Outcomes of revision anterior cruciate ligament reconstruction in soccer players : a cohort study

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.

Use of Publicly Obtained Data in Sports Medicine Research: A Systematic Review and Bibliometric Analysis

BACKGROUND

Publicly obtained data (POD) have recently been utilized frequently by sports medicine researchers to describe injury patterns, risk factors, and outcomes in elite athletes. The relative ease of this type of research that is based solely on internet and media sources has resulted in a near exponential increase in the number of these POD studies.

PURPOSE

To systematically review the sports medicine literature for studies based solely on POD.

STUDY DESIGN

Systematic review and bibliometric analysis; Level of evidence, 4.

METHODS

A systematic review of POD studies published since 2000 was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies of interest were those relying on publicly available injury reports or online media for data acquisition in collegiate, semiprofessional, and professional athletes.

RESULTS

There were 209 POD studies published between 2000 and 2022, with 173 (82.8%) of these studies published after 2016. Studies were published most frequently on athletes participating in North American professional leagues: National Football League (n = 69 [28.4%]), Major League Baseball (n = 56 [23.0%]), National Basketball Association (n = 37 [15.2%]), and National Hockey League (n = 33 [13.6%]). The most common injuries assessed were head injuries/concussions (n = 43 [21.1%]), anterior cruciate ligament injuries (n = 33 [16.2%]), and ulnar collateral ligament injuries (n = 23 [11.3%]). One-quarter of the studies (n = 53 [25.4%]) reported only 1 POD source, and 1 study (0.5%) reported no source. Additionally, 65 studies (31.1%) listed nonspecific POD resources or solely cited previous literature to describe the POD search methodology and data acquisition.

CONCLUSION

POD studies are exponentially increasing in number, particularly across major North American professional sports leagues, with significant variability in the injury of interest, search methodology, and number of data sources. The accuracy of the conclusions reached based on the POD methodology appears highly variable. Given the potential impact of these publications as both contributors to current knowledge and drivers of future research, the sports medicine community should be aware of the inherent biases and limitations of POD injury studies.

Autograft Demonstrates Superior Outcomes for Revision Anterior Cruciate Ligament Reconstruction When Compared With Allograft: A Systematic Review

BACKGROUND

Multiple studies have compared outcomes among patients undergoing revision anterior cruciate ligament reconstruction (ACLR) with autograft versus allograft, but these data are inconsistently reported and long-term outcomes depending on graft type are yet to be determined.

PURPOSE

To perform a systematic review of clinical outcomes after revision ACLR (rACLR) with autograft versus allograft.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of the literature was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that compared the outcomes of patients undergoing rACLR with autograft versus allograft. The search phrase used was autograft allograft revision anterior cruciate ligament reconstruction. Graft rerupture rates, return-to-sports rates, anteroposterior laxity, and patient-reported outcome scores (subjective International Knee Documentation Committee, Tegner, Lysholm, and Knee injury and Osteoarthritis Outcome Score) were evaluated.

RESULTS

Eleven studies met inclusion criteria, including 3011 patients undergoing rACLR with autograft (mean age, 28.9 years) and 1238 patients undergoing rACLR with allograft (mean age, 28.0 years). Mean follow-up was 57.3 months. The most common autograft and allograft types were bone-patellar tendon-bone grafts. Overall, 6.2% of patients undergoing rACLR experienced graft retear, including 4.7% in the autograft group and 10.2% in the allograft group (P < .0001). Among studies that reported return-to-sports rates, 66.2% of patients with an autograft returned to sports as opposed to 45.3% of patients with an allograft (P = .01). Two studies found significantly greater postoperative knee laxity in the allograft group as compared with the autograft group (P < .05). Among all patient-reported outcomes, 1 study found 1 significant difference between groups: patients with an autograft had a significantly higher postoperative Lysholm score when compared with patients with an allograft.

CONCLUSION

Patients undergoing revision ACLR with an autograft can be expected to experience lower rates of graft retear, higher rates of return to sports, and less postoperative anteroposterior knee laxity when compared with patients undergoing revision ACLR with an allograft.

Cost-effectiveness analysis of a pragmatic randomized trial evaluating surgical reconstruction versus rehabilitation in patients with long-standing anterior cruciate ligament injury

Aims

The aim of this study was to estimate the incremental use of resources, costs, and quality of life outcomes associated with surgical reconstruction compared to rehabilitation for long-standing anterior cruciate ligament (ACL) injury in the NHS, and to estimate its cost-effectiveness.

Methods

A total of 316 patients were recruited and randomly assigned to either surgical reconstruction or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment). Healthcare resource use and health-related quality of life data (EuroQol five-dimension five-level health questionnaire) were collected in the trial at six, 12, and 18 months using self-reported questionnaires and medical records. Using intention-to-treat analysis, differences in costs, and quality-adjusted life years (QALYs) between treatment arms were estimated adjusting for baseline differences and following multiple imputation of missing data. The incremental cost-effectiveness ratio (ICER) was estimated as the difference in costs divided by the difference in QALYs between reconstruction and rehabilitation.

Results

At 18 months, patients in the surgical reconstruction arm reported higher QALYs (0.052 (95% confidence interval (CI) -0.012 to 0.117); p = 0.177) and higher NHS costs (£1,017 (95% CI 557 to 1,476); p < 0.001) compared to rehabilitation. This resulted in an ICER of £19,346 per QALY with the probability of surgical reconstruction being cost-effective of 51% and 72% at a willingness-to-pay threshold of £20,000 and £30,000 per QALY, respectively.

Conclusion

Surgical reconstruction as a management strategy for patients with long-standing ACL injury is more effective, but more expensive, at 18 months compared to rehabilitation management. In the UK setting, surgical reconstruction is cost-effective.

Quadriceps tendon autograft has similar clinical outcomes when compared to hamstring tendon and bone-patellar tendon-bone autografts for revision ACL reconstruction: a systematic review and meta-analysis

PURPOSE

Research regarding revision anterior cruciate ligament reconstruction (RACLR) with quadriceps tendon (QT) autografts is lacking. The purpose of this study was to perform a systematic review and meta-analysis of RACLR with QT and compare its patient outcomes to RACLR with hamstring tendon (HT) and bone-patellar tendon-bone (BTB) autografts.

METHODS

Adhering to PRISMA guidelines, a search for studies using QT in RACLR was performed within PubMed, Scopus, and CINAHL from database date of inception through December 26, 2022. Primary outcomes sought included: failure rate, Lysholm scores, International Knee Documentation Committee (IKDC) scores, IKDC grades, arthrometric knee side-to-side differences (STSD), pivot shift grade, donor site morbidity, return to sport, visual analog scale (VAS) pain scores.

RESULTS

Nine studies were included consisting of 606 RACLR: 349 QT, 169 HT, and 88 BTB. Overall failure rates were 7.6% QT, 13.3% HT, and 8.7% BTB. Mean weighted Lysholm scores were 85.8 ± 3.8 QT, 82.5 ± 3.8 HT and 86.6 ± 4.5 BTB. IKDC average scores were 82.3 ± 1.6 QT, 80.1 ± 1.7 HT, and 81.7 ± 5.5BTB. Combined rates of IKDC A/B grades were 88.4% and 80.0% for QT and HT, respectively. VAS average scores were 0.9 ± 1.1 QT, 1.4 ± 0.2 HT, and 0.7 ± 0.8 for BTB. Side-to-side difference was reported for QT and HT with average values of 1.7 ± 0.6 mm and 2.1 ± 0.5 mm, respectively. Grade 0 or 1 pivot shifts were reported in 96.2% of QT patients and 91.3% of HT. Donor site morbidity, only reported for QT and HT, was 14.6 ± 9.7% and 23.6 ± 14.1%, respectively. QT resulted in a mean Tegner score of 5.9 ± 1.5 versus HT 5.7 ± 1.5. Rate of return to pivoting sports was 38.0% QT, 48.6% HT, and 76.9% BTB. Across all outcomes, there was no significant difference when comparing QT to HT, QT to BTB, and QT compared to HT and BTB combined.

CONCLUSIONS

RACLR with QT yields satisfactory patient reported outcomes, satisfactory improvement in knee laxity, expected return to sport rates, and has an overall 7.6% failure rate. Outcomes are comparative to those of HT and BTB making it an acceptable graft choice for RACLR. Surgeons should consider using QT autograft for RACLR, especially when other autografts are unavailable.

LEVEL OF EVIDENCE

IV.

Technology-assisted anterior cruciate ligament reconstruction improves tunnel placement but leads to no change in clinical outcomes: a systematic review and meta-analysis

PURPOSE

To investigate the effect of technology-assisted Anterior Cruciate Ligament Reconstruction (ACLR) on post-operative clinical outcomes and tunnel placement compared to conventional arthroscopic ACLR.

METHODS

CENTRAL, MEDLINE, and Embase were searched from January 2000 to November 17, 2022. Articles were included if there was intraoperative use of computer-assisted navigation, robotics, diagnostic imaging, computer simulations, or 3D printing (3DP). Two reviewers searched, screened, and evaluated the included studies for data quality. Data were abstracted using descriptive statistics and pooled using relative risk ratios (RR) or mean differences (MD), both with 95% confidence intervals (CI), where appropriate.

RESULTS

Eleven studies were included with total 775 patients and majority male participants (70.7%). Ages ranged from 14 to 54 years (391 patients) and follow-up ranged from 12 to 60 months (775 patients). Subjective International Knee Documentation Committee (IKDC) scores increased in the technology-assisted surgery group (473 patients; P = 0.02; MD 1.97, 95% CI 0.27 to 3.66). There was no difference in objective IKDC scores (447 patients; RR 1.02, 95% CI 0.98 to 1.06), Lysholm scores (199 patients; MD 1.14, 95% CI - 1.03 to 3.30) or negative pivot-shift tests (278 patients; RR 1.07, 95% CI 0.97 to 1.18) between the two groups. When using technology-assisted surgery, 6 (351 patients) of 8 (451 patients) studies reported more accurate femoral tunnel placement and 6 (321 patients) of 10 (561 patients) studies reported more accurate tibial tunnel placement in at least one measure. One study (209 patients) demonstrated a significant increase in cost associated with use of computer-assisted navigation (mean 1158€) versus conventional surgery (mean 704€). Of the two studies using 3DP templates, production costs ranging from $10 to $42 USD were cited. There was no difference in adverse events between the two groups.

CONCLUSION

Clinical outcomes do not differ between technology-assisted surgery and conventional surgery. Computer-assisted navigation is more expensive and time consuming while 3DP is inexpensive and does not lead to greater operating times. ACLR tunnels can be more accurately located in radiologically ideal places by using technology, but anatomic placement is still undetermined because of variability and inaccuracy of the evaluation systems utilized.

LEVEL OF EVIDENCE

Level III.

Revision anterior cruciate ligament reconstruction

Anterior cruciate ligament (ACL) graft failure from rupture, attenuation, or malposition may cause recurrent subjective instability and objective laxity, and occurs in 3% to 22% of ACL reconstruction (ACLr) procedures. Revision ACLr is often indicated to restore knee stability, improve knee function, and facilitate return to cutting and pivoting activities. Prior to reconstruction, a thorough clinical and diagnostic evaluation is required to identify factors that may have predisposed an individual to recurrent ACL injury, appreciate concurrent intra-articular pathology, and select the optimal graft for revision reconstruction. Single-stage revision can be successful, although a staged approach may be used when optimal tunnel placement is not possible due to the position and/or widening of previous tunnels. Revision ACLr often involves concomitant procedures such as meniscal/chondral treatment, lateral extra-articular augmentation, and/or osteotomy. Although revision ACLr reliably restores knee stability and function, clinical outcomes and reoperation rates are worse than for primary ACLr.

Rates and Levels of Elite Sport Participation at 5 Years After Revision ACL Reconstruction

BACKGROUND

There is a paucity of data regarding return to play (RTP), level of competition, and longevity of play after revision of anterior cruciate ligament (ACL) reconstruction (ACLR) in elite athletes.

PURPOSE

To report RTP rates and competition levels in elite athletes at the point of RTP, as well as at 2 and 5 years after revision ACLR, and the effect of meniscal and chondral pathology at revision surgery on these outcomes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective review of a consecutive series of all revision ACLRs undertaken by the senior author between 2009 and 2019, with a minimum 2-year follow-up, was carried out. Outcome measures were RTP rates and competition level.

RESULTS

A total of 49 knees in 48 elite athletes met the inclusion criteria. After revision ACLR, 43 (87.8%) elite athletes achieved RTP, of whom 75.5% were at the same level. At 2 years after surgery, 39 (79.6%) were still playing, 25 (51%) at the same level; at 5 years after surgery, 20 (44.4%) were still playing, 9 (20%) at the same level. Elite athletes with <50% thickness or no articular cartilage lesions were more likely to RTP (94.6% vs 66.7%; P = .026), as well as return to the same competition level (83.8% vs 50%; P = .047), compared with those with ≥50% thickness chondral lesions. Those without medial meniscal pathology were more likely to RTP at the same level after revision surgery (94.4% vs 64.5%; P = .036). The median time elite athletes continued to play after revision ACLR was 73 months (95% CI, 43.4-102.6); 23 months at the same level (95% CI, 13.6-32.4). The probability of still playing at 5 years after surgery was 55.9%, with a 22.5% chance of maintaining preinjury competition level.

CONCLUSION

In elite athletes, RTP rates and competition level decreased over time after revision ACLR. The presence of >50% thickness chondral pathology was associated with lower RTP rates and competition level at RTP time, while medial meniscal pathology was associated with lower competition level at RTP.

Influence of hamstring tendon and bone-patellar tendon-bone autografts on worsened patient reported outcome measurements in revision anterior cruciate ligament reconstruction: Comparing outcomes between primary and revision reconstructions

Background

This study aimed to compare the clinical outcomes and patient reported outcome measurement scales (PROMs) between hamstring tendon (HT) or bone-patellar tendon-bone (BTB) grafts in each primary and revision anterior cruciate ligament (ACL) reconstruction. Additionally, the clinical outcomes and PROMs between primary and revision surgeries were compared.

Methods

A total of 150 patients (109 primary and 41 revision ACL reconstructions) were enrolled and followed up for an average of 3.9 years (2 years minimum). Knee injury and osteoarthritis outcome scores (KOOS) were examined as PROMs. Side-to-side differences of anterior knee laxity were assessed using KT-1000 and were recorded at the final follow-up. After categorizing patients into HT and BTB reconstruction groups, regression analysis was performed to determine the relationship between revision surgery and changes in KOOS.

Results

In patients who underwent primary surgery, there was no significant difference in side-to-side differences of anterior laxity and KOOS between HT and BTB grafts. In those who underwent revision surgery, BTB grafts had a higher KOOS for activities of daily living (ADL) than HT grafts (p = 0.032). Comparing primary and revision surgeries, postoperative side-to-side differences of anterior laxity in the revision group were significantly larger than those in the primary group (p = 0.001). The KOOS for sports after overall revision reconstruction was significantly lower than that after primary reconstruction (p = 0.026). Comparing the KOOS after dividing all patients into HT and BTB reconstruction groups, in the HT reconstruction group, postoperative KOOS results were not different in any subscale from BTB grafts. In contrast, the KOOS for sports (p = 0.008) and QOL (p = 0.039) were significantly lower in revision surgery than in primary surgery. Furthermore, regression analysis including multiple confounders in the HT reconstruction group showed revision surgery using HT graft was correlated with worsened KOOS for symptoms (p = 0.012) and sports (p = 0.010). Revision surgery using BTB graft was not correlated with decreased KOOS.

Conclusions

There were no differences between the clinical outcome and KOOS in primary and revision surgery, except for ADL scores following revision ACL reconstruction using BTB graft. Side-to-side difference of anterior laxity and KOOS for sports following revision ACL reconstruction were inferior to those following primary ACL reconstruction.

Furthermore, revision ACL reconstruction using HT grafts were correlated with low scores in KOOS for symptoms and sports, while there was no difference of anterior laxity between BTB and HT grafts in revision surgery.