Little is known about physical activity level and knee function including jump capacity and fear of movement/reinjury more than 20 years after injury of the anterior cruciate ligament (ACL). Seventy persons with unilateral ACL injury participated (23 ± 2 years post-injury): 33 treated with physiotherapy in combination with surgical reconstruction (ACLR ), and 37 treated with physiotherapy alone (ACLPT ). These were compared with 33 age- and gender-matched controls. Assessment included knee-specific and general physical activity level [Tegner activity scale, International Physical Activity Questionnaire (IPAQ)], knee function [Lysholm score, Knee injury and Osteoarthritis Outcome Score (KOOS)], jump capacity (one-leg hop, vertical jump, side hops), and fear of movement/reinjury [Tampa Scale for Kinesiophobia (TSK)]. Outcomes were related to degree of osteoarthritis (OA). ACL-injured had lower Lysholm, KOOS, and Tegner scores than controls (P < 0.001), while IPAQ score was similar. ACL-injured demonstrated inferior jump capacity in injured compared with noninjured leg (6-25%, P < 0.001-P = 0.010 in the different jumps), while noninjured leg had equal jump capacity as controls. ACL groups scored 33 ± 7 and 32 ± 7 of 68 on TSK. Lower scores on Lysholm and KOOS symptom were seen for persons with moderate-to-high OA than for no-or-low OA, while there were no differences for physical activity and jump capacity. Regardless of treatment, there are still negative knee-related effects of ACL injury more than 20 years later.

Anterior cruciate ligament reconstruction with 4-strand hamstring autograft and accelerated rehabilitation: a 10-year prospective study on clinical results, knee osteoarthritis and its predictors

PURPOSE

Analysis of long-term clinical and radiological outcomes after anterior cruciate ligament (ACL) reconstruction with special attention to knee osteoarthritis and its predictors.

METHODS

A prospective, consecutive case series of 100 patients. Arthroscopic transtibial ACL reconstruction was performed using 4-strand hamstring tendon autografts with a standardized accelerated rehabilitation protocol. Analysis was performed preoperatively and 10 years postoperatively. Clinical examination included Lysholm and Tegner scores, IKDC, KT-1000 testing (MEDmetric Co., San Diego, CA, USA) and leg circumference measurements. Radiological evaluation included AP weight bearing, lateral knee, Rosenberg and sky view X-rays. Radiological classifications were according to Ahlbäck and Kellgren & Lawrence. Statistical analysis included univariate and multivariate logistic regressions. RESULTS CLINICAL OUTCOME: A significant improvement (p < 0.001) between preoperative and postoperative measurements could be demonstrated for the Lysholm and Tegner scores, IKDC patient subjective assessment, KT-1000 measurements, pivot shift test, IKDC score and one-leg hop test. A pivot shift phenomenon (glide) was still present in 43 (50%) patients and correlated with lower levels of activity (p < 0.022). Radiological outcome: At follow-up, 46 (53.5%) patients had signs of osteoarthritis (OA). In this group, 33 patients (72%) had chondral lesions (≥grade 2) at the time of ACL reconstruction. A history of medial meniscectomy before or at the time of ACL reconstruction increased the risk of knee OA 4 times (95% CI 1.41-11.5). An ICRS grade 3 at the time of ACL reconstruction increased the risk of knee OA by 5.2 times (95% CI 1.09-24.8). There was no correlation between OA and activity level (Tegner score ≥6) nor between OA and a positive pivot shift test.

CONCLUSION

Transtibial ACL reconstruction with 4-strand hamstring autograft and accelerated rehabilitation restored anteroposterior knee stability. Clinical parameters and patient satisfaction improved significantly. At 10-year follow-up, radiological signs of OA were present in 53.5 % of the subjects. Risk factors for OA were meniscectomy prior to or at the time of ACL reconstruction and chondral lesions at the time of ACL reconstruction.

LEVEL OF EVIDENCE

II.

Surgical and Biomechanical Perspectives on Osteoarthritis and the ACL Deficient Knee: A Critical Review of the Literature

This review was undertaken to better understand the debate regarding the issue of osteoarthritis associated with anterior cruciate ligament (ACL) injuries, from a surgical and biomechanical standpoint. Much of the current debate focuses on contributory surgical factors and their relative roles in increasing or decreasing the risk of future osteoarthritis development, primarily highlighting the controversy over whether reconstructive surgery itself is necessarily protective. This review addresses the evolution of ACL reconstruction techniques over time, and with a view to thoroughly examine the role of surgery, outcome differences in procedural technique are reviewed, with a focus on open versus arthroscopic methods, graft choice and the use of a double versus single bundle reconstruction technique. Moreover, other potentially important contributory factors are identified and discussed, such as intrinsic biomechanical alterations sustained at the time of initial injury, and how these may have a more significant role with regard to future osteoarthritic changes in the knee than previously attributed.

Treatment and Prevention of (Early) Osteoarthritis Using Articular Cartilage Repair-Fact or Fiction? A Systematic Review

Early osteoarthritis (OA) is increasingly being recognized in patients who wish to remain active while not accepting the limitations of conservative treatment or joint replacement. The aim of this systematic review was to evaluate the existing evidence for treatment of patients with early OA using articular cartilage repair techniques. A systematic search was performed in EMBASE, MEDLINE, and the Cochrane collaboration. Articles were screened for relevance and appraised for quality. Nine articles of generally low methodological quality (mean Coleman score 58) including a total of 502 patients (mean age range = 36-57 years) could be included. In the reports, both radiological and clinical criteria for early OA were applied. Of all patients included in this review, 75% were treated with autologous chondrocyte implantation. Good short-term clinical outcome up to 9 years was shown. Failure rates varied from 8% to 27.3%. The conversion to total knee arthroplasty rate was 2.5% to 6.5%. Although a (randomized controlled) trial in this patient category with long-term follow-up is needed, the literature suggests autologous chondrocyte implantation could provide good short- to mid-term clinical outcome and delay the need for total knee arthroplasty. The use of standardized criteria for early OA and implementation of (randomized) trials with long-term follow-up may allow for further expansion of the research field in articular cartilage repair to the challenging population with (early) OA.

Long-term results of arthroscopically assisted anatomical single-bundle anterior cruciate ligament reconstruction using patellar tendon autograft: are there any predictors for the development of osteoarthritis?

PURPOSE

The primary purpose of our study was to analyse the long-term outcome of patients treated for anterior cruciate ligament (ACL) tears by anatomical single-bundle ACL reconstruction with patellar tendon autograft. The secondary purpose was to identify predictive factors for good outcome and occurrence of osteoarthritis.

METHODS

Sixty-three patients (m:f = 54:9; mean age at surgery, 27 ± 7 years) treated by ACL reconstruction were evaluated with a mean follow-up of 16 ± 1 years using IKDC2000, the SF36, Lysholm and Tegner score, Knee Society score, visual analogue scale for pain and satisfaction and KOOS. The femoral tunnel position was evaluated according to Sommer. It was also assessed in percentage of the Blumensaat line and the tibial tunnel position in percentage of the total anterior-posterior plateau length. The extent of osteoarthritis was graded according to the Kellgren-Lawrence score.

RESULTS

The total IKDC2000 was normal in 20 (32 %), nearly normal in 29 (46 %), abnormal in 12 (19 %) and severely abnormal in 3 (5 %) of patients. The mean total SF-36 was 89 ± 13, the Lysholm score 95 ± 12, the Knee Society score 191 ± 16 and the total KOOS 84 ± 19. The Tegner score decreased from pre-injury 7(4-10) to 6 (2-10) at follow-up. The Kellgren-Lawrence score was normal in 17 (27 %), suspected osteoarthritis in 25 (40 %), minimal osteoarthritis in 5 (8 %), moderate osteoarthritis in 9 (14 %) and severe osteoarthritis in 3 patients (5 %). The femoral tunnel was in zone A in 43 patients (68 %), in zone B in 16 (25 %) and in zone C in 4 patients (7 %). The femoral tunnel position in percentage of the Blumensaat line was 49 ± 3 (range, 44-57), and the tibial tunnel position in percentage of the total anterior-posterior plateau length was 32 ± 6 (range, 21-46). Patients with meniscal lesion at the time of ACL tear showed significantly less favourable outcomes than those without.

CONCLUSIONS

Patients treated by the proposed ACL reconstruction technique showed on average good to excellent long-term results. A meniscal lesion at the time of ACL tear was highly predictive for less favourable outcome.

The role of ACL injury in the development of posttraumatic knee osteoarthritis

Acute anterior cruciate ligament (ACL) tears are most frequently sustained by young, physically active individuals. ACL injuries are seen at high incidence in adolescents and young adults performing sports and occupational activities that involve pivoting. Young women participating in pivoting sports have a 3 to 5 times higher risk of ACL injury than men. Studies show that ACL injury increases osteoarthritis (OA) risk with symptomatic OA appearing in roughly half of individuals 10-15 years later. Because the majority of patients sustaining acute ACL tears are younger than 30, this leads to early onset OA with associated pain and disability during premium work and life growth years between ages 30 and 50. Effective strategies to prevent ACL injury and to reduce subsequent OA risk in those sustaining acute ACL tears are needed.

Two different fatigue protocols and lower extremity motion patterns during a stop-jump task

CONTEXT

Altered neuromuscular control strategies during fatigue probably contribute to the increased incidence of noncontact anterior cruciate ligament injuries in female athletes.

OBJECTIVE

To determine biomechanical differences between 2 fatigue protocols (slow linear oxidative fatigue protocol [SLO-FP] and functional agility short-term fatigue protocol [FAST-FP]) when performing a running-stop-jump task.

DESIGN

Controlled laboratory study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

A convenience sample of 15 female soccer players (age = 19.2 ± 0.8 years, height = 1.67 ± 0.05 m, mass = 61.7 ± 8.1 kg) without injury participated.

INTERVENTION(S)

Five successful trials of a running-stop-jump task were obtained prefatigue and postfatigue during the 2 protocols. For the SLO-FP, a peak oxygen consumption (Vo(2)peak) test was conducted before the fatigue protocol. Five minutes after the conclusion of the Vo(2)peak test, participants started the fatigue protocol by performing a 30-minute interval run. The FAST-FP consisted of 4 sets of a functional circuit. Repeated 2 (fatigue protocol) × 2 (time) analyses of variance were conducted to assess differences between the 2 protocols and time (prefatigue, postfatigue).

MAIN OUTCOME MEASURE(S)

Kinematic and kinetic measures of the hip and knee were obtained at different times while participants performed both protocols during prefatigue and postfatigue.

RESULTS

Internal adduction moment at initial contact (IC) was greater during FAST-FP (0.064 ± 0.09 Nm/kgm) than SLO-FP (0.024 ± 0.06 Nm/kgm) (F(1,14) = 5.610, P = .03). At IC, participants had less hip flexion postfatigue (44.7° ± 8.1°) than prefatigue (50.1° ± 9.5°) (F(1,14) = 16.229, P = .001). At peak vertical ground reaction force, participants had less hip flexion postfatigue (44.7° ± 8.4°) than prefatigue (50.4° ± 10.3°) (F(1,14) = 17.026, P = .001). At peak vertical ground reaction force, participants had less knee flexion postfatigue (-35.9° ± 6.5°) than prefatigue (-38.8° ± 5.03°) (F(1,14) = 11.537, P = .001).

CONCLUSIONS

Our results demonstrated a more erect landing posture due to a decrease in hip and knee flexion angles in the postfatigue condition. The changes were similar between protocols; however, the FAST-FP was a clinically applicable 5-minute protocol, whereas the SLO-FP lasted approximately 45 minutes.

Indications and contraindications for double-bundle ACL reconstruction

Over recent years, double-bundle reconstruction has gained popularity after studies showed significant advantages of adding a second bundle with regard to outcomes and biomechanics; in particular, it resulted in less rotational instability than after reconstruction with a traditional single-bundle technique. As the focus shifted further towards the restoration of the native anatomy, both single-bundle and double-bundle ACL reconstruction were performed in an anatomical fashion and yielded similar results. To date, no consensus has developed as to whether double-bundle reconstruction is better than single-bundle reconstruction or vice versa. However, after surgeons started to individualise their surgical approach to the patient, it has been found that both the anatomical single- and double-bundle techniques have their own set of indications and contraindications. Reconstruction of the ligament should focus on restoration of the native functional and anatomical properties and should take the size, shape and orientation of the ACL into account. When indications and contraindications for the technique used are based on native anatomical characteristics, either a single-bundle or a double-bundle procedure can be performed according to the same double-bundle concept.

Non-traumatic anterior cruciate ligament abnormalities and their relationship to osteoarthritis using morphological grading and cartilage T2 relaxation times: data from the Osteoarthritis Initiative (OAI)

OBJECTIVES

The aim of this work was to study anterior cruciate ligament (ACL) degeneration in relation to MRI-based morphological knee abnormalities and cartilage T2 relaxation times in subjects with symptomatic osteoarthritis.

METHODS

Two radiologists screened the right knee MRI of 304 randomly selected participants in the Osteoarthritis Initiative cohort with symptomatic OA, for ACL abnormalities. Of the 52 knees with abnormalities, 28 had mucoid degeneration, 12 had partially torn ACLs, and 12 had completely torn ACLs. Fifty-three randomly selected subjects with normal ACLs served as controls. Morphological knee abnormalities were graded using the WORMS score. Cartilage was segmented and compartment-specific T2 values were calculated.

RESULTS

Compared to normal ACL knees, those with ACL abnormalities had a greater prevalence of, and more severe, cartilage, meniscal, bone marrow, subchondral cyst, and medial collateral ligament lesions (all p < 0.05). T2 measurements did not significantly differ by ACL status.

CONCLUSIONS

ACL abnormalities were associated with more severe degenerative changes, likely because of greater joint instability. T2 measurements may not be well suited to assess advanced cartilage degeneration.

Femoral press-fit fixation in ACL reconstruction using bone-patellar tendon-bone autograft: results at 15 years follow-up

Background

If anterior cruciate ligament (ACL) reconstruction is to be performed, decision regarding graft choice and its fixation remains one of the most controversial. Multiple techniques for ACL reconstruction are available. To avoid disadvantages related to fixation devices, a hardware-free, press-fit ACL reconstruction technique was developed.

The aim of this study was to evaluate clinical outcome and osteoarthritis progression in long term after ACL reconstruction with central third patellar-tendon autograft fixed to femur by press-fit technique.

Methods

Fifty two patients met inclusion/excusion criteria for this study. The patients were assessed preoperatively and at 15 years after surgery with International Knee Documentation Committee Knee Ligament Evaluation Form, Lysholm knee score, Tegner activity scale and radiographs.

Results

Good overall clinical outcomes and self-reported assessments were documented, and remained good at 15 years. The mean Lysholm and Tegner scores improved from 59.7 ± 18.5 and 4.2 ± 1.0 preoperatively to 86.4 ± 5.6 (p = 0.004) and 6.9 ± 1.4 (p = 0.005) respectively at follow-up. The IKDC subjective score improved from 60.1 ± 9.2 to 80.2 ± 8.1 (p = 0.003).

According to IKDC objective score, 75% of patients had normal or nearly normal knee joints at follow-up. Grade 0 or 1 results were seen in 85% of patients on laxity testing. Degenerative changes were found in 67% of patients. There was no correlation between arthritic changes and stability of knee and subjective evaluation (p > 0.05).

Conclusions

ACL reconstruction with patellar tendon autograft fixed to femur with press-fit technique allows to achieve good self-reported assessments and clinical ligament evaluation up to 15 years. Advantages of the bone-patellar-tendon-bone (BPTB) press-fit fixation include unlimited bone-to-bone healing, cost effectiveness, avoidance of disadvantages associated with hardware, and ease for revision surgery. BPTB femoral press-fit fixation technique can be safely applied in clinical practice and enables patients to return to preinjury activities including high-risk sports.

Tibial rotation during pivoting in anterior cruciate ligament reconstructed knees using a single bundle technique

BACKGROUND

Anterior cruciate ligament reconstruction does not necessarily restore normal knee movement. Increased tibial rotation has previously been noted during pivoting activities and may be due to the orientation of the anterior cruciate ligament graft associated with traditional single bundle reconstruction techniques. Recent research has shown that it is possible to limit rotation during level walking using a single bundle anterior cruciate ligament reconstruction. This study evaluated rotational knee kinematics during a pivot task in a group of patients who had undergone anterior cruciate ligament reconstruction using a single bundle technique and compared the findings to a normal control group.

METHODS

In 27 anterior cruciate ligament reconstruction and 25 control participants, internal-external rotation was measured during a descend stairs and pivot task in a gait laboratory.

FINDINGS

Results showed that the anterior cruciate ligament reconstruction patients had less internal tibial rotation (for both range of rotation and maximum rotation) than the control participants (effect size=0.7).

INTERPRETATION

These results suggest that it is possible to limit rotation after anterior cruciate ligament reconstruction using a single bundle technique, even during a pivoting movement that places a high rotational load at the knee joint. The positioning of the femoral tunnel in a more anatomical position may be responsible for the reduced tibial rotation.

Individualized anatomic anterior cruciate ligament reconstruction

Arthroscopic anterior cruciate ligament reconstruction (ACL-R) is a technique that continues to evolve. Good results have been established with respect to reducing anteroposterior laxity. However, these results have come into question because nonanatomic techniques have been ineffective at restoring knee kinematics and raised concerns that abnormal kinematics may impact long-term knee health. Anatomic ACL-R attempts to closely reproduce the patient's individual anatomic characteristics. Measurements of the patient's anatomy help determine graft choice and whether anatomic reconstruction should be performed with a single- or double-bundle technique. The bony landmarks and insertions of the anterior cruciate ligament (ACL) are preserved to assist with anatomic placement of both tibial and femoral tunnels. An anatomic single- or double-bundle reconstruction is performed with a goal of reproducing the characteristics of the native ACL. Long-term outcomes for anatomic ACL reconstruction are unknown. By individualizing ACL-R, we strive to reproduce the patient's native anatomy and restore knee kinematics to improve patient outcomes.

Allograft anterior cruciate ligament reconstruction: indications, techniques, and outcomes

The anterior cruciate ligament (ACL) is an important stabilizer of the knee against translational and rotational forces. The goal of anatomic reconstruction of the ACL-deficient knee is to re-create a stable knee that will allow for return to sport and prevent recurrent injury. Multiple graft options exist for ACL reconstruction, and each option has unique advantages and disadvantages. With appropriate patient selection, each graft can be utilized to optimize patient outcomes. Allograft options limit morbidity following ACL reconstruction, but care must be taken with surgical technique and postoperative rehabilitation to allow for graft incorporation. An understanding of the surgical technique and differences between graft options will allow the patient, surgeon, and physical therapist to maximize outcomes following ACL reconstruction.

Cartilage injury after acute, isolated anterior cruciate ligament tear: immediate and longitudinal effect with clinical/MRI follow-up

BACKGROUND

Anterior cruciate ligament (ACL) tears have been implicated in the development of osteoarthritis. Limited data exist on longitudinal follow-up of isolated ACL injury.

HYPOTHESES

All isolated ACL tears are associated with some degree of cartilage injury that will deteriorate over time. There is a threshold of magnetic resonance imaging (MRI)-detectable cartilage injury that will correlate with adverse change in subjective patient-reported outcome measures.

STUDY DESIGN

Cohort study, Level of evidence, 2.

METHODS

The authors conducted a prospective, observational analysis of 42 knees in 40 patients with acute, isolated ACL injury (14 treated nonoperatively, 28 by reconstruction) with imaging at the time of injury and yearly follow-up for a maximum of 11 years. Morphologic MRI and quantitative T2 mapping was performed with validated outcome measures.

RESULTS

All patients sustained chondral damage at initial injury. The adjusted risk of cartilage loss doubled from year 1 for the lateral compartment and medial femoral condyle (MFC) and tripled for the patella. By years 7 to 11, the risk for the lateral femoral condyle was 50 times baseline, 30 times for the patella, and 19 times for the MFC. There was increased risk of cartilage degeneration over the medial tibial plateau (MTP) (P = .047; odds ratio = 6.23; 95% confidence interval [CI], 1.03-37.90) and patella (P = .032; odds ratio = 4.88; 95% CI, 1.14-20.80) in nonsurgical patients compared with surgically treated patients. Size of the bone-marrow edema pattern was associated with cartilage degeneration from baseline to year 3 (P = .001 to .039). Each increase in the MFC Outerbridge score resulted in a 13-point decrease in the International Knee Documentation Committee subjective knee score (P = .0002). Each increase in the MTP resulted in a 2.4-point decrease in the activity rating scale (P = .002).

CONCLUSION

All patients with acute, traumatic ACL disruption sustained a chondral injury at the time of initial impact with subsequent longitudinal chondral degradation in compartments unaffected by the initial "bone bruise," a process that is accelerated at 5 to 7 years' follow-up.

Arthroscopically pertinent landmarks for tunnel positioning in single-bundle and double-bundle anterior cruciate ligament reconstructions

BACKGROUND

Quantification of the overall anterior cruciate ligament (ACL) and anteromedial (AM) and posterolateral (PL) bundle centers in respect to arthroscopically pertinent bony and soft tissue landmarks has not been thoroughly assessed.

HYPOTHESIS

A standardized anatomical measurement method can quantitate the locations of the ACL and AM and PL bundle centers in reference to each other and anatomical landmarks.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Quantification of the ACL and its bundle attachments was performed on 11 cadaveric knees using a radio frequency-tracking device.

RESULTS

The tibial ACL attachment center was 7.5 mm medial to the anterior horn of the lateral meniscus, 13.0 mm anterior to the retro-eminence ridge, and 10.5 mm posterior to the ACL ridge. The femoral ACL attachment center was 1.7 mm proximal to the bifurcate ridge and 6.1 mm posterior to the lateral intercondylar ridge. The tibial AM attachment center was 8.3 mm medial to the anteromedial aspect of the lateral meniscus anterior horn, 17.8 mm anterior to the retro-eminence ridge, and 5.6 mm posterior to the ACL ridge. The femoral AM attachment center was 4.8 mm proximal to the bifurcate ridge and 7.1 mm posterior to the lateral intercondylar ridge. The tibial PL bundle attachment center was 6.6 mm medial to the posteromedial aspect of the lateral meniscus anterior horn, 10.8 mm anteromedial to the root attachment of the lateral meniscus posterior horn, and 8.4 mm anterior to the retro-eminence ridge. The femoral PL bundle attachment center was 5.2 mm distal to the bifurcate ridge and 3.6 mm posterior to the lateral intercondylar ridge.

CONCLUSION

The authors developed a comprehensive compilation of measurements of arthroscopically pertinent bony and soft tissue landmarks that quantitate the ACL and its individual bundle attachment centers on the tibia and femur.

CLINICAL RELEVANCE

These clinically relevant arthroscopic landmarks may enhance single- and double-bundle ACL reconstructions through improved tunnel placement.

Long-term results of anterior cruciate ligament reconstruction: a comparison with non-operative treatment with a follow-up of 17-20 years

PURPOSE

The aim of our study was to review the clinical and radiological outcome of patients who had undergone anterior cruciate ligament (ACL) reconstruction in comparison to a group of non-operatively treated patients.

METHODS

In a retrospective study we compared ACL reconstruction using a bone-patellar tendon-bone graft with a non-operatively treated group of patients 17-20 years later. Fifty-four patients that met the inclusion criteria, with arthroscopically proven ACL rupture, were treated between 1989 and 1991. Thirty-three patients underwent ACL reconstruction, forming group one. Eighteen non-reconstructed patients continued with rehabilitation and modification of activities (group two). The International Knee Documentation Committee (IKDC) subjective and objective evaluation forms and the Lysholm and Tegner scale were used to assess the knees at follow-up. Radiographic assessment was performed using the IKDC grading scale.

RESULTS

Follow-up results showed that 83% of reconstructed patients had stable knees and normal or nearly normal IKDC grade. Patients in the non-reconstructed group had unstable knees with 84% having abnormal or severe laxity. The subjective IKDC score was significantly in favour of group one: 83.15 compared to 64.6 in group two. The Lysholm and Tegner score was also significantly better in group one. Conservatively treated patients all had unstable knees and worse scores. The rate of osteoarthritis showed more severe changes in non-reconstructed patients with additional meniscus injury.

CONCLUSIONS

We can conclude that 94% of patients who underwent ACL reconstruction had stable knees after 15-20 years and there was a significantly lower percentage of osteoarthritis in comparison to conservatively treated patients.

Alterations in joint kinematics during walking following hamstring and patellar tendon anterior cruciate ligament reconstruction surgery

BACKGROUND

Previous research has shown that patients with anterior cruciate ligament reconstruction have altered movement patterns in the reconstructed knee during walking. In the sagittal plane, graft specific changes in knee joint motion have been reported between hamstring and patellar tendon anterior cruciate ligament reconstruction grafts. This study examined the secondary planes of movement during walking in anterior cruciate ligament reconstructed knees to evaluate the influences of graft type (hamstring or patellar tendon) and control condition (control group or contralateral knee).

METHODS

In 54 participants (18 patellar tendon graft, 18 hamstring graft and 18 controls) varus-valgus and internal-external rotation was measured during level walking in a gait laboratory at mean of 10 months after surgery. All patients had undergone primary unilateral anterior cruciate ligament reconstruction within 12 months of injury.

FINDINGS

For internal-external rotation there was no difference between the graft types and both patient groups had reduced internal rotation (an external rotation offset) and reduced internal rotation range when compared to the control group and contralateral knee. For 31 of 36 patients, internal rotation values were less than the control group mean. The hamstring group had reduced varus rotation compared to both the patellar tendon and control groups, but not when compared to the contralateral knee.

INTERPRETATION

The results show that there are differences in tibial rotation during walking in anterior cruciate ligament reconstructed knees compared to both the contralateral knee and uninjured control group. These kinematic alterations may relate to the high incidence of knee osteoarthritis observed in this population over time. Reduced varus in the hamstring group may relate to the graft harvest.

Pattern of joint damage in persons with knee osteoarthritis and concomitant ACL tears

Anterior cruciate ligament (ACL) tears are known to be a risk factor for incident knee osteoarthritis (OA). At the present time, it is unknown whether an incidental ACL tear in those with established knee OA alters the pattern of synovial joint damage. Therefore, our aim was to assess whether ACL tears in persons with knee OA are associated with specific patterns of cartilage loss, meniscal degeneration, and bone marrow lesion (BML) location. We included 160 participants from the progression subcohort of the Osteoarthritis Initiative (OAI) Study, an ongoing 4-year, multicenter study, focusing on knee OA. Regional cartilage morphometry measures including cartilage volume (mm(3)), denuded area, normalized cartilage volume, bone surface area, as well as location of meniscal pathology and BMLs in index knees on the same side were compared between those with and without ACL tears. Of the 160 subjects (51% women, age 62.1 (±9.9), BMI 30.3 (±4.7) kg/m(2)), 14.4% had an ACL tear. After adjusting for age, BMI and gender participants with ACL tears had significantly greater cartilage volume in the posterior lateral femur (P = 0.04) and the central medial tibia (0.001) compared to those without ACL tears. Normalized cartilage volume was not different between those with and without ACL tears. In addition, individuals with ACL tears had significantly larger bone surface areas in the medial tibia (P = 0,006), the central medial tibia (P = 0.008), the posterior lateral femur (P = 0.004), and the posterior medial femur (P = 0.04). Furthermore, participants with ACL tears showed significantly more meniscal derangement in the lateral posterior horn (P = 0.019) and significantly more BMLs in the lateral femur (P = 0.0025). We found clear evidence of predominant lateral tibiofemoral involvement, with OA-associated findings on MRI, including increased denuded area and bone surface area, BMLs, and meniscal derangement in knees of individuals with ACL tears compared to those without.

Fifteen-year outcome of endoscopic anterior cruciate ligament reconstruction with patellar tendon autograft for "isolated" anterior cruciate ligament tear

BACKGROUND

Few studies report the long-term results of anterior cruciate ligament rupture and single-incision endoscopic reconstructive surgery. Outcomes are often clouded by concomitant meniscal, chondral, or ligament injuries.

PURPOSE

To determine the 15-year outcomes of anterior cruciate ligament ruptures treated with endoscopic anterior cruciate ligament reconstruction using middle-third patellar tendon autograft.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between January 1993 and April 1994, 333 consecutive patients underwent anterior cruciate ligament reconstruction. Patients with associated ligamentous injury requiring surgery, previous meniscectomy, or meniscal injury requiring more than one-third meniscectomy; chondral injury diagnosed at arthroscopy; and an abnormal contralateral knee were excluded. Ninety patients met the inclusion criteria. Outcomes included range of motion, Lachman and pivot-shift tests, instrumented ligament testing, single-legged hop test, Lysholm Knee Score, the International Knee Documentation Committee evaluation, and radiographic assessment.

RESULTS

Thirty percent of patients had further anterior cruciate ligament injury. Twenty-four percent of patients (n = 22) sustained contralateral anterior cruciate ligament ruptures, and 8% (n = 7) ruptured the graft (P = .009). Graft rupture was associated with a graft inclination angle <17° (P = .02). Contralateral anterior cruciate ligament rupture was associated with age <18 years at time of primary injury (P = .001). All patients had normal or nearly normal (International Knee Documentation Committee evaluation) Lachman and instrumented testing, and 91% had a negative pivot-shift result. Seventy percent of patients had kneeling pain. Median subjective International Knee Documentation Committee evaluation was 91 of 100. Fifty-one percent of patients had radiographic evidence of osteoarthritis (41% grade B; 10% grade C).

CONCLUSION

Good results are maintained at 15 years after surgery with respect to ligamentous stability, subjective outcomes, and range of motion. Kneeling pain remains a significant problem. Concern remains regarding the incidence of further anterior cruciate ligament injury and the increasing number of patients with radiographic and clinical signs of osteoarthritis despite surgical stabilization.

Differences in tibial rotation during walking in ACL reconstructed and healthy contralateral knees

This study tested the hypotheses that in patients with a successful anterior cruciate ligament (ACL) reconstruction, the internal-external rotation, varus-valgus, and knee flexion position of reconstructed knees would be different from uninjured contralateral knees during walking. Twenty-six subjects with unilateral ACL reconstructions (avg 31 years, 1.7 m, 68 kg, 15 female, 24 months past reconstruction) and no other history of serious lower limb injury walked at a self-selected speed in the gait laboratory, with the uninjured contralateral knee as a matched control. Kinematic measurements of tibiofemoral motion were made using a previously-described point-cluster technique. Repeated-measures ANOVA (alpha=0.017) was used to compare ACL-reconstructed knees to their contralateral knees at four distinct points during the stance phase of walking. An offset towards external tibial rotation in ACL-reconstructed knees was maintained over all time points (95%CI 2.3+/-1.3 degrees ). Twenty-two out of twenty-six individuals experienced an average external tibial rotation offset throughout stance phase. Varus-valgus rotation and knee flexion were not significantly different between reconstructed and contralateral knees. These findings show that differences in tibial rotation during walking exist in ACL reconstructed knees compared to healthy contralateral knees, providing a potential explanation why these patients are at higher risk of knee osteoarthritis in the long-term.

Knee joint kinematics and kinetics during a lateral false-step maneuver

CONTEXT

Cutting maneuvers have been implicated as a mechanism of noncontact anterior cruciate ligament (ACL) injuries in collegiate female basketball players.

OBJECTIVE

To investigate knee kinematics and kinetics during running when the width of a single step, relative to the path of travel, was manipulated, a lateral false-step maneuver.

DESIGN

Crossover design.

SETTING

University biomechanics laboratory.

PATIENTS OR OTHER PARTICIPANTS

Thirteen female collegiate basketball athletes (age = 19.7 +/- 1.1 years, height = 172.3 +/- 8.3 cm, mass = 71.8 +/- 8.7 kg).

INTERVENTION(S)

Three conditions: normal straight-ahead running, lateral false step of width 20% of body height, and lateral false step of width 35% of body height.

MAIN OUTCOME MEASURE(S)

Peak angles and internal moments for knee flexion, extension, abduction, adduction, internal rotation, and external rotation.

RESULTS

Differences were noted among conditions in peak knee angles (flexion [P < .01], extension [P = .02], abduction [P < .01], and internal rotation [P < .01]) and peak internal knee moments (abduction [P < .01], adduction [P < .01], and internal rotation [P = .03]). The lateral false step of width 35% of body height was associated with larger peak flexion, abduction, and internal rotation angles and larger peak abduction, adduction, and internal rotation moments than normal running. Peak flexion and internal rotation angles were also larger for the lateral false step of width 20% of body height than for normal running, whereas peak extension angle was smaller. Peak internal rotation angle increased progressively with increasing step width.

CONCLUSIONS

Performing a lateral false-step maneuver resulted in changes in knee kinematics and kinetics compared with normal running. The differences observed for lateral false steps were consistent with proposed mechanisms of ACL loading, suggesting that lateral false steps represent a hitherto neglected mechanism of noncontact ACL injury.

Knee laxity measurements after anterior cruciate ligament reconstruction, using either bone-patellar-tendon-bone or hamstring tendon autografts, with special emphasis on comparison over time

The aims of the study were to analyse the change in knee laxity over time after anterior cruciate ligament (ACL) reconstruction, using either bone-patellar-tendon-bone (BPTB) or hamstring (HS) tendon autografts, and to compare the knee laxity measurements between the study groups both pre-operatively and on multiple follow-up occasions. Another aim was to compare the radiographic findings in terms of degenerative changes between the study groups. A randomised series of 71 patients, who underwent ACL reconstruction using BPTB or HS tendon autografts and interference screw fixation, were included in the study. Of these patients, 47/71 (66%) attended a clinical examination, including laxity measurements using the KT-1000 arthrometer, pre-operatively and on four post-operative occasions; 6 months, 1 year, 2 years and 7 years after the reconstruction. The BPTB group consisted of 22 patients, while there were 25 patients in the HS group. There were no significant differences in the mean side-to-side knee laxity between the BPTB and the HS group pre-operatively or at the follow-up examinations. There was a tendency towards a reduction in side-to-side knee laxity over time in both groups, measured with the KT-1000 arthrometer. The decrease was significant when analysing the injured and uninjured knee separately (injured side p < 0.001 (BPTB) and p = 0.005 (HS), uninjured side p = 0.008 and p = 0.042, respectively). Forty-four patients (BPTB 21, ST 23) underwent a radiographic assessment at the 7-year follow-up, which revealed no significant differences between the study groups in terms of osteoarthritic findings classified according to the Fairbank and Ahlbäck rating systems. In overall terms, osteoarthritis was identified in 16% (BPTB 19%; ST 13%; n.s.) according to the Ahlbäck rating system and 68% (BPTB 67%; ST 70%; n.s.) according to the Fairbank rating system. There were no significant differences in knee laxity measurements between the two study groups pre-operatively or at 7 years. A decrease in knee laxity over time was seen in both groups. There were no significant differences between the BPTB and ST groups in terms of osteoarthritic findings at 7 years.

MR imaging of intra- and periarticular soft tissues and subchondral bone in knee osteoarthritis

Osteoarthritis of the knee has to be considered a disease of the whole joint. Magnetic resonance imaging allows superior assessment of all joint tissues that may be involved in the disease process, such as the subchondral bone, synovium, ligaments, and periarticular soft tissues. Reliable MR imaging-based scoring systems are available to assess and quantify these structures and associated pathology. Cross-sectional and longitudinal evaluation has enabled us to understand their relevance in explaining pain and structural progression.

Central and peripheral region tibial plateau chondrocytes respond differently to in vitro dynamic compression

OBJECTIVE

The objective of this study was to test the hypotheses that chondrocytes from distinct regions of the porcine tibial plateau: (1) display region-specific baseline gene expression, and (2) respond differently to in vitro mechanical loading.

METHODS

Articular cartilage explants were obtained from central (not covered by meniscus) and peripheral (covered by meniscus) regions of porcine tibial plateaus. For baseline gene expression analysis, samples were snap frozen. To determine the effect of mechanical loading, central and peripheral region explants were exposed to equivalent dynamic compression (0-100 kPa) and compared to site-matched free-swelling controls (FSCs). mRNA levels for type II collagen (CII), aggrecan (AGGR), matrix metalloproteinase 1 (MMP-1), MMP-3, MMP-13, A disintegrin and metalloproteinase with thrombospondin motifs 4 (ADAM-TS4), ADAM-TS5, tissue inhibitor of metalloproteinases 1 (TIMP-1), TIMP-2, and tumor necrosis factor alpha (TNFalpha) were quantified using real time polymerase chain reaction (RT-PCR).

RESULTS

At baseline, mRNA levels for the structural proteins CII and AGGR were approximately twofold greater in the central region compared with peripheral region explants. In vitro dynamic compression strongly affected expression levels for CII, AGGR, MMP-3, and TIMP-2 relative to FSCs. Response differed significantly by region, with greater upregulation of CII, AGGR, and MMP-3 in central region explants.

CONCLUSIONS

Chondrocytes from different regions of the porcine tibial plateau express mRNA for structural proteins at different levels and respond to equivalent in vitro mechanical loading with distinctive changes in gene expression. These regional biological variations appear to be related to the local mechanical environment in the normal joint, and thus may indicate a sensitivity of the joint to conditions that alter joint loading such as anterior cruciate ligament (ACL) injury, meniscectomy, or joint instability.

Magnetic resonance imaging of 3-dimensional in vivo tibiofemoral kinematics in anterior cruciate ligament-reconstructed knees

PURPOSE

The purpose of this study was to use magnetic resonance imaging (MRI) to determine 3-dimensional knee kinematics after anterior cruciate ligament (ACL) reconstruction.

METHODS

Nine ACL-reconstructed and contralateral knees were tested 12 +/- 8 months after surgery. MRI was performed at full extension and 40 degrees of knee flexion under simulated weight-bearing conditions. Femoral condyle positions, tibial rotation, contact area, and contact location were analyzed by use of MRI-based 3-dimensional models.

RESULTS

When knees were fully extended, tibiae in ACL-reconstructed knees were externally rotated by 3.6 degrees +/- 4.2 degrees compared with contralateral knees. The external rotation was due to anterior subluxation of the medial side of the tibia. At 40 degrees of knee flexion, tibiae in ACL-reconstructed knees and contralateral knees were both internally rotated by 5.3 degrees. There were no significant differences in contact area or contact location between ACL-reconstructed and contralateral knees. When moving from extension to flexion, ACL-reconstructed knees exhibited 3.5 degrees +/- 5.9 degrees more internal tibial rotation than contralateral knees.

CONCLUSIONS

Reconstruction of the ACL restored normal motion on the lateral side of the knee but not on the medial side, resulting in increased internal tibial rotation when moving from full extension to 40 degrees of flexion. These results suggest that ACL reconstruction does not restore normal kinematics on the medial side of the knee, which may lead to early cartilage degeneration.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Knee osteoarthritis after anterior cruciate ligament injury: a systematic review

BACKGROUND

This is a systematic review of studies on the prevalence of osteoarthritis in the tibiofemoral joint more than 10 years after an anterior cruciate ligament injury, the radiologic classification methods used, and risk factors for development of knee osteoarthritis.

METHODS

A systematic search was performed in PubMed, EMBASE, and AMED. Inclusion criteria were studies involving patients with anterior cruciate ligament injury, either isolated or combined with medial collateral ligament or meniscal injury and either surgically or nonsurgically treated, and a minimum 10-year follow-up with radiologic assessment. Methodological quality was evaluated using a modified version of the Coleman methodology score.

RESULTS

Seven prospective and 24 retrospective studies were included. The mean modified Coleman methodology score was 52 of 90. Reported prevalence of knee osteoarthritis for subjects with isolated anterior cruciate ligament injury was between 0% and 13%. For subjects with anterior cruciate ligament and additional meniscal injury, the prevalence varied between 21% and 48%. Seven different radiologic classification systems were used in the studies. Only 3 studies reported reliability results for the radiologic assessments. The most frequently reported risk factor for development of knee osteoarthritis was meniscal injury.

CONCLUSION

This systematic review suggests that the prevalence rates of knee osteoarthritis after anterior cruciate ligament reconstruction reported by previous reviews have been too high. The highest rated studies reported low prevalence of knee osteoarthritis for individuals with isolated anterior cruciate ligament injury (0%-13%) and a higher prevalence of knee osteoarthritis for subjects with combined injuries (21%-48%). Overall, the modified Coleman methodology score was low for the included studies. No universal methodological radiologic classification method exists, making comparisons of the studies and stating firm conclusions on the prevalence of knee osteoarthritis more than 10 years after anterior cruciate ligament injury difficult.

Outcome and knee-related quality of life after anterior cruciate ligament reconstruction: a long-term follow-up

The aim of the present investigation was to study patient-reported long-term outcome after anterior cruciate ligament (ACL) reconstruction. On an average 11.5 years after ACL reconstruction with bone-patellar tendon-bone (BPTB) autograft 56 patients were asked to answer four different questionnaires about their knee function and knee-related quality of life. Another aim was to study whether there were any correlations between clinical tests, commonly used for evaluating patients with ACL injuries, which were performed 2 years after ACL reconstruction, and patient-reported outcome in terms of knee function and knee-related quality of life on an average 9.5 years later. All patients who had unilateral BPTB ACL reconstructions were examined at 2 years and on an average 11.5 years after surgery. At 2 years one-leg hop test for distance, isokinetic muscle torque measurement, sagittal knee laxity, Lysholm knee scoring scale and Tegner activity scale were used for clinical evaluation. At the follow-up on an average 9.5 years later the patients were evaluated with knee injury osteoarthritis outcome score (KOOS), short form health survey (SF 36), Lysholm knee scoring scale and Tegner activity scale. The SF-36 showed that the patients had a similar health condition as an age- and gender-matched normal population in Sweden on an average 11.5 years after ACL reconstruction. There was no correlation between the results of one-leg hop test for distance, isokinetic muscle torque measurement, sagittal knee laxity evaluated 2 years after surgery and the result of KOOS (function in sport and recreation, knee-related quality of life) and SF-36 evaluated on an average 11.5 years after surgery. We also compared patients that 2 years after surgery demonstrated a side-to-side difference in anterior-posterior knee laxity of more than 3 mm with those with 3 mm or less and found no significant group differences in terms of knee function as determined with KOOS. We found no correlation between the results of KOOS and SF-36 at the long-term follow-up and the time between injury and surgery, age at surgery or gender, respectively. We conclude that there is no correlation between patient-reported knee function in sport and recreation and knee-related quality of life on an average 11.5 years after BPTP ACL reconstruction and the evaluation methods used 2 years after surgery.