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Dadoo S, Herman ZJ, Hughes JD. Surgical Techniques in Primary ACL Reconstruction: Getting It Right the First Time. Clin Sports Med 2024; 43:399-412. [PMID: 38811118 DOI: 10.1016/j.csm.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
The ideal anterior cruciate ligament reconstruction (ACLR) is an individualized anatomic approach aimed at restoring the native structure and function of the knee. Surgeons are tasked with difficult decisions during operative planning, including the optimal graft choice for the patient and appropriate anatomic tunnel placement. Special considerations should additionally be given for skeletally immature patients and those at high-risk for failure, including younger, active patients participating in pivoting sports. The purpose of this review is to provide an overview of the individualized approach to ACLR, including the necessary preoperative and operative considerations to optimize patient outcomes.
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Affiliation(s)
- Sahil Dadoo
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water Street, Pittsburgh, PA 15203, USA.
| | - Zachary J Herman
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water Street, Pittsburgh, PA 15203, USA
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water Street, Pittsburgh, PA 15203, USA; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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2
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Klein B, Bartlett LE, Huyke-Hernandez FA, Tauro TM, Landman F, Cohn RM, Sgaglione NA. Analysis of Changing Practice Trends in Anterior Cruciate Ligament Reconstruction: A Multicenter, Single-Institution Database Analysis. Arthroscopy 2024:S0749-8063(24)00169-5. [PMID: 38447628 DOI: 10.1016/j.arthro.2024.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 02/24/2024] [Accepted: 02/24/2024] [Indexed: 03/08/2024]
Abstract
PURPOSE To identify trends in anterior cruciate ligament reconstruction (ACLR), including graft choice, femoral tunnel drilling techniques, and augmentation techniques, and to assess how various surgeon factors impact these trends. METHODS A retrospective review of primary ACLRs performed between 2014 and 2022 was completed using a multicenter institutional database. Patient demographic characteristics, graft type, femoral drilling technique, use of extra-articular tenodesis, and use of suture augmentation were recorded from the medical record. Surgeon fellowship training (sports trained vs non-sports trained), experience (high [minimum of 15 years in practice] vs low), and volume (high [minimum of 15 ACLRs/year] vs low) were used to stratify technique utilization. The z test for proportions was used to compare categorical variables. Pearson correlation analyses identified trends and assessed statistical significance, defined as P < .05. RESULTS Our cohort consisted of 2,032 ACLRs performed in 2,006 patients. The average patient age was 28.3 ± 11.6 years, with more procedures performed in male patients (67.3%). The average length of surgeon experience was 19.7 ± 11.4 years, with an average annual procedural volume of 4.0 ± 5.4 ACLRs. Most surgeons were sports trained (n = 55, 64.7%), high experience (n = 44, 57.1%), and low volume (n = 80, 94.1%). There was an increasing annual proportion of ACLRs performed by sports-trained surgeons (R = 0.748, P = .020) and low-experience surgeons (R = 0.940, P < .001). Autograft reconstructions were most often performed by sports-trained (71.2%), low-experience (66.1%), and high-volume (76.9%) surgeons. There was an increasing proportion of autograft ACLRs that used quadriceps tendon among sports-trained (R = 0.739, P = .023), high-experience (R = 0.768, P = .016), and low-volume (R = 0.785, P = .012) surgeons. Independent drilling techniques were used in an increasing proportion of ACLRs performed by non-sports-trained (R = 0.860, P = .003) and high-volume (R = 0.864, P = .003) surgeons. Augmentation of ACLR with concomitant suture augmentation (n = 24, 1.2%) or extra-articular tenodesis (n = 6, 0.3%) was rarely performed. CONCLUSIONS In our multicenter institution, the quadriceps tendon autograft has been increasingly used in ACLR by sports-trained, low-volume, and high-experience surgeons. Independent drilling techniques have been increasingly used by non-sports-trained and high-volume surgeons. CLINICAL RELEVANCE Surgeons must stay current with the literature that affects their procedures to ensure that evidence-based medicine is being practiced.
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Affiliation(s)
- Brandon Klein
- Department of Orthopaedic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Huntington, New York, U.S.A..
| | - Lucas E Bartlett
- Rowan-Virtua School of Osteopathic Medicine, Stratford, New Jersey, U.S.A
| | | | - Tracy M Tauro
- Rowan-Virtua School of Osteopathic Medicine, Stratford, New Jersey, U.S.A
| | - Francis Landman
- Mount Sinai South Nassau, Department of Internal Medicine, Oceanside, New York, U.S.A
| | - Randy M Cohn
- Department of Orthopaedic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Huntington, New York, U.S.A
| | - Nicholas A Sgaglione
- Department of Orthopaedic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Huntington, New York, U.S.A
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Högberg J, Piussi R, Simonsson R, Wernbom M, Samuelsson K, Thomeé R, Hamrin Senorski E. The NordBord test reveals persistent knee flexor strength asymmetry when assessed two and five years after ACL reconstruction with hamstring tendon autograft. Phys Ther Sport 2024; 66:53-60. [PMID: 38330681 DOI: 10.1016/j.ptsp.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 02/10/2024]
Abstract
OBJECTIVE Comparison of knee flexor strength limb symmetry index (LSI) between the NordBord-test and the Biodex-test, and to determine the relationship between knee flexor strength and function in patients 2 and 5 years after anterior cruciate ligament reconstruction (ACL-R) with hamstring tendon (HT) autografts. DESIGN Observational registry study. SETTING Primary care. PATIENTS Cross-sectional data from 96 patients (55% women) participating in a rehabilitation-registry after ACL-R with HT autografts. MAIN OUTCOME MEASURES Comparison of knee flexor strength symmetry between the Biodex-test and the NordBord-test. Secondly, the relationship between knee flexor strength test and perceived knee function, activity level, and hop performance. RESULTS The NordBord-test demonstrated greater strength deficits compared to the Biodex-test with a mean difference of 12.5% ± 15.1% 95 % CI [8.1; 16.9%] at 2 years, and 11.1% ± 11.9% 95 % CI [7.7; 14.6 %] at 5 years after ACL-R. Relative concentric knee flexor strength (Nm/kg) in the Biodex demonstrated significant weak-to-moderate correlations with activity level and hop performance (r = 0.33-0.67) at 2 and 5 years. CONCLUSION The NordBord-test identified deficits in knee flexor strength LSI not seen with the Biodex-test at 2 and 5 years after ACL-R. No significant correlations were found between the persistent knee flexor strength asymmetry and perceived function, activity level or hop performance.
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Affiliation(s)
- Johan Högberg
- Sportrehab Sports Medicine Clinic, Stampgatan 14, SE-411 01 Gothenburg, Sweden; Sahlgrenska Sports Medicine Center, Gothenburg, Sweden; Unit of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Box 455, SE-405 30 Gothenburg, Sweden.
| | - Ramana Piussi
- Sportrehab Sports Medicine Clinic, Stampgatan 14, SE-411 01 Gothenburg, Sweden; Sahlgrenska Sports Medicine Center, Gothenburg, Sweden; Unit of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Box 455, SE-405 30 Gothenburg, Sweden
| | - Rebecca Simonsson
- Sportrehab Sports Medicine Clinic, Stampgatan 14, SE-411 01 Gothenburg, Sweden; Sahlgrenska Sports Medicine Center, Gothenburg, Sweden; Unit of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Box 455, SE-405 30 Gothenburg, Sweden
| | - Mathias Wernbom
- Sportrehab Sports Medicine Clinic, Stampgatan 14, SE-411 01 Gothenburg, Sweden; Unit of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Box 455, SE-405 30 Gothenburg, Sweden; Swedish Olympic Committee, Stockholm, Sweden
| | - Kristian Samuelsson
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Roland Thomeé
- Sportrehab Sports Medicine Clinic, Stampgatan 14, SE-411 01 Gothenburg, Sweden; Unit of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Box 455, SE-405 30 Gothenburg, Sweden
| | - Eric Hamrin Senorski
- Sportrehab Sports Medicine Clinic, Stampgatan 14, SE-411 01 Gothenburg, Sweden; Sahlgrenska Sports Medicine Center, Gothenburg, Sweden; Unit of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Box 455, SE-405 30 Gothenburg, Sweden; Swedish Olympic Committee, Stockholm, Sweden
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Tang H, Xiao YF, Wu YM, Xiong YL, Gao SG. Physeal-Sparing, All-Inside Anterior Cruciate Ligament Reconstruction Using Quadrupled Semitendinosus Autograft and Suture Tape Augmentation for Skeletally Immature Patients. Arthrosc Tech 2024; 13:102889. [PMID: 38584626 PMCID: PMC10995729 DOI: 10.1016/j.eats.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/04/2023] [Indexed: 04/09/2024] Open
Abstract
The anterior cruciate ligament (ACL) is the primary soft-tissue structure for anterior stabilization of the knee and is one of the most frequently injured structures. The incidence of ACL injuries in children and adolescents ranges from 92 to 151 per 100,000 person-years. The choice of surgical treatment for this population group is controversial, with a widespread concern that adult reconstruction techniques may damage the epiphyseal plate, compromise growth, or cause deformity. In this article, we describe a physeal-sparing, all-inside ACL reconstruction technique for skeletally immature patients. This technique is supported by retrograde drilling of the femoral tunnel and retrograde drilling of the tibial tunnel, both of which are able to avoid the epiphyseal growth line. Fixation of the quadrupled semitendinosus autograft and suture tape augmentation are achieved by soft-tissue buttons on the femur and tibia. The surgical details of this reproducible reconstruction technique are elaborated.
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Affiliation(s)
- Hang Tang
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yi-Fan Xiao
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yu-Mei Wu
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yi-Lin Xiong
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Shu-Guang Gao
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan, China
- Hunan Engineering Research Center of Osteoarthritis, Changsha, Hunan, China
- National Clinical Research Center of Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
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Tang H, Xiao YF, Liu WJ, Meng JH, Wu YM, Xiong YL, Gao SG. Preferences in anterior cruciate ligament reconstruction: A survey among orthopedic surgeons in China. Medicine (Baltimore) 2024; 103:e36482. [PMID: 38363894 PMCID: PMC10869037 DOI: 10.1097/md.0000000000036482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 11/14/2023] [Indexed: 02/18/2024] Open
Abstract
The purpose of this study was to reveal the current trends and preferences of Chinese orthopedic surgeons regarding anterior cruciate ligament (ACL) reconstruction through a nationwide web-based survey conducted in China. The survey questionnaire was distributed via WeChat to the chairmen of provincial orthopedic and sports medicine organizing committees in China, who then shared it in their respective WeChat workgroups. The questionnaire consisted of 52 multiple-choice questions covering 8 sections. Data collection was implemented by Questionnaire Star. A total of 812 valid questionnaires were returned: 94.21% of the respondents preferred single-bundle reconstruction of ACL, while 61.70% preferred autogenous semitendinosus plus gracilis reconstruction; 76.35% of the respondents preferred establishing the femoral tunnel first, while 47.29% preferred establishing the femoral tunnel through a medial auxiliary approach; and 85.10% of the respondents recommended patients to undergo surgery within 3 months after ligament injury. Besides, the vast majority of respondents chose to retain the ligamentous remnant bundle (92.98%) and recommended routine use of knee braces postoperatively (94.09%). It is recommended to perform arthroscopic single-bundle ACL reconstruction with the remnant preserving technique using a hamstring autograft within 3 months of ACL rupture, with support of postoperative functional braces.
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Affiliation(s)
- Hang Tang
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Yi-fan Xiao
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Wei-jie Liu
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Jia-hao Meng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Yu-mei Wu
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Yi-lin Xiong
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, China
- Hunan Engineering Research Center of Osteoarthritis, Changsha, China
- National Clinical Research Center of Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Shu-guang Gao
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, China
- Hunan Engineering Research Center of Osteoarthritis, Changsha, China
- National Clinical Research Center of Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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Itoh M, Itou J, Okazaki K, Iwasaki K. Estimation Failure Risk by 0.5-mm Differences in Autologous Hamstring Graft Diameter in Anterior Cruciate Ligament Reconstruction: A Meta-analysis. Am J Sports Med 2024; 52:535-543. [PMID: 36876736 DOI: 10.1177/03635465221150654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
BACKGROUND Because grafts are made in 0.5-mm increments clinically for anterior cruciate ligament (ACL) reconstruction, it is important to clarify how the failure rate decreases as the diameter increases. Moreover, it is important to know whether even a slight increase in the graft diameter decreases the risk of failure. HYPOTHESIS The risk of failure decreases significantly with each 0.5-mm increase in hamstring graft diameter. STUDY DESIGN Meta-analysis; Level of evidence, 4. METHODS The systematic review and meta-analysis have estimated the diameter-specific failure risk for each 0.5-mm increase in ACL reconstruction using autologous hamstring grafts. We searched for studies describing the relationship between graft diameter and failure rate published before December 1, 2021, in leading databases, such as PubMed, EMBASE, Cochrane Library, and Web of Science, according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We included studies using single-bundle autologous hamstring grafts to investigate the relationship between failure rate and graft diameter of 0.5-mm intervals with >1-year follow-up. Then, we calculated the failure risk caused by 0.5-mm differences in autologous hamstring graft diameter. Assuming Poisson distribution for the statistical model, we employed an extended linear mixed-effects model in the meta-analyses. RESULTS Five studies containing 19,333 cases were eligible. The meta-analysis revealed that the estimated value of the coefficient of diameter in the Poisson model was -0.2357 with a 95% CI of -0.2743 to -0.1971 (P < .0001). With every 1.0-mm increase in diameter, the failure rate decreased by 0.79 (0.76-0.82) times. In contrast, the failure rate increased by 1.27 (1.22-1.32) times for each 1.0-mm decrease in diameter. The failure rate significantly decreased with each 0.5-mm increase in graft diameter in the range of <7.0 to >9.0 mm from 3.63% to 1.79%. CONCLUSION The risk of failure decreased correspondingly with each 0.5-mm increase in graft diameter in the range of <7.0 to >9.0 mm. Failure is multifactorial; however, increasing the graft diameter as much as possible to match each patient's anatomic space without overstuffing is an effective precaution that surgeons can take to reduce failures.
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Affiliation(s)
- Masafumi Itoh
- Department of Orthopedic Surgery, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan
- Institute for Medical Regulatory Science, Comprehensive Research Organization, Waseda University, Shinjuku, Tokyo, Japan
- Cooperative Major in Advanced Biomedical Sciences, Joint Graduate School of Tokyo Women's Medical University and Waseda University, Shinjuku, Tokyo, Japan
| | - Junya Itou
- Department of Orthopedic Surgery, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan
- Cooperative Major in Advanced Biomedical Sciences, Joint Graduate School of Tokyo Women's Medical University and Waseda University, Shinjuku, Tokyo, Japan
| | - Ken Okazaki
- Department of Orthopedic Surgery, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan
| | - Kiyotaka Iwasaki
- Institute for Medical Regulatory Science, Comprehensive Research Organization, Waseda University, Shinjuku, Tokyo, Japan
- Cooperative Major in Advanced Biomedical Sciences, Joint Graduate School of Tokyo Women's Medical University and Waseda University, Shinjuku, Tokyo, Japan
- Department of Modern Mechanical Engineering, Waseda University, Shinjuku, Tokyo, Japan
- Department of Integrative Bioscience and Biomedical Engineering, Graduate School of Advanced Science and Engineering, Waseda University, Shinjuku, Tokyo, Japan
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Kaarre J, Benvegnu NA, Engler ID, Nazzal EM, Zsidai B, Senorski EH, Musahl V, Samuelsson K. Metal interference screw fixation combinations show high revision rates in primary hamstring tendon ACL reconstruction. BMC Musculoskelet Disord 2024; 25:2. [PMID: 38166808 PMCID: PMC10759459 DOI: 10.1186/s12891-023-07109-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 12/11/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Different fixation methods in anterior cruciate ligament reconstruction (ACLR) have been associated with different revision rates, specifically in the early postoperative period. However, most previous research has either grouped together different fixation types or evaluated femoral-sided fixation or tibial-sided fixation separately. Therefore, the purpose of this study was to determine ACL revision rates for specific combinations of femoral and tibial fixation methods within 2 years of primary hamstring tendon autograft ACLR based on data from the Swedish National Knee Ligament Registry (SNKLR). METHODS Patients that underwent primary hamstring tendon autograft ACLR between 2005 and 2018 in the SNKLR were included. The collected data included patient characteristics (age, sex, body mass index [BMI]), activity at time of injury, surgical information (concomitant injuries, time from injury to surgery, fixation types at the femur and tibia), and subsequent revision ACLR. Revision rate within 2 years of the index procedure was chosen, as ACLR fixation is most likely to contribute to ACLR revision within the first 2 years, during graft maturation. RESULTS Of the 23,238 included patients undergoing primary hamstring ACLR, 581 (2.5%) underwent revision ACLR within 2 years of the index procedure. Among the combinations used for > 300 patients, the femoral metal interference screw/tibial metal interference screw fixation combination had the highest revision rate followed by metal interference screw/resorbable screw and Endobutton/AO screw fixation combinations, with respective revision rates of 4.0, 3.0, and 3.0%. The lowest revision rate within 2 years of ACLR was found in the Endobutton/metal interference screw with backup Osteosuture fixation combination, used in 433 cases, with a failure rate of 0.9%. CONCLUSION Different early ACL revision rates were found across different combinations of femoral and tibial fixation devices within 2 years of primary hamstring tendon autograft ACLR. Metal interference screw fixation, particularly when performed on both the femoral and tibial sides, most frequently resulted in revision ACLR. These findings may be helpful for surgeons in selecting appropriate fixation devices for hamstring ACLR. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Janina Kaarre
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden.
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, USA.
| | - Neilen A Benvegnu
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, USA
| | - Ian D Engler
- Central Maine Healthcare Orthopedics, Central Maine Medical Center, Auburn, ME, USA
| | - Ehab M Nazzal
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, USA
| | - Bálint Zsidai
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
| | - Eric Hamrin Senorski
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, USA
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
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Lee SS, Kwon KB, Lee J, Ryu DJ, Jang S, Wang JH. Single Bundle Anterior Cruciate Ligament With Anterolateral Ligament Reconstruction Yields Similar Clinical and Radiographic Results at Minimum 2-Year Follow-Up Versus Double Bundle Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Controlled Trial. Arthroscopy 2023; 39:2502-2512. [PMID: 37207917 DOI: 10.1016/j.arthro.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/27/2023] [Accepted: 04/27/2023] [Indexed: 05/21/2023]
Abstract
PURPOSE To compare the clinical, radiographic, and second-look arthroscopic outcomes between double-bundle (DB) anterior cruciate ligament (ACL) reconstruction (DB group) and combined single-bundle (SB) ACL and anterolateral ligament (ALL) reconstruction (SB + ALL group) by a prospective randomized controlled trial. METHODS From May 2019 to June 2020, 84 patients were enrolled in this study. Among them, 10 were lost to follow-up. Thirty-six and 38 patients were successfully allocated to the DB (mean follow up 27.3 ± 4.2 months) and SB + ALL groups (27.2 ± 4.5 months), respectively. The preoperative and postoperative Lachman test, pivot shift test, anterior translation on stress radiographs, KT-2000 arthrometer, Lysholm score, International Knee Documentation Committee score, and Tegner activity score were evaluated and compared. Graft continuity was evaluated using postoperative magnetic resonance imaging (MRI) (32 and 36 patients underwent MRI in the DB and SB + ALL groups at 7.4 ± 3.2 and 7.5 ± 2.9 months after surgery, respectively), and second-look examinations (second-look examination and tibial screw removal were performed concomitantly when patients (1) had tibial screw-related irritation or (2) needed the screws removed, 28 and 23 patients underwent examinations in the DB and SB + ALL groups at 24.0 ± 6.8 and 24.9 ± 8.1 months after surgery, respectively). All measurements were compared between the groups. RESULTS Postoperative clinical outcomes significantly improved in both groups. (All variables showed P < .001) No statistically different outcomes were found between the 2 groups. Additionally, postoperative graft continuity on MRI and second-look examinations were not different between the 2 groups. CONCLUSIONS The DB and SB + ALL groups showed similar postoperative clinical, radiographic, and second-look arthroscopic outcomes. Both groups showed excellent postoperative stability and clinical outcomes compared with the preoperative measurements. LEVEL OF EVIDENCE Level II, randomized controlled trial.
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Affiliation(s)
- Sung-Sahn Lee
- Department of Orthopaedic Surgery, Ilsan Paik Hospital, Inje University School of Medicine, Goyangsi, Gyeonggido, Korea
| | - Kyeu Baek Kwon
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeounghun Lee
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Jin Ryu
- Department of Orthopaedic Surgery, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Seungpil Jang
- Department of Orthopaedic Surgery, Bupyeong Himchan Hospital, Incheon, Korea
| | - Joon Ho Wang
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; Department of Health Sciences and Technology and Department of Medical Device Management and Research, SAIHST, Sungkyunkwan University, Seoul, Korea.
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9
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Lifka S, Rehberger Y, Pastl K, Rofner-Moretti A, Reichkendler M, Baumgartner W. The Development and Biomechanical Analysis of an Allograft Interference Screw for Anterior Cruciate Ligament Reconstruction. Bioengineering (Basel) 2023; 10:1174. [PMID: 37892904 PMCID: PMC10604633 DOI: 10.3390/bioengineering10101174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/06/2023] [Indexed: 10/29/2023] Open
Abstract
Graft fixation during cruciate ligament reconstruction using interference screws is a common and frequently used surgical technique. These interference screws are usually made of metal or bioabsorbable materials. This paper describes the development of an allograft interference screw from cortical human bone. During the design of the screw, particular attention was paid to the choice of the screw drive and the screw shape, as well as the thread shape. Based on these parameters, a prototype was designed and manufactured. Subsequently, the first biomechanical tests using a bovine model were performed. The test procedure comprised a torsion test to determine the ultimate failure torque of the screw and the insertion torque during graft fixation, as well as a pull-out test to asses the ultimate failure load of the graft fixation. The results of the biomechanical analysis showed that the mean value of the ultimate failure torque was 2633 Nmm, whereas the mean occurring insertion torque during graft fixation was only 1125 Nmm. The mean ultimate failure load of the graft fixation was approximately 235 N. The results of this work show a good overall performance of the allograft screw compared to conventional screws, and should serve as a starting point for further detailed investigations and studies.
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Affiliation(s)
- Sebastian Lifka
- Institute of Biomedical Mechatronics, Johannes Kepler University Linz, 4040 Linz, Austria
| | | | | | | | - Markus Reichkendler
- Department of Orthopedic and Trauma Surgery, District Hospital Schwaz, 6130 Schwaz, Austria
| | - Werner Baumgartner
- Institute of Biomedical Mechatronics, Johannes Kepler University Linz, 4040 Linz, Austria
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10
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Ito N, Silva RS, Sigurðsson HB, Cortes DH, Silbernagel KG. Challenging the assumption of uniformity in patellar tendon structure: Regional patellar tendon morphology and mechanical properties in vivo. J Orthop Res 2023; 41:2232-2237. [PMID: 36970753 PMCID: PMC10522788 DOI: 10.1002/jor.25563] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 01/31/2023] [Accepted: 03/24/2023] [Indexed: 04/10/2023]
Abstract
Patellar tendons are assumed to be uniform in morphology and mechanical properties despite a higher prevalence of tendinopathies observed in the medial region. The purpose of this study was to compare the thickness, length, viscosity, and shear modulus of the medial, central, and lateral regions of healthy patellar tendons of young males and females in vivo. B-mode ultrasound and continuous shear wave elastography were performed on 35 patellar tendons (17 females, 18 males) over three regions of interest. A linear mixed-effects model (α = 0.05) was used to determine differences between the three regions and sexes followed by pairwise comparisons for significant findings. The lateral region (mean [95% confidence interval] = 0.34 [0.31-0.37] cm) was thinner compared with the medial (0.41 [0.39-0.44] cm, p < 0.001), and central (0.41 [0.39-0.44] cm, p < 0.001) regions regardless of sex. Viscosity was lower in the lateral (19.8 [16.9-22.7] Pa-s) versus medial region (27.4 [24.7-30.2] Pa-s, p = 0.001). Length had a region-by-sex interaction (p = 0.003) characterized by a longer lateral (4.83 [4.54-5.13] cm) versus medial (4.42 [4.12-4.72] cm) region in males (p < 0.001), but not females (p = 0.992). Shear modulus was uniform between regions and sexes. The thinner, and less viscous lateral patellar tendon may reflect the lower load the tendon experiences explaining the differences in regional prevalence of developing tendon pathology. Statement of Clinical Significance: Healthy patellar tendons are not uniform in morphology or mechanical properties. Considering regional tendon properties may help guide targeted interventions for patellar tendon pathologies.
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Affiliation(s)
- Naoaki Ito
- Biomechanics and Movement Science Program, University of Delaware, Newark, DE, USA
- Department of Physical Therapy, University of Delaware, Newark, DE, USA
| | - Rodrigo Scattone Silva
- Biomechanics and Movement Science Program, University of Delaware, Newark, DE, USA
- Department of Physical Therapy, University of Delaware, Newark, DE, USA
- Postgraduate Program in Rehabilitation Sciences, Postgraduate Program in Physical Therapy, Federal University of Rio Grande do Norte, Santa Cruz, RN, Brazil
| | | | - Daniel H. Cortes
- Department of Mechanical Engineering, Penn State University, State College, PA, USA
| | - Karin Grävare Silbernagel
- Biomechanics and Movement Science Program, University of Delaware, Newark, DE, USA
- Department of Physical Therapy, University of Delaware, Newark, DE, USA
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11
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Dadoo S, Engler ID, Kaarre J, Chang AY, Shannon MF, Smith CN, Keeling LE, Musahl V. Low-Volume Surgeons Use Allograft in Younger Patients and Show Greater Rates of Revision Following Primary Allograft Anterior Cruciate Ligament Reconstruction Compared With High-Volume Surgeons. Arthrosc Sports Med Rehabil 2023; 5:100746. [PMID: 37645389 PMCID: PMC10461138 DOI: 10.1016/j.asmr.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/09/2023] [Indexed: 08/31/2023] Open
Abstract
Purpose To determine whether surgeon volume affects revision rate following primary anterior cruciate ligament reconstruction (ACLR) with allograft and to determine whether surgeon volume impacts allograft tissue type used. Methods All patients aged 14 years or older who underwent primary allograft ACLR at a large hospital system between January 2015 to December 2019 with minimum 2-year follow-up were included. Patients with double-bundle ACLR, multiligament reconstruction, and absent allograft type data were excluded. Surgeon volume was categorized as 35 or more ACLR/year for high-volume surgeons and less than 35 ACLR/year for low-volume surgeons. Revision was defined as subsequent ipsilateral ACLR. Patient characteristics, operative details, allograft type, and revision ACLR rates were retrospectively collected. Revision rate and allograft type were analyzed based on surgeon volume. Results A total of 457 primary allograft ACLR cases (mean age: 38.8 ± 12.3 years) were included. Low-volume surgeons experienced greater revision rates (10% vs 5%, P = .04) and used allograft in a younger population (37.6 vs 40.0 years old, P = .03) than high-volume surgeons. Subgroup analysis of the total cohort identified a significantly increased failure rate in patients <25 years old compared with ≥25 years old (30% vs 4%, P < .001). Allograft type selection varied significantly between surgeon volume groups, with low-volume surgeons using more bone-patellar tendon-bone (P < .001) and less semitendinosus allograft (P = .01) than high-volume surgeons. No differences in revision rate were observed based on allograft type (P = .71). Conclusions There was a greater revision rate following primary allograft ACLR among low-volume surgeons compared with high-volume surgeons. Low-volume surgeons also used allograft in a younger population than did high-volume surgeons. Level of Evidence Level III, retrospective comparative prognostic trial.
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Affiliation(s)
- Sahil Dadoo
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Ian D. Engler
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
- Central Maine Healthcare Orthopedics, Central Maine Medical Center, Auburn, Maine, U.S.A
| | - Janina Kaarre
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
- Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Audrey Y. Chang
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Michael F. Shannon
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Clair N. Smith
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Laura E. Keeling
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Volker Musahl
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
- Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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12
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Sood M, Kulshrestha V, Kumar S, Kumar P, Amaravati RS, Singh S. "Trends and beliefs in ACL reconstruction surgery: Indian perspectives". J Clin Orthop Trauma 2023; 39:102148. [PMID: 36974199 PMCID: PMC10039028 DOI: 10.1016/j.jcot.2023.102148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 01/19/2023] [Accepted: 03/15/2023] [Indexed: 03/26/2023] Open
Abstract
Objectives The survey aimed to assess trends and beliefs in the management of anterior cruciate ligament reconstruction (ACLR) amongst orthopaedic surgeons in India. Methods A survey was created and distributed among the various orthopaedic surgeons from India. The questionnaire included brief details of surgeons and their experience, clinical assessment, management strategies and the rehabilitation protocol. Results 135 surgeons completed the survey. 35% of them were having experience of more than 12 years. A large number of surgeons were from government academic institutes (35.5%). The most common criteria for deciding about surgery was Clinical evaluation (94.8%). The most common graft choice was hamstring tendon (94%), and suspensory fixation on the femur side and interference screw on the tibial side (80%) is the most common fixation method. Almost two-thirds of surgeons in this survey use bracing to protect ACL graft in the initial phase. Conclusion We presented the preferences amongst the group of surgeons on the management of ACL injuries. Hamstring tendon graft remains the most preferred graft for ACL reconstruction. Further, the suspensory loop on the femoral side and interference screw on the tibial side are the preferred fixation method. This group of surgeons is conservative in terms of the timing of surgeries and post-operative bracing. Level of evidence Level V, Expert Opinion.
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Affiliation(s)
| | | | | | | | | | - Shalendra Singh
- Department of Anesthesia, Armed Forces Medical College, Pune, 411040, India
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13
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Barnes DA, Flannery SW, Badger GJ, Yen YM, Micheli LJ, Kramer DE, Fadale PD, Hulstyn MJ, Owens BD, Murray MM, Fleming BC, Kiapour AM. Quantitative MRI Biomarkers to Predict Risk of Reinjury Within 2 Years After Bridge-Enhanced ACL Restoration. Am J Sports Med 2023; 51:413-421. [PMID: 36645042 PMCID: PMC9905304 DOI: 10.1177/03635465221142323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Quantitative magnetic resonance imaging (qMRI) methods were developed to establish the integrity of healing anterior cruciate ligaments (ACLs) and grafts. Whether qMRI variables predict risk of reinjury is unknown. PURPOSE To determine if qMRI measures at 6 to 9 months after bridge-enhanced ACL restoration (BEAR) can predict the risk of revision surgery within 2 years of the index procedure. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Originally, 124 patients underwent ACL restoration as part of the BEAR I, BEAR II, and BEAR III prospective trials and had consented to undergo an MRI of the surgical knee 6 to 9 months after surgery. Only 1 participant was lost to follow-up, and 4 did not undergo MRI, leaving a total of 119 patients for this study. qMRI techniques were used to determine the mean cross-sectional area; normalized signal intensity; and a qMRI-based predicted failure load, which was calculated using a prespecified equation based on cross-sectional area and normalized signal intensity. Patient-reported outcomes (International Knee Documentation Committee subjective score), clinical measures (hamstring strength, quadriceps strength, and side-to-side knee laxity), and functional outcomes (single-leg hop) were also measured at 6 to 9 months after surgery. Univariate and multivariable analyses were performed to determine the odds ratios (ORs) for revision surgery based on the qMRI and non-imaging variables. Patient age and medial posterior tibial slope values were included as covariates. RESULTS In total, 119 patients (97%), with a median age of 17.6 years, underwent MRI between 6 and 9 months postoperatively. Sixteen of 119 patients (13%) required revision ACL surgery. In univariate analyses, higher International Knee Documentation Committee subjective score at 6 to 9 months postoperatively (OR = 1.66 per 10-point increase; P = .035) and lower qMRI-based predicted failure load (OR = 0.66 per 100-N increase; P = .014) were associated with increased risk of revision surgery. In the multivariable model, when adjusted for age and posterior tibial slope, the qMRI-based predicted failure load was the only significant predictor of revision surgery (OR = 0.71 per 100 N; P = .044). CONCLUSION Quantitative MRI-based predicted failure load of the healing ACL was a significant predictor of the risk of revision within 2 years after BEAR surgery. The current findings highlight the potential utility of early qMRI in the postoperative management of patients undergoing the BEAR procedure.
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Affiliation(s)
- Dominique A. Barnes
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Sean W. Flannery
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Gary J. Badger
- Department of Medical Biostatistics, Larner College of
Medicine, University of Vermont, Burlington, VT, USA
| | - Yi-Meng Yen
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Lyle J. Micheli
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Dennis E. Kramer
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Paul D. Fadale
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Michael J. Hulstyn
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Brett D. Owens
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Martha M. Murray
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Ata M. Kiapour
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
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14
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ACL surgical trends evolve in the last five years for young European surgeons: results of the survey among the U45 ESSKA members. Knee Surg Sports Traumatol Arthrosc 2023; 31:619-625. [PMID: 35699743 DOI: 10.1007/s00167-022-07005-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 05/10/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE Although the outcomes of ACL reconstruction are generally satisfying, there are several patients who do not regain their pre-injury sporting level and suffer persistent symptoms. Orthopaedic practice has evolved significantly over the last five years to address these drawbacks. The aim of the present survey was to analyze the changes in the approach to ACL reconstruction among a population of young ESSKA surgeons dedicated to ACL surgery. METHODS The survey was uploaded on the ESSKA website and was accessible to members under the age of 45. The ESSKA society has 1035 U45 members involved in multiple aspects of Orthopaedic practice. One hundred and forty questionnaires were returned. Several aspects of ACL surgery were investigated at baseline and 5 years prior. They included general details such as the volume of ACL reconstructions per surgeon per year, the graft choice in cases of low and high demanding patients, the technique for femoral tunnel drilling and the preferred device for femoral fixation. The approach to the management of damage to peripheral structures, as well as meniscal ramp and root tears were also investigated. RESULTS Hamstrings and quadrupled semitendinosus were the preferred graft choice in low-demanding patients (92.9%) while quadriceps tendon is gaining popularity in contact sport practitioners (from 4.3 to 10.7%). The percentage of surgeons using femoral screws had decreased from 37.9 to 29.3 while the percentage of those who used buttons increased from 52.9 to 69.3%. Extra-articular procedures (antero-lateral ligament (ALL) or lateral tenodesis have become popular. The percentage of surgeons who perform an additional peripheral reconstruction rose from 28.5 to 71.5%. Of those who perform the meniscal repair more than 50% of patients rose from 14.3 to 27.9%. Similarly, the percentage of surgeons who performed a medial meniscus ramp lesion repair rose from 29.4 to 54.7%. While the percentage of those who choose to perform a transtibial pull-out repair of lateral meniscus root tears significantly rose from 17.9 to 59.3%. CONCLUSIONS The present survey among under 45 years old ESSKA surgeons yields some notable findings. The new evidence on the impact of injuries on peripheral structures and menisci is stimulating surgeons towards a more anatomic approach if identified at the time of ACL reconstruction. This evidence will probably influence future research and decision-making. LEVEL OF EVIDENCE IV.
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15
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Tiao J, Wang K, Carbone AD, Herrera M, Zubizarreta N, Gladstone JN, Colvin AC, Anthony SG. Ambulatory Surgery Centers Significantly Decrease Total Health Care Expenditures in Primary Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2023; 51:97-106. [PMID: 36453721 DOI: 10.1177/03635465221136542] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND Anterior cruciate ligament reconstruction (ACLR) is a commonly performed orthopaedic procedure. The volume and cost of ACLR procedures are increasing annually, but the drivers of these cost increases are not well described. PURPOSE To analyze the modifiable drivers of total health care utilization (THU), immediate procedure reimbursement, and surgeon reimbursement for patients undergoing ACLR using a large national commercial insurance database from 2013 to 2017. STUDY DESIGN Descriptive epidemiology study. METHODS For this study, the cohort consisted of patients identified in the MarketScan Commercial Claims and Encounters database who underwent outpatient arthroscopic ACLR in the United States from 2013 to 2017. Patients with Current Procedural Terminology code 29888 were included. THU was defined as the sum of any payment related to the ACLR procedure from 90 days preoperatively to 180 days postoperatively. A multivariable model was utilized to describe the patient- and procedure-related drivers of THU, immediate procedure reimbursement, and surgeon reimbursement. RESULTS There were 34,862 patients identified. On multivariable analysis, the main driver of THU and immediate procedure reimbursement was an outpatient hospital as the surgical setting (US$6789 increase in THU). The main driver of surgeon reimbursement was an out-of-network surgeon (US$1337 increase). Health maintenance organization as the insurance plan type decreased THU, immediate procedure reimbursement, and surgeon reimbursement (US$955, US$108, and US$38 decrease, respectively, compared with preferred provider organization; P < .05 for all). CONCLUSION Performing procedures in more cost-efficient ambulatory surgery centers had the largest effect on decreasing health care expenditures for ACLR. Health maintenance organizations aided in cost-optimization efforts as well, but had a minor effect on surgeon reimbursement. Overall, this study increases transparency into what drives reimbursement and serves as a foundation for how to decrease health care expenditures related to ACLR.
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Affiliation(s)
- Justin Tiao
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kevin Wang
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Andrew D Carbone
- Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, USA
| | - Michael Herrera
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nicole Zubizarreta
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - James N Gladstone
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexis C Colvin
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shawn G Anthony
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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16
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Surgeon's experience, sports participation and a concomitant MCL injury increase the use of patellar and quadriceps tendon grafts in primary ACL reconstruction: a nationwide registry study of 39,964 surgeries. Knee Surg Sports Traumatol Arthrosc 2023; 31:475-486. [PMID: 35896755 PMCID: PMC9898417 DOI: 10.1007/s00167-022-07057-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 06/20/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE To investigate the influence of surgeon-related factors and clinic routines on autograft choice in primary anterior cruciate ligament reconstruction (ACLR). METHODS Data from the Swedish National Knee Ligament Registry (SNKLR), 2008-2019, were used to study autograft choice (hamstring; HT, patellar; PT, or quadriceps tendon; QT) in primary ACLR. Patient/injury characteristics (sex, age at surgery, activity at time of injury and associated injuries) and surgeon-/clinic-related factors (operating volume, caseload and graft type use) were analyzed. Surgeon/clinic volume was divided into tertiles (low-, mid- and high-volume categories). Multivariable logistic regression was performed to assess variables influencing autograft choice in 2015-2019, presented as the odds ratio (OR) with a 95% confidence interval (CI). RESULTS 39,964 primary ACLRs performed by 299 knee surgeons in 91 clinics were included. Most patients received HT (93.7%), followed by PT (4.2%) and QT (2.1%) grafts. Patients were mostly operated on by high-volume (> 28 ACLRs/year) surgeons (68.1%), surgeons with a caseload of ≥ 50 ACLRs (85.1%) and surgeons with the ability to use ≥ two autograft types (85.9%) (all p < 0.001). Most patients underwent ACLR at high-volume (> 55 ACLRs/year) clinics (72.2%) and at clinics capable of using ≥ two autograft types (93.1%) (both p < 0.001). Significantly increased odds of receiving PT/QT autografts were found for ACLR by surgeons with a caseload of ≥ 50 ACLRs (OR 1.41, 95% CI 1.11-1.79), but also for injury during handball (OR 1.31, 95% CI 1.02-1.67), various other pivoting sports (basketball, hockey, rugby and American football) (OR 1.59, 95% CI 1.24-2.03) and a concomitant medial collateral ligament (MCL) injury (OR 4.93, 95% CI 4.18-5.80). In contrast, female sex (OR 0.87, 95% CI 0.77-0.97), injury during floorball (OR 0.71, 95% CI 0.55-0.91) and ACLR by mid-volume relative to high-volume surgeons (OR 0.62, 95% CI 0.53-0.73) had significantly reduced odds of receiving PT/QT autografts. CONCLUSION An HT autograft was used in the vast majority of cases, but PT/QT autografts were used more frequently by experienced surgeons. Prior research has demonstrated significant differences in autograft characteristics. For this reason, patients might benefit if surgery is performed by more experienced surgeons. LEVEL OF EVIDENCE Level III.
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17
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Pichler L, Pichler L, Liu M, Payr S, Binder H, Kaiser G, Hofbauer M, Tiefenboeck T. Functional Outcome of All-Soft-Tissue Quadriceps Tendon Autograft in ACL Reconstruction in Young and Athletic Patients at a Minimum Follow-Up of 1 Year. J Clin Med 2022; 11:jcm11226706. [PMID: 36431183 PMCID: PMC9698015 DOI: 10.3390/jcm11226706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 11/06/2022] [Accepted: 11/11/2022] [Indexed: 11/16/2022] Open
Abstract
To investigate the functional outcome in young and athletic patients with ACL injuries, treated with an all-soft-tissue quadriceps tendon autograft at a minimum follow-up of 12 months. Methods: Patients who received a QT autograft ACL reconstruction between August 2018 and December 2020 were included in this study. Range of motion in the operated knee was described at 6 and 18 weeks after surgery and the functional outcome parameters (Lysholm score, IKDC score and Tegner activity scale) were calculated at 6 and ≥ 12 months after surgery. Results: Forty patients were included in this study, of which 29 identified as male and 11 as female. The average age was 31.3 years (range 16 to 57 years) and the mean follow-up time was 16.8 months (range 12 to 30 months). All functional outcome scores showed improvement over the course of the follow-up: Lysholm score 94.2 to 95.5 (n.s.), IKDC score 90.1 to 93.9 (n.s.), Tegner activity scale 3.7 to 5.0 (p > 0.001), all at six months and ≥12 months. No reruptures happened during the time of the follow-up. Conclusions: This study shows that the all-soft-tissue quadriceps tendon autograft technique can improve functional outcome in young and athletic patients with an ACL injury at short to intermediate follow-up.
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Affiliation(s)
- Lorenz Pichler
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | | | - Markus Liu
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Stephan Payr
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Harald Binder
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Georg Kaiser
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Marcus Hofbauer
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Thomas Tiefenboeck
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, 1090 Vienna, Austria
- Correspondence:
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18
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Schaffer JC, Kuhns B, Reuter J, Sholtis C, Karnyski S, Goldblatt JP, Bronstein RD, Maloney MD, Baumhauer J, Mannava S. Clinically Depressed Patients Having Anterior Cruciate Ligament Reconstruction Show Improved but Inferior Rate of Achieving Minimum Clinically Important Difference for Patient-Reported Outcomes Measurement Information System Compared With Situationally Depressed or Nondepressed Patients. Arthroscopy 2022; 38:2863-2872. [PMID: 35550418 DOI: 10.1016/j.arthro.2022.04.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/07/2022] [Accepted: 04/19/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether the preoperative diagnosis of depression predicted worse postoperative outcomes, including physical therapy (PT) compliance, return-to-sport, and patient-reported outcomes using the Patient-Reported Outcomes Measurement Information System (PROMIS) after anterior cruciate ligament (ACL) reconstruction. METHODS A multisurgeon series of consecutive patients who had undergone ACL reconstruction with minimum 2-year follow-up were included. Chart review was conducted to determine depression diagnosis status, demographic data, rehabilitation PT compliance, return to sports, and patient-reported outcome data using PROMIS. Patients who met the PROMIS threshold for mild depression but did not carry a clinical diagnosis of depression were classified as "situationally depressed." RESULTS Ninety-five of 115 consecutive patients (81%) met inclusion criteria with an average follow-up of 34 ± 1.9 months. Fourteen patients (15%) had a preoperative diagnosis of depression, whereas 21 (22%) were considered situationally depressed. Clinically depressed patients had a greater rate of PT noncompliance (33.2% ± 17.6% vs 21.9% ± 12.6%; P = .02) and a lower postoperative PROMIS Physical Function (50.8 ± 7.7 vs 57.8 ± 11.0; P = .03 compared with patients without depression. Situationally depressed patients had lower preoperative physical function (35.4 vs 42.5; P = .04) with no differences in postoperative outcomes scores compared to the non-depressed cohort.19/21 (90.5%) of situationally depressed patients had postoperative resolution of their depressive symptoms. CONCLUSIONS Situationally depressed patients without a clinical diagnosis of depression can expect significant improvements in both pain and function, as well as a resolution of their depressed mood based on PROMIS scores as they progress through recovery after ACL reconstruction. Clinically depressed patients also experience significant improvements; however, their rate of achieving the minimum clinically important difference for PROMIS outcomes may be less than their nondepressed or situationally depressed counterparts. LEVEL OF EVIDENCE III, prognostic comparative trial.
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Affiliation(s)
- Joseph C Schaffer
- Department of Orthopaedics & Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Benjamin Kuhns
- Department of Orthopaedics & Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A.
| | - John Reuter
- Department of Orthopaedics & Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Connor Sholtis
- Department of Orthopaedics & Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Steven Karnyski
- Department of Orthopaedics & Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - John P Goldblatt
- Department of Orthopaedics & Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Robert D Bronstein
- Department of Orthopaedics & Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Michael D Maloney
- Department of Orthopaedics & Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Judith Baumhauer
- Department of Orthopaedics & Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Sandeep Mannava
- Department of Orthopaedics & Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A
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Kremen TJ, Arnold MT, Trivellas M, Shi BY, Jones KJ, Garcia-Mansilla I. Combined Assessments of Patellar Tendon and Hamstring Tendon Parameters on Preoperative Magnetic Resonance Imaging Can Improve Predictability of Hamstring Tendon Autograft Diameter in the Setting of Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2022; 4:e1913-e1921. [PMID: 36579048 PMCID: PMC9791872 DOI: 10.1016/j.asmr.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/27/2022] [Indexed: 12/31/2022] Open
Abstract
Purpose To evaluate whether preoperative magnetic resonance imaging (MRI) measurements of multiple tendon autograft sources could be used to improve estimates of intraoperative hamstring tendon autograft (HTA) diameter. Methods Patients who underwent anterior cruciate ligament reconstruction with HTA at our institution were identified through electronic health records. Preoperative MRI tendon measurements of the patellar tendon (PT) length, PT width, PT thickness, quadriceps tendon thickness, semitendinosus tendon (ST) cross-sectional area (CSA), and gracilis tendon (GT) CSA were conducted by 2 independent evaluators using digital imaging measurement tools. Results A total of 53 patients met the inclusion criteria, with a mean HTA diameter of 7.98 ± 0.7 mm. Height greater than 1.63 m, weight greater than 63.4 kg, PT length greater than 4.2 cm, PT thickness greater than 0.33 cm, ST CSA greater than 10.8 mm2, and GT CSA greater than 6.3 mm2 were associated with an HTA of 8 mm or greater (P < .005). Female sex was associated with an HTA of less than 8 mm (P < .05). PT length, PT thickness, and GT CSA were the strongest predictors of an HTA of 8 mm or greater and were combined into an additive logistic regression model: Score = -23.24 + (1.68 × PT length) + (20.104 × PT thickness) + (1.48 × GT CSA). If the score was greater than 0.237, the HTA graft diameter was predicted to be 8 mm or greater with 83% specificity, 91% sensitivity, and 87% accuracy. Conclusions By combining PT length and PT thickness measurements with GT CSA measurements in a logit function model, we were able to show improved overall specificity, sensitivity, and accuracy of estimated HTA diameters in our data set when compared with assessments of anthropometric, ST CSA, GT CSA, or combined ST-GT CSA measurements in isolation. Clinical Relevance Preoperative MRI measurements may be used to screen whether a patient is likely to have an 8-mm graft in the setting of anterior cruciate ligament reconstruction with HTA and thus may help guide graft choice.
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Affiliation(s)
- Thomas J. Kremen
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA,Address correspondence to Thomas J. Kremen Jr, M.D., Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1225 15th St, Ste 2100, Santa Monica, CA 90404, USA
| | - Michael T. Arnold
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Myra Trivellas
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Brendan Y. Shi
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Kristofer J. Jones
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
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20
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Leyes M, González-Martín D, Flores-Lozano C, González-Salvador M, Martín-Buenadicha E, García-Crespo R. Supplementary Tibial Fixation in Anterior Cruciate Ligament Reconstruction With Bone-Tendon-Bone Graft. Arthrosc Tech 2022; 11:e1551-e1556. [PMID: 36185108 PMCID: PMC9519938 DOI: 10.1016/j.eats.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 04/26/2022] [Indexed: 02/03/2023] Open
Abstract
Good to excellent results at long-term follow-up have been published for anterior cruciate ligament reconstruction with bone-tendon-bone graft. Despite improvements in fixation devices, concerns regarding the stability of graft fixation on the tibial side remain. We present supplementary tibial fixation for anterior cruciate ligament reconstruction with bone-tendon-bone graft using a transosseous technique that is simple and inexpensive and avoids the risk of symptomatic hardware.
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Affiliation(s)
- Manuel Leyes
- Department of Orthopaedic Surgery and Traumatology, Olympia, Quirón Salud, Madrid, Spain
| | - David González-Martín
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario de Canarias, Tenerife, Spain,Universidad de La Laguna, Tenerife, Spain,Address correspondence to David González-Martín, M.D., Ph.D., Department of Orthopaedic Surgery and Traumatology, Olympia, Quirón Salud, Madrid, Spain.
| | - César Flores-Lozano
- Department of Orthopaedic Surgery and Traumatology, Olympia, Quirón Salud, Madrid, Spain
| | | | | | - Rodrigo García-Crespo
- Department of Orthopaedic Surgery and Traumatology, Olympia, Quirón Salud, Madrid, Spain,Department of Orthopedics, Hospital Clinico San Carlos, Madrid, Spain
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21
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Carbone AD, Wang K, Tiao J, Chu B, Poeran J, Colvin AC, Gladstone JN, Anthony SG. Trends in Health Care Expenditures and Patient Out-of-Pocket Expenses in Primary Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2022; 50:2680-2687. [PMID: 35834951 DOI: 10.1177/03635465221107082] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament reconstruction (ACLR) is one of the most commonly performed orthopaedic procedures in the United States, and the number of procedures is increasing annually, as is the cost. Patients are expected to shoulder a larger out-of-pocket expenditure. PURPOSE To answer the following questions: (1) How is reimbursement changing for ACLR, and how is this affecting patients' out-of-pocket expenditures? (2) How are reimbursements from payers and patients' out-of-pocket expenses for ACLR distributed, and how is this changing? (3) Does performing ACLR in an ambulatory surgery center (ASC) result in lower costs for payers and patients? STUDY DESIGN Economic and decision analysis study; Level of evidence, 4. METHODS A total of 37,763 patients who underwent outpatient primary arthroscopic ACLR in the United States between 2013 and 2017 were identified using the IBM MarketScan Commercial Claims and Encounters Database. Patients with concomitant procedures and revision ACLR were excluded. Recorded outcomes were total patient payments and reimbursed claim totals in US dollars. RESULTS Day-of-surgery reimbursement decreased 4.3% from $11,536 in 2013 to $11,044 in 2017, while patient out-of-pocket expenses increased 36% from $1085 in 2013 to $1480 in 2017. Day-of-surgery charges were the highest expense for patients, followed by physical therapy and magnetic resonance imaging (MRI) costs. Total reimbursement for MRI decreased 22.5%, while patient out-of-pocket expenses for MRI increased 166%. ACLR performed in an outpatient hospital resulted in 61% greater day-of-surgery expenditure for payers compared with ACLR performed in an ASC; however, the median total patient out-of-pocket savings for ACLRs performed in an ASC versus outpatient hospital was only $11. CONCLUSION Out-of-pocket expenses for patients are increasing as they are forced to cover a larger percentage of their health care costs despite overall payer reimbursement decreasing. High-deductible health plans reimbursed the least out of all insurance types while having the highest patient out-of-pocket expenditure.
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Affiliation(s)
- Andrew D Carbone
- Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, USA
| | - Kevin Wang
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Justin Tiao
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brennan Chu
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jashvant Poeran
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Population Health Science & Policy, Institute for HealthCare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexis C Colvin
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - James N Gladstone
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shawn G Anthony
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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22
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Forsythe B, Chahla J, Korrapati A, Lavoie-Gagne O, Forlenza E, Diaz CC, Chung CB, Bae WC, Bach BR, Cole B, Yanke AB, Verma NN. Bone Marrow Aspirate Concentrate Augmentation May Accelerate Allograft Ligamentization in Anterior Cruciate Ligament Reconstruction: A Double-Blinded Randomized Controlled Trial. Arthroscopy 2022; 38:2255-2264. [PMID: 35042007 DOI: 10.1016/j.arthro.2022.01.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 01/03/2022] [Accepted: 01/06/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the effect of bone marrow aspiration concentrate (BMAC) augmentation on clinical outcomes and magnetic resonance imaging (MRI) findings in anterior cruciate ligament (ACL) reconstruction (ACLR) with bone-patellar tendon-bone (BTB) allografts. METHODS A double-blinded, randomized controlled trial was conducted on 80 patients undergoing ACL reconstruction using BTB allografts. Patients were randomized to 2 groups: (1) bone marrow aspirate was collected from the iliac crest, concentrated, and approximately 2.5 mL was injected into the BTB allograft, or (2) a small sham incision was made at the iliac crest (control). MRI was performed at 3 months and 9 months postoperatively to determine the signal intensity ratio of the ACL graft. RESULTS Seventy-three patients were available for follow-up at 1-year postoperatively (36 BMAC, 37 control). International Knee Documentation Committee (IKDC) scores were significantly greater in the BMAC group versus the control at the 9-month postoperative period (81.6 ± 10.5 vs 74.6 ± 14.2, P = .048). There was no significant difference in the proportion of patients who met the minimal clinically important difference for IKDC between the BMAC and control groups at 9 months (89% vs 85%; P = .7). Three months postoperatively, signal intensity ratio of the inferior third of the ACL graft was significantly greater in the BMAC group versus the control group (3.2 ± 2.2 vs 2.1 ± 1.5; P = .02). CONCLUSIONS Patients who received BMAC augmentation of the BTB allograft during ACL reconstruction demonstrated greater signal intensity scores on MRI at 3 months, suggesting increased metabolic activity and remodeling, and potentially accelerated ligamentization. Additionally, patients in the BMAC group had greater patient-reported outcomes (IKDC) at 9 months postoperatively when compared with those who underwent a standard surgical procedure. There was no significant difference in the proportion of patients who met the minimal clinically important difference for IKDC between the BMAC and control groups at 9 months, suggesting limited clinical significance at this time point. LEVEL OF EVIDENCE I, randomized control trial.
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Affiliation(s)
- Brian Forsythe
- Department of Sports Medicine, Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A..
| | - Jorge Chahla
- Department of Sports Medicine, Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | - Avinaash Korrapati
- Department of Sports Medicine, Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | - Ophelie Lavoie-Gagne
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Enrico Forlenza
- Department of Sports Medicine, Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | - Connor C Diaz
- Department of Sports Medicine, Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | - Christine B Chung
- Department of Radiology, University of California, San Diego, California, U.S.A
| | - Won C Bae
- Department of Radiology, University of California, San Diego, California, U.S.A
| | - Bernard R Bach
- Department of Sports Medicine, Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | - Brian Cole
- Department of Sports Medicine, Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | - Adam B Yanke
- Department of Sports Medicine, Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | - Nikhil N Verma
- Department of Sports Medicine, Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
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23
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Variations in common operations in athletes and non-Athletes. J Orthop 2022; 32:160-165. [PMID: 35747324 DOI: 10.1016/j.jor.2022.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 06/11/2022] [Indexed: 12/27/2022] Open
Abstract
Background Achieving pre-injury activity level after an injury is the fundamental goal of any orthopedic treatment for an athlete. Unfortunately, pre-injury activity levels differ significantly in different patient categories, especially in athletes and non-athlete. Hence, an outcome suitable to a non-athlete may not be adequate for an athlete. This has led to variations in the surgical approach to the same injury in an athlete and non-athlete.There is plenty of literature published comparing the outcome in athletes and non-athletes after a particular surgery. Scattered discussion about variations in these surgeries based on functional demand was done in many publications. But there was a lack of a comprehensive narrative review summarizing variations in common operations among athletes and non-athletes. Aim This review attempted to summarize variations in common sports operations between high functional demand patients and low demand patients and discuss the variations from the author's perspective. Methods A review of all the relevant papers were conducted focusing on athletes and non-athletes. Most commonly performed sports surgeries were ACL reconstruction, Meniscal repair, PCL reconstruction, and Shoulder instability surgery. A literature search was done for each commonly performed surgery using relevant keywords in PubMed and Google Scholars. Summary of papers pertinent to athletes and non-athletes were compiled to prepare this narrative review. Results There is a lack of papers directly comparing results in athletes and non-athletes. However, many research papers discussed surgical variations in athletes (high demand) and non-athletes (low demand) patients. There are controversies in all commonly performed surgeries, and none of the papers gives a definitive guideline on the approach to athletes and non-athlete. Conclusion Rather than a common suggestion on surgical variation, an individualized approach would be appropriate to decide on variation in particular surgery in both athletes and non-athletes.
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24
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Ammann E, Hecker A, Bachmann E, Snedeker JG, Fucentese SF. Evaluation of Tibial Fixation Devices for Quadrupled Hamstring ACL Reconstruction. Orthop J Sports Med 2022; 10:23259671221096107. [PMID: 35592018 PMCID: PMC9112421 DOI: 10.1177/23259671221096107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 02/25/2022] [Indexed: 11/26/2022] Open
Abstract
Background: Shortcomings to tibial-side fixation have been reported as causes of failure
after anterior cruciate ligament reconstruction. Adjustable-loop suspensory
devices have become popular; however, no comparison with hybrid fixation
(ie, interference screw and cortical button) exists to our knowledge. Purpose: The purpose of this study was to compare the biomechanical properties of
adjustable loop devices (ALDs) in full-tunnel and closed-socket
configurations in relation to hybrid fixation. We hypothesized that primary
stability of fixation by a tibial ALD will not be inferior to hybrid
fixation. Study Design: Controlled laboratory study. Methods: Tibial fixation of a quadrupled tendon graft was biomechanically investigated
in a porcine tibia–bovine tendon model using 5 techniques (n = 6 specimens
each). The tested constructs included hybrid fixation with a cortical
fixation button and interference screw (group 1), single cortical fixation
with the full-tunnel technique using an open-suture strand button (group 2)
or an ALD (group 3), or closed-socket fixation using 2 different types of
ALDs (groups 4 and 5). Each specimen was evaluated using a materials testing
machine (1000 cycles from 50-250 N and pull to failure). Force at failure,
cyclic displacement, stiffness, and ability to pretension the graft during
insertion were compared among the groups. Results: No differences in ultimate load to failure were found between the ALD
constructs (groups 3, 4, and 5) and hybrid fixation (group 1). Cyclic
displacement was significantly higher in group 2 vs all other groups
(P < .001); however, no difference was observed in
groups 3, 4, and 5 as compared with group 1. The remaining tension on the
construct after fixation was significantly higher in groups 3 and 4 vs
groups 1, 2, and 5 (P < .02 for all comparisons),
irrespective of whether a full-tunnel or closed-socket approach was
used. Conclusion: Tibial anterior cruciate ligament graft fixation with knotless ALDs achieved
comparable results with hybrid fixation in the full-tunnel and closed-socket
techniques. The retention of graft tension appears to be biomechanically
more relevant than tunnel type. Clinical Relevance: The study findings emphasize the importance of the tension at which fixation
is performed.
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Affiliation(s)
- Elias Ammann
- Balgrist University Hospital, Zürich, Switzerland
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25
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Moon HS, Choi CH, Yoo JH, Jung M, Lee TH, Hong KB, Kim SH. Graft isometry during anatomical ACL reconstruction has little effect on surgical outcomes. Knee Surg Sports Traumatol Arthrosc 2022; 30:1594-1604. [PMID: 34264371 DOI: 10.1007/s00167-021-06654-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 07/01/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE To investigate the surgical outcomes of anatomical anterior cruciate ligament (ACL) reconstruction according to the graft isometry measured during surgery. METHODS Electrical medical records of patients who underwent an arthroscopic ACL reconstruction through the transportal technique using hamstring tendon autograft between 2012 and 2016 were retrospectively reviewed. The patients were classified into two groups based on the graft length change throughout the knee range of motion measured just before graft fixation (Group 1, graft length change ≤ 2 mm; Group 2, graft length change > 2 mm). Comparative analyses, including a non-inferiority trial, were performed regarding the clinical scores, knee laxity, and radiographic parameters between the groups. RESULTS A total of 67 patients were included in the study. The total change in the length of ACL graft throughout the knee range of motion was 1.4 ± 0.4 mm in Group 1 (range, 0.2-2.0 mm), and 3.0 ± 0.7 mm in Group 2 (range, 2.2-5.0 mm). Group 1 showed a relatively high (proximal) femoral tunnel and shallow (anterior) tibial tunnel compared to Group 2 (P < 0.001 and P = 0.028, respectively), but there were no apparent differences in the macroscopic view. There were no statistically significant differences in the clinical outcomes between groups at 2 years after surgery, which satisfied the non-inferiority criterion of Group 1 in terms of clinical scores and knee laxity compared to Group 2. CONCLUSION The surgical outcomes of anatomical ACL reconstruction in patients with non-isometric ACL graft were not inferior in terms of clinical scores and knee laxity, compared to those with nearly-isometric ACL graft. The graft tunnel placement in the isometric position during anatomical ACL reconstruction, which is technically challenging in the clinical setting, is not a crucial factor in terms of clinical outcomes. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Hyun-Soo Moon
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Chong-Hyuk Choi
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Je-Hyun Yoo
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Min Jung
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae-Ho Lee
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 20 Eonju-ro 63-gil, Gangnam-gu, Seoul, 06229, Republic of Korea
| | - Kee-Bum Hong
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung-Hwan Kim
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea. .,Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 20 Eonju-ro 63-gil, Gangnam-gu, Seoul, 06229, Republic of Korea.
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26
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Drigny J, Ferrandez C, Gauthier A, Guermont H, Praz C, Reboursière E, Hulet C. Knee strength symmetry at 4 months is associated with criteria and rates of return to sport after anterior cruciate ligament reconstruction. Ann Phys Rehabil Med 2022; 65:101646. [PMID: 35167984 DOI: 10.1016/j.rehab.2022.101646] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 12/24/2021] [Accepted: 01/24/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Strength limb symmetry index (LSI) is a useful criterion to help in return-to-sport performance (RTP) after anterior cruciate ligament reconstruction (ACLR). OBJECTIVES We aimed to assess whether knee extensor and flexor LSI values at 4 months after ACLR are associated with those recommended at 8 months after ACLR for RTP (80%, 85% and 90%) and with successful RTP after 2 years. METHODS This was prospective cohort study of 113 participants who underwent primary ACLR. Personal factors such as demographic and sport information, injury and surgery characteristics were collected at 6 weeks after surgery. Isokinetic strength LSI (60°/s) was calculated at 4 months (LSI[4m]) and 8 months (LSI[8m]) for knee extensors (Q-LSI) and flexors (H-LSI). Participants were followed at 2 years after ACLR to determine their self-reported RTP. Multiple linear regression analysis was used to determine associations between personal factors and LSI at 4 and 8 months. Associations between passing the optimal cut-off thresholds and RTP were tested with chi-square tests and odds ratios (ORs) with effect sizes (ES). RESULTS Among the 113 participants (mean age 25.2 [SD 9.7] years; 42% females), extended tourniquet time and lower level of pre-injury sport were associated with lower Q-LSI[4m] and H-LSI[4m]. Bone-patellar tendon-bone graft was associated with lower Q-LSI[4m] and Q-LSI[8m], and older age was associated with lower Q-LSI[4m]. For knee extensors, Q-LSI[4m] >59% was associated with Q-LSI[8m] >80% (OR= 31.50, p <0.001, large ES) and increased odds of successful RTP (60% vs 31%, OR= 3.45, p= 0.003, medium ES). For knee flexors, H-LSI[4m] >72% was associated with H-LSI[8m] >90% (OR= 6.03, p <0.001, large ES) and increased odds of successful RTP (53% vs 23%, OR= 3.76, p= 0.013, small-to-medium ES). CONCLUSIONS After primary ACLR, 4-month post-operative strength symmetry was negatively associated with age, pre-injury sport and tourniquet time and bone-patellar tendon-bone graft. Four-month post-operative LSI was associated with 8-month post-operative LSI, and Q-LSI[4m] >59% or H-LSI[4m] >72% was associated with increased RTP rates after 2 years. CLINICALTRIALS.GOV: : NCT04071912.
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Affiliation(s)
- Joffrey Drigny
- Service de Médecine Physique et de Réadaptation, Service de Médecine du Sport, CHU de Caen Normandie, Normandie Univ, UNICAEN, INSERM, COMETE, GIP CYCERON, Caen 14000, France.
| | - Clémence Ferrandez
- Service de Médecine Physique et de Réadaptation, Service de Médecine du Sport, CHU de Caen Normandie, Caen 14000, France
| | - Antoine Gauthier
- Normandie Univ, UNICAEN, INSERM, COMETE, GIP CYCERON, Caen 14000, France
| | - Henri Guermont
- Service de Médecine du Sport, CHU de Caen Normandie, Caen 14000, France
| | - César Praz
- Département d'orthopédie et de traumatologie, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen 14000, France
| | | | - Christophe Hulet
- Département d'orthopédie et de traumatologie, Normandie Univ, UNICAEN, INSERM, COMETE, GIP CYCERON, Caen 14000, France
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27
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Wilder JH, Patel AH, Ross BJ, Weldy JM, Wang H, Sherman WF. Fracture Risk With Patella Resurfacing During Total Knee Arthroplasty After Anterior Cruciate Ligament Reconstruction Using Bone-Patella-Bone Autograft: A Biomechanical Analysis. Arthroplast Today 2022; 13:142-148. [PMID: 35106351 PMCID: PMC8784308 DOI: 10.1016/j.artd.2021.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/09/2021] [Accepted: 10/25/2021] [Indexed: 11/04/2022] Open
Abstract
Background Anterior cruciate ligament (ACL) tears are common injuries. Ipsilateral bone patellar tendon bone (BPTB) autograft has been frequently used for ACL reconstructions. A large percentage of patients who sustain ACL ruptures develop early osteoarthritis and require total knee arthroplasty (TKA). When patients with previous BPTB autograft for an ACL tear undergo TKA, there may be an increased risk of fracture after patellar resurfacing. Methods There were 20 artificial Sawbones and 10 cadaveric patellae resurfaced. To simulate the presence of a previous BPTB autograft, a bone plug was removed from the anterior surface of the patellae and was resurfaced with a cemented patellar button. Biomechanical testing was performed to determine the compressive load to fracture of patellae with and without previous BPTB autograft. Results The average maximum load to failure for the artificial Sawbones patellae without a previous BPTB autograft was 4551.40 N ± 753.12 compared with 2855.39 N ± 531.46 with a previous BPTB autograft (P < .001). The average maximum load to failure for the cadaveric patellae without a previous BPTB autograft was 7256.37 N ± 1473.97 compared with 5232.22 N ± 475.04 with a previous BPTB autograft (P = .021). Conclusions The results demonstrate a significantly lower maximum load to failure of a resurfaced patella in the presence of a previous BPTB autograft. This can be used to aid in the decision of whether to resurface the patellae in these patients and to educate patients that the presence of a previous BPTB autograft may be an increased risk factor for patella fracture after TKA.
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28
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Chu CR. Can we afford to ignore the biology of joint healing and graft incorporation after ACL reconstruction? J Orthop Res 2022; 40:55-64. [PMID: 34314066 DOI: 10.1002/jor.25145] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/23/2021] [Accepted: 07/01/2021] [Indexed: 02/04/2023]
Abstract
Anterior cruciate ligament (ACL) reconstruction is successful at restoring stability to return ACL injured patients to high-demand work, sports, and recreational activities. The development of posttraumatic osteoarthritis (OA) in roughly half of patients just 10-15 years after ACLR highlight the need to improve clinical care pathways. Graft failure and reinjury rates, which further increase OA risk, also remain high for younger and more active patients. The biological components of joint recovery and graft incorporation, therefore, impact short- and long-term clinical outcomes. Biochemical and magnetic resonance imaging (MRI) data show substantial compromise of articular cartilage metabolism and matrix composition after ACL injury and reconstructive surgery suggesting a potential need for activity modulation in early recovery. Furthermore, joint recovery is variable with compositional MRI studies showing progressive cartilage degeneration 1 and 2 years after ACLR. Biopsy and MRI studies also show high variability in ACL graft characteristics within the 1st year after ACLR followed by continued graft maturation into the 2nd year and beyond. To improve the care of ACL injured patients, there is a critical need for clinical attention and scientific inquiry into timing the reintroduction of higher load activities in relationship to neuromuscular recovery, joint biology, and graft maturation. In addition to symptomatic and mechanical recovery, development and validation of biological markers for joint and cartilage homeostasis as well as ACL graft healing are needed for personalized decision making on rehabilitation needs, reduction of OA risk, and resumption of athletic, recreational, and vocational activities.
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Affiliation(s)
- Constance R Chu
- Department Orthopaedic Surgery, Stanford University, Stanford, California, USA.,Veterans Affairs Palo Alto Healthcare System, Livermore, California, USA
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Takahashi T, Watanabe S, Ito T. Current and future of anterior cruciate ligament reconstruction techniques. World J Meta-Anal 2021; 9:411-437. [DOI: 10.13105/wjma.v9.i5.411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/09/2021] [Accepted: 10/25/2021] [Indexed: 02/06/2023] Open
Abstract
In recent years, anterior cruciate ligament (ACL) reconstruction has generally yielded favorable outcomes. However, ACL reconstruction has not provided satisfactory results in terms of the rate of returning to sports and prevention of osteoarthritis (OA) progression. In this paper, we outline current techniques for ACL reconstruction such as graft materials, double-bundle or single-bundle reconstruction, femoral tunnel drilling, all-inside technique, graft fixation, preservation of remnant, anterolateral ligament reconstruction, ACL repair, revision surgery, treatment for ACL injury with OA and problems, and discuss expected future trends. To enable many more orthopedic surgeons to achieve excellent ACL reconstruction outcomes with less invasive surgery, further studies aimed at improving surgical techniques are warranted. Further development of biological augmentation and robotic surgery technologies for ACL reconstruction is also required.
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Affiliation(s)
- Toshiaki Takahashi
- Department of Sports and Health Science, Ehime University, Matsuyama 790-8577, Ehime, Japan
| | - Seiji Watanabe
- Department of Orthopedic Surgery, Ehime University Graduate School of Medicine, Toon 791-0295, Ehime, Japan
| | - Toshio Ito
- Department of Orthopaedic Surgery, Murakami Memorial Hospital, Saijo 793-0030, Ehime, Japan
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Olotu O, Siddiqui A, Peterson D, de Sa D. The Superficial "Swing-Down" Quadriceps Tendon Autograft Is a Viable Option for Medial Patellofemoral Ligament Reconstruction: A Systematic Review. Arthroscopy 2021; 37:3187-3197. [PMID: 33961979 DOI: 10.1016/j.arthro.2021.04.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 04/06/2021] [Accepted: 04/12/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this systematic review is to ascertain the reported clinical outcomes and complication profiles of medial patellofemoral ligament (MPFL) reconstruction performed using a superficial "swing-down" quadriceps tendon autograft. METHODS Three databases (PubMed, EMBASE, and MEDLINE) were searched from January 1, 2000, to April 06, 2020. Keywords used in the search included: "medial patellofemoral ligament" and "reconstruction". After screening based on inclusion and exclusion criteria, patient demographics, graft type, outcomes, and complications were extracted. Methodological Index for Non-Randomized Studies criteria were used to assess the quality of each included study. RESULTS Eleven studies were included, comprising data from 226 patients with mean follow up ranging from 12 to 38 months. All reconstructions used a superficial "swing-down" quadriceps tendon autograft fixed at 20-30 degrees of knee flexion where reported. Eight of eleven studies reported significant improvement in patient reported outcomes such as Kujala score, Lysholm score, and Tegner score. The mean preoperative Kujala score ranged from 35.8 to 82.1 (167 patients), while the mean postoperative Kujala score ranged from 88.4 to 94.8 (197 patients). The mean of the preoperative Lysholm score ranged from 43.3 to 79.3 (77 patients), while the mean of the postoperative Lysholm score ranged from 81.9 to 90.9 (99 patients). The I2 statistic for Lysholm and Kujala scores was 94% and 97%, respectively. Across data reported on 194 patients, there was no incidence of patellar redislocation, patellar fracture, or graft site morbidity. CONCLUSION The quadriceps tendon produced improved clinical outcomes with low rates of recurrent postoperative patellar dislocation. These data suggest that the quadriceps tendon remains a suitable alternative for MPFL reconstruction and should remain part of the arsenal of knee ligament surgeons. LEVEL OF EVIDENCE Systematic review of Level III and IV studies.
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Affiliation(s)
- Olumide Olotu
- MACSports Research Program, McMaster University, Hamilton, Ontario, Canada; School of Medicine, St. George's University, True Blue, Grenada, West Indies
| | - Ali Siddiqui
- MACSports Research Program, McMaster University, Hamilton, Ontario, Canada
| | - Devin Peterson
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Darren de Sa
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada.
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Nazari G, Barton KI, Bryant D, Getgood A, Brown CH. Five- and six-strand hamstring grafts consistently produce appropriate graft diameters for anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:2940-2947. [PMID: 33037449 DOI: 10.1007/s00167-020-06313-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/28/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Hamstring tendon graft diameter less than 8 mm has been correlated with an increased risk of anterior cruciate ligament reconstruction (ACLR) graft failure. The purpose of this study was to measure and compare the diameter of 3-, 4-, 5-, and 6-strand gracilis and semitendinosus (ST) hamstring tendon (HT) ACLR grafts, and to determine if there is a correlation between anthropometric data, HT length, and diameter of the HT ACLR graft. METHODS Male patients (n = 78) undergoing primary or revision ACLR with a HT autograft between July 2018 and March 2020 were recruited. Pre-operative anthropometric data was collected. Gracilis and ST tendons were harvested and the length and diameter measured. The following HT graft configurations were prepared in each patient: triple ST; double gracilis + double ST; double gracilis + triple ST; triple gracilis + triple ST. Paired t-tests and Pearson's correlation coefficients were used to assess demographics, anthropometrics, graft diameter, and tendon length. A non-parametric test was used to compare femoral and tibial ACL graft diameters of the 3-, 4-, 5-, and 6-strand HT graft configurations. RESULTS For the femoral end, 10%, 19%, 69% and 86% of the patients achieved graft diameters of equal to or greater than 8 mm in 3-, 4-, 5- and 6-strand HT graft configurations respectively. For the tibial end, 27%, 10%, 83%, and 92% of the patients achieved graft diameters of equal to or greater than 8 mm in 3-, 4-, 5-, and 6-strand HT graft configurations respectively. The largest increases in HT graft diameters were noted between the femoral end of 6- vs. 3-strand grafts (mean difference 1.7 ± 0.5 mm; p < 0.001) and between the tibial end of 6- vs. 4-strand grafts (mean difference 2.0 ± 0.5 mm; p < 0.001). Height and leg length were moderately positively correlated with ST tendon length (r = 0.54-0.51) and gracilis tendon length (r = 0.52-0.45), and thigh and shank lengths were moderately positively correlated with ST tendon length (r = 0.43 and 0.40, respectively). CONCLUSION Traditional 4-strand HT ACL autografts in male patients undergoing ACLR in the United Arab Emirates result in graft diameters less than 8 mm in the majority of patients. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | - Kristen I Barton
- Western University, London, Canada
- Orthopaedic Surgery, London Health Sciences Centre, London, Canada
| | - Dianne Bryant
- Western University, London, Canada
- Fowler Kennedy Sports Medicine Clinic, London, Canada
| | - Alan Getgood
- Western University, London, Canada
- Orthopaedic Surgery, London Health Sciences Centre, London, Canada
- Fowler Kennedy Sports Medicine Clinic, London, Canada
- International Knee and Joint Centre, Abu Dhabi, United Arab Emirates
| | - Charles H Brown
- International Knee and Joint Centre, Abu Dhabi, United Arab Emirates.
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The Graft Insertion Length in the Femoral Tunnel During Anterior Cruciate Ligament Reconstruction With Suspensory Fixation and Tibialis Anterior Allograft Does Not Affect Surgical Outcomes but Is Negatively Correlated With Tunnel Widening. Arthroscopy 2021; 37:2903-2914.e1. [PMID: 33887417 DOI: 10.1016/j.arthro.2021.03.072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 03/28/2021] [Accepted: 03/30/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the surgical outcomes of anterior cruciate ligament (ACL) reconstruction using a low-dose irradiated tibialis anterior allograft with a fixed-loop cortical suspension device for the femur based on the graft insertion length (GIL) in the femoral tunnel. METHODS Between January 2010 and January 2018, the medical records of consecutive patients who underwent arthroscopic ACL reconstruction with a tibialis anterior allograft fixed with the EndoButton CL for the femur and who had at least 2 years of follow-up were retrospectively evaluated. Patients were classified into 3 groups based on the GIL in the femoral tunnel (group 1, GIL < 15 mm; group 2, GIL of 15-20 mm; and group 3, GIL > 20 mm), and their functional scores, knee laxity, and radiographic parameters were evaluated. RESULTS A total of 91 patients were analyzed. There were no statistically significant differences in the functional scores and knee laxity between the 3 groups at 2 years postoperatively. However, significant differences were observed in tunnel widening at 1 year postoperatively in the femur (P = .045 for absolute value and P = .004 for relative value) and the tibia (P = .014 for absolute value and P = .012 for relative value), revealing that both the femoral and tibial tunnels widened as the GIL decreased. Additional linear regression analyses were performed to identify whether the GIL independently affects tunnel widening. Consequently, the femoral tunnel depth, tunnel diameter, and GIL were found to independently influence femoral tunnel widening (P = .008, P = .019, and P < .001, respectively), whereas the tunnel diameter and GIL affected tibial tunnel widening (P < .001 and P = .004, respectively). CONCLUSIONS The GIL in the femoral tunnel during ACL reconstruction using a tibialis anterior allograft with a fixed-loop cortical suspension device for the femur has no significant association with the postoperative functional outcomes and knee laxity, but it has a negative correlation with tunnel widening in the femur and the tibia. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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ACL Reconstruction–Tunnel Placement is Critical for Success! OPER TECHN SPORT MED 2021. [DOI: 10.1016/j.otsm.2021.150829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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He X, Huang Z, Liu W, Liu Y, Qian H, Lei T, Hua L, Hu Y, Zhang Y, Lei P. Electrospun polycaprolactone/hydroxyapatite/ZnO films as potential biomaterials for application in bone-tendon interface repair. Colloids Surf B Biointerfaces 2021; 204:111825. [PMID: 33984615 DOI: 10.1016/j.colsurfb.2021.111825] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/07/2021] [Accepted: 05/04/2021] [Indexed: 11/28/2022]
Abstract
The bone-tendon interface (BTI) is a graded structure consisting of bone, mineralized and nonmineralized fibrocartilage, and tendons. Due to the complexity of the BTI structure, BTI healing is particularly challenging. To achieve a better material for BTI healing, polycaprolactone (PCL)/hydroxyapatite (HA)/ZnO films were constructed by the electrospinning method; in addition, the relevant material characteristics were tested. After culturing MC3T-E1 cells, ATDC5 cells, mouse primary fibrochondrocytes, and mouse primary tenocytes on films, PCL-5%HA-1%ZnO films (HA and ZnO weight ratios of 5% and 1%, respectively) displayed superior cell compatibility and cell adhesion. PCL-5%HA-1%ZnO films also promoted osteogenesis, chondrogenesis, fibrocartilage formation, and tendon healing. The antibacterial characteristics of PCL-5%HA-1%ZnO films were also identified in this study. The PCL-5%HA-1%ZnO films have great application potential in the field of BTI repair.
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Affiliation(s)
- Xi He
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, 410078, China; Hunan Engineering Research Center of Biomedical Metal and Ceramic Implants, Xiangya Hospital, Central South University, Changsha, 410078, China
| | - Zongwang Huang
- Department of Inorganic Materials, School of Minerals Processing and Bioengineering, Central South University, Changsha, 410083, China
| | - Wenbin Liu
- Department of Orthopaedical Surgery, Xiangya Hospital, Central South University, Changsha, 410078, China; Hunan Engineering Research Center of Biomedical Metal and Ceramic Implants, Xiangya Hospital, Central South University, Changsha, 410078, China
| | - Yanling Liu
- Provincial Laboratory for Diagnosis and Treatment of Genitourinary System Disease, Department of Urology, Xiangya Hospital, Central South University, Changsha, 410078, China
| | - Hu Qian
- Department of Orthopaedical Surgery, Xiangya Hospital, Central South University, Changsha, 410078, China; Hunan Engineering Research Center of Biomedical Metal and Ceramic Implants, Xiangya Hospital, Central South University, Changsha, 410078, China
| | - Ting Lei
- Department of Orthopaedical Surgery, Xiangya Hospital, Central South University, Changsha, 410078, China; Hunan Engineering Research Center of Biomedical Metal and Ceramic Implants, Xiangya Hospital, Central South University, Changsha, 410078, China
| | - Long Hua
- Department of Orthopaedical Surgery, Xiangya Hospital, Central South University, Changsha, 410078, China; Hunan Engineering Research Center of Biomedical Metal and Ceramic Implants, Xiangya Hospital, Central South University, Changsha, 410078, China
| | - Yihe Hu
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, 410078, China; Department of Orthopaedical Surgery, Xiangya Hospital, Central South University, Changsha, 410078, China; Hunan Engineering Research Center of Biomedical Metal and Ceramic Implants, Xiangya Hospital, Central South University, Changsha, 410078, China.
| | - Yi Zhang
- Department of Inorganic Materials, School of Minerals Processing and Bioengineering, Central South University, Changsha, 410083, China.
| | - Pengfei Lei
- Department of Orthopaedical Surgery, Xiangya Hospital, Central South University, Changsha, 410078, China; Hunan Engineering Research Center of Biomedical Metal and Ceramic Implants, Xiangya Hospital, Central South University, Changsha, 410078, China.
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Anterior Cruciate Ligament Reconstruction Graft Preference Most Dependent on Patient Age: A Survey of United States Surgeons. Arthroscopy 2021; 37:1559-1566. [PMID: 33539983 DOI: 10.1016/j.arthro.2021.01.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 01/12/2021] [Accepted: 01/15/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to define the anterior cruciate ligament (ACL) reconstruction (ACLR) graft preference of surgeons and to explore factors associated with their predilection. METHODS A 15-question survey regarding ACLR graft preference in various situations was completed by 514 American Orthopaedic Society for Sports Medicine and Arthroscopy Association of North America surgeons. Surgeon and practice demographics, along with various patient factors, were evaluated with bivariate and multivariable models for association with surgeon preference. Surgeons were also queried about their preference for their own ACLR. For surgeons who personally sustained an ACL, an additional 6 questions inquired about their experience. RESULTS Surgeons reported the 5 most important factors in patient graft choice, in order: patient age, graft failure in literature and practice, pivot sport, and patient preference. Autograft patellar and quadriceps tendon were strongly preferred for younger, pivoting athletes (P < .001), among those with fellowship training (47% vs 33%, P = .006), in academic practices (52% vs 44%, P = .003), and in more sports medicine-specific practices, with a higher number of ACLRs performed per year (P < .001). Northeast, Southeast, Midwest, and Southwest surgeons had lower hamstring autograft preference (P < .001). Non-fellowship-trained surgeons preferred hamstring autograft (P = .010). Allograft was preferred for older patients (P < .001). Nonsignificant predictors included highest level of athlete for whom an ACLR had been performed, level of athlete serving as team physician, and years in practice. No factors were associated with surgeon preference for their own ACLR despite deeming these factors important for patients. ACL tears were reported by 13% of respondents, with 86% stating it influenced their decision to enter orthopaedics. CONCLUSIONS Patient age was the most important factor in graft choice, with patellar and quadriceps tendon autograft the preferred graft for ACLR for younger, pivoting athletes. Fellowship training and practice demographics were also correlated with graft choice for patients. CLINICAL RELEVANCE Graft preference for ACLR varies among surgeons and is associated with surgeon experience and patient characteristics, including patient age, type of sport, and patient preference.
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Hamstrings substitution via anteromedial portal with optional anterolateral ligament reconstruction is the preferred surgical technique for anterior cruciate ligament reconstruction: a survey among ESSKA members. Knee Surg Sports Traumatol Arthrosc 2021; 29:1120-1127. [PMID: 32591846 DOI: 10.1007/s00167-020-06107-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 06/11/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE The objective of this study was to report on a worldwide web-based survey among the ESSKA community developed to investigate current recommendations regarding ACL reconstruction surgical procedures. METHODS All contacts in the official mailing list of the ESSKA were contacted to investigate preferences regarding graft type, anterolateral ligament reconstruction, femoral tunnel drilling technique, single-bundle vs double-bundle technique, femoral and tibial fixation methods. RESULTS Eight-hundred and twenty responses were analyzed. Hamstrings autograft was the graft of choice in male patients for 634 (79%) and in female patients for 674 (84%) responders, while its preference for ACL reconstruction in professional athletes was for 401 (50%). 480 (63%) surgeons surveyed would include anterolateral ligament reconstruction only if diagnosed and remaining instability after ACL surgery or revision. 598 (75%) respondents were in favor of anteromedial portal for femoral tunnel drilling. The most popular femoral fixation technique was found to be cortical suspension (500-66%), while a compression system was preferred on the tibial side by 537 (71% of the sample). CONCLUSIONS This survey study found that HT autograft, single-bundle reconstruction, anteromedial portal for femoral tunnel drilling, cortical suspension systems for femoral fixation and compression systems for tibial fixation represent the current standard of ACLR in a large community of orthopedic surgeons. The present study performed with surgeons who are members of the ESSKA community will help to comprehend the actual ACLR worldwide practice patterns. Due to low response rate, these results should be interpreted with caution and not to be intended to represent the state of the art of ESSKA community. LEVEL OF EVIDENCE III.
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Bowman EN, Freeman TH, Limpisvasti O, Cole BJ, ElAttrache NS. Anterior cruciate ligament reconstruction femoral tunnel drilling preference among orthopaedic surgeons. Knee 2021; 29:564-570. [PMID: 33774590 DOI: 10.1016/j.knee.2021.02.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 01/13/2021] [Accepted: 02/22/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Anterior cruciate ligament reconstruction (ACLR) technique for femoral tunnel drilling varies substantially, each with advantages and disadvantages. The purpose of this study was to define ACLR femoral tunnel technique predilection among surgeons and to explore factors associated with their preference. METHODS An 11-question survey regarding ACLR femoral tunnel technique was completed by 560 AANA/AOSSM members. Surgeon and practice demographics and residency and fellowship experiences were evaluated with bivariate and multivariable models for association with surgeon preference. RESULTS In current practice, 55% of surgeons prefer anteromedial (AM) portal drilling, 32% retrograde, and 14% transtibial (TT). Sports Medicine fellowship experience was the strongest predictor of current practice (p < 0.001), followed by residency technique (p = 0.014). A significant increase in TT drilling was noted for those practicing >15 years TT (29% vs 3%, p < 0.001), with an inverse relationship for retrograde drilling (38% vs 21%, p < 0.001). Number of ACLRs/year and percent Sports specific practice were significant predictors for AM drilling (p < 0.001). Though less than AM and retrograde, TT was more common for those in private practice (17% vs 8%, p < 0.001), and more prevalent in the Midwest/Southeast (19% vs 10%, p = 0.003). Non-significant predictors included highest level of athlete for whom an ACLR had been performed, level of athlete serving as team physician, and Certificate of Added Qualifications status. CONCLUSION Surgeon training, practice setting, and years in practice significantly predict preference for femoral tunnel drilling technique. Surgeon comfort and confidence in attaining an anatomic reconstruction should drive choice of technique.
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Affiliation(s)
- Eric N Bowman
- Department of Orthopaedics, Vanderbilt University Medical Center, 1215 21st Avenue South, 4200 Medical Center East, Nashville, TN 37232-8774, United States.
| | - Thomas H Freeman
- Department of Orthopaedics, Vanderbilt University Medical Center, 1215 21st Avenue South, 4200 Medical Center East, Nashville, TN 37232-8774, United States.
| | - Orr Limpisvasti
- Attending Orthopaedic Surgeon, Kerlan Jobe Institute, 6801 Park Terrace, Los Angeles, CA 90045, United States
| | - Brian J Cole
- Department of Orthopaedics, Rush University Medical Center, 1611 W Harrison, Suite 300, Chicago, IL 60612, United States.
| | - Neal S ElAttrache
- Attending Orthopaedic Surgeon, Kerlan Jobe Institute, 6801 Park Terrace, Los Angeles, CA 90045, United States.
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Lebedeva K, Bryant D, Docter S, Litchfield RB, Getgood A, Degen RM. The Impact of Resident Involvement on Surgical Outcomes following Anterior Cruciate Ligament Reconstruction. J Knee Surg 2021; 34:287-292. [PMID: 31461757 DOI: 10.1055/s-0039-1695705] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hands-on participation in the operating room (OR) is an integral component of surgical resident training. However, the implications of resident involvement in many orthopaedic procedures are not well defined. This study aims to assess the effect of resident involvement on short-term outcomes following anterior cruciate ligament reconstruction (ACLR). The National Surgical Quality Improvement Program (NSQIP) database was queried to identify all patients who underwent ACLR from 2005 to 2012. Demographic variables, resident participation, 30-day complications, and intraoperative time parameters were assessed for all cases. Resident and nonresident cases were matched using propensity scores. Outcomes were analyzed using univariate and multivariate regression analyses, as well as stratified by resident level of training. Univariate analysis of 1,222 resident and 1,188 nonresident cases demonstrated no difference in acute postoperative complication rates between groups. There was no significant difference in the incidence of overall complications based on resident level of training (p = 0.109). Operative time was significantly longer for cases in which a resident was involved (109.5 vs. 101.7 minutes; p < 0.001). Multivariate analysis identified no significant predictors of major postoperative complications, while patient history of chronic obstructive pulmonary disease was the only independent risk factor associated with minor complications. Resident involvement in ACLR was not associated with 30-day complications despite a slight increase in operative time. These findings provide reassurance that resident involvement in ACLR procedures is safe, although future investigations should focus on long-term postoperative outcomes.
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Affiliation(s)
- Kate Lebedeva
- Department of Orthopedic Surgery, School of Physical Therapy, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Dianne Bryant
- Department of Orthopedic Surgery, School of Physical Therapy, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Shgufta Docter
- Department of Orthopedic Surgery, School of Physical Therapy, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Robert B Litchfield
- Fowler Kennedy Sport Medicine Clinic/Department of Surgery, Western University, London, Ontario, Canada
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic/Department of Surgery, Western University, London, Ontario, Canada
| | - Ryan M Degen
- Fowler Kennedy Sport Medicine Clinic/Department of Surgery, Western University, London, Ontario, Canada
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Parkes CW, Leland DP, Levy BA, Stuart MJ, Camp CL, Saris DBF, Krych AJ. Hamstring Autograft Anterior Cruciate Ligament Reconstruction Using an All-Inside Technique With and Without Independent Suture Tape Reinforcement. Arthroscopy 2021; 37:609-616. [PMID: 33144236 PMCID: PMC7867617 DOI: 10.1016/j.arthro.2020.09.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 08/30/2020] [Accepted: 09/01/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the (1) rates of complications and reoperations, (2) rate of anterior cruciate ligament (ACL) graft failure, and (3) patient-reported outcomes (PROs) among patients after hamstring autograft ACL reconstruction (ACLR) with and without independent suture tape reinforcement at a minimum 2-year clinical follow-up. METHODS We performed a 1:2 matched-cohort comparison of patients who underwent hamstring autograft ACLR with and without independent suture tape reinforcement between July 2011 and July 2017. Patients were matched according to age, sex, body mass index, preinjury Tegner activity score, and concomitant meniscal injury. Medical records were reviewed for demographic characteristics, additional injuries, and concomitant procedures. PRO scores (including Tegner activity, Lysholm, and International Knee Documentation Committee scores) and physical examination findings were collected both preoperatively and at a minimum of 2 years postoperatively. RESULTS Overall, 108 patients who underwent ACLR were included: 36 patients (mean age, 25.3 years; range, 13-44 years) with independent suture tape reinforcement and 72 patients (mean age, 24.9 years; range, 13-54 years) without suture tape reinforcement. Overall, 5 of 36 suture tape patients (14%) and 10 of 72 control patients (14%) underwent reoperations. At an average follow-up of 26.1 months in the suture tape cohort and 31.3 months in the control cohort, 1 patient in the suture tape cohort and 4 patients in the control cohort experienced graft failure. There were no statistically significant differences between the suture tape and control groups regarding return-to-sport rate (89% and 88%, respectively), postoperative International Knee Documentation Committee score (94.4 and 93.8, respectively), and postoperative Lysholm score (95.6 and 94, respectively). There was a statistically significant difference between the suture tape and control groups in postoperative Tegner activity score, at 7.1 (95% confidence interval, 6.5-7.6) and 6.4 (95% confidence interval, 6.2-6.6), respectively (P = .026). CONCLUSIONS ACLR with hamstring autograft and independent suture tape reinforcement was performed safely with low rates of complications, graft failure, and reoperations with similar PROs, function, and return-to-sport rates when compared with hamstring autograft ACLR without suture tape reinforcement at a minimum 2-year follow-up. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Chad W Parkes
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Devin P Leland
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Bruce A Levy
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Michael J Stuart
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Christopher L Camp
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Daniel B F Saris
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Aaron J Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A..
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Zhu M, Han Lee DY, Williams A. Safe Femoral Fixation Depth and Orientation for Lateral Extra-Articular Tenodesis in Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2021; 9:2325967120976591. [PMID: 33614797 PMCID: PMC7869183 DOI: 10.1177/2325967120976591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 08/27/2020] [Indexed: 12/02/2022] Open
Abstract
Background: Patients who undergo anterior cruciate ligament (ACL) reconstruction (ACLR)
can have a persistent postoperative pivot shift. Performing lateral
extra-articular tenodesis (LET) concurrently has been proposed to address
this; however, LET femoral fixation may interfere with the ACLR femoral
tunnel, which could damage the ACL graft or its fixation. Purpose: To evaluate the safe maximum implant or tunnel depth for a modified Lemaire
LET when combined with ACLR anteromedial portal femoral tunnel drilling and
to validate the safe LET drilling angles to avoid conflict with the ACLR
femoral tunnel. Study Design: Descriptive laboratory study. Methods: Twelve fresh-frozen cadaveric knees were used. With each knee at 120° of
flexion, an ACLR femoral tunnel in the anteromedial bundle position was
created arthroscopically via the anteromedial portal using a 5-mm offset
guide, a guide wire, and an 8-mm reamer, which was left in situ. A modified
Lemaire LET was performed using a 1 cm-wide iliotibial band strip harvested
with the distal attachment intact, to be fixed in the femur. The desired LET
fixation point was identified with an external aperture 10 mm proximal and 5
mm posterior to the fibular collateral ligament’s femoral attachment, and a
2.4-mm guide wire was drilled, aiming at 0°, 10°, 20°, or 30° anteriorly in
the axial plane and at 0°, 10°, or 20° proximally in the coronal plane (12
different drilling angle combinations). The relationship between the LET
drilling guide wire and the ACLR femoral tunnel reamer was recorded for each
combination. When a collision with the femoral tunnel was recorded, the LET
wire depth was measured. Results: Collision with the ACLR femoral tunnel occurred at a mean LET wire depth of
23.6 mm (range, 15-33 mm). No correlation existed between LET wire depth and
LET drilling orientation (r = 0.066; P =
.67). Drilling angle in the axial plane was significantly associated with
the occurrence of tunnel conflict (P < .001). However,
no such association was detected when comparing the drilling angle in the
coronal plane (P = .267). Conclusion: Conflict of LET femoral fixation with the ACLR femoral tunnel using
anteromedial portal drilling occurred at a mean depth of 23.6 mm but also at
a depth as little as 15 mm, which is shorter than most implants. When longer
implants or tunnels are used, the orientation should be directed at least
30° anteriorly in the axial plane to minimize the risk of tunnel conflict,
bearing in mind the risk of joint violation. Clinical Relevance: This study provides important information for surgeons performing LET in
combination with ACLR anteromedial portal femoral tunnel drilling regarding
safe femoral implant or tunnel length and orientation.
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Affiliation(s)
- Meng Zhu
- Department of Orthopaedic Surgery, Changi General Hospital, Singapore
| | - Dave Yee Han Lee
- Department of Orthopaedic Surgery, Changi General Hospital, Singapore
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Fiber splay precludes the direct identification of ligament material properties: Implications for ACL graft selection. J Biomech 2020; 113:110104. [PMID: 33161304 DOI: 10.1016/j.jbiomech.2020.110104] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/08/2020] [Accepted: 10/17/2020] [Indexed: 11/20/2022]
Abstract
Anterior cruciate ligament (ACL) injuries typically require surgical reconstruction to restore adequate knee stability. The middle third of an injured patient's patellar tendon (PT) is a commonly used graft for ACL reconstruction. However, many clinicians and researchers question whether it is the best option, as several studies have suggested that it is a stiffer material than the ACL. Still, there is little to no consensus on even the most basic material property of ligaments/tendons: the tangent modulus in the fiber direction, or slope of the linear portion of the uniaxial stress-strain curve. In this study, we investigate the effect of fiber splay (the tendency of collagen fibers to spread out near the enthesis) on the apparent tangent modulus. Using a simplified theoretical model, we establish a quantity we call the splay ratio, which describes the relationship between splay geometry and the apparent tangent modulus. We then more rigorously investigate the effect of the splay ratio on the apparent tangent modulus of the ovine PT and anteromedial and posterolateral regions of the ACL using experimental and computational methods. Both approaches confirmed that splay geometry significantly affects the apparent material behavior. Because true material properties are independent of geometry, we conclude that the macroscopic response of ligaments and tendons is not sufficient for the characterization of their material properties, but rather is reflective of both material and structural properties. We further conclude that the PT is probably not a stiffer material than ACL, but that the PT graft is likely a stiffer structure than either ACL region.
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Castile RM, Jenkins MJ, Lake SP, Brophy RH. Microstructural and Mechanical Properties of Grafts Commonly Used for Cruciate Ligament Reconstruction. J Bone Joint Surg Am 2020; 102:1948-1955. [PMID: 32740264 DOI: 10.2106/jbjs.19.01395] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Injuries to the anterior cruciate ligament and posterior cruciate ligament are common, and often are treated with reconstruction. Limited quantitative data are available describing material properties of grafts used for reconstructions such as the bone-patellar tendon-bone (BPTB), hamstring tendon (HS), and quadriceps tendon (QT). The purpose of this study was to quantify and compare microstructural and mechanical properties of BPTB, HS, and QT grafts. METHODS Forty specimens (13 BPTB, 13 HS, and 14 QT grafts) from 24 donors were used. Specimens were subjected to preconditioning, stress relaxation, and ramp to failure. Mechanical parameters were calculated for each sample, and polarization imaging was used to evaluate the direction and strength of collagen fiber alignment during testing. RESULTS QT had the largest modulus values, and HS had the smallest. BPTB exhibited the least disperse collagen organization, while HS were the least strongly aligned. Microstructural properties showed more strongly aligned collagen with increasing load for all grafts. All tissues showed stress relaxation and subtle microstructural changes during the hold period. CONCLUSIONS The mechanical and microstructural properties differed significantly among BPTB, HS, and QT grafts. QT exhibited the largest moduli and greatest strength of collagen alignment, while HS had the smallest moduli and least strongly aligned collagen. CLINICAL RELEVANCE This study identified mechanical and microstructural differences among common grafts and between these grafts and the cruciate ligaments they replace. Further research is needed to properly interpret the clinical relevance of these differences.
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Affiliation(s)
- Ryan M Castile
- Departments of Mechanical Engineering & Materials Science (R.M.C., M.J.J., and S.P.L.) and Orthopaedic Surgery (S.P.L. and R.H.B.), Washington University in St. Louis, St. Louis, Missouri
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Eliya Y, Nawar K, Rothrauff BB, Lesniak BP, Musahl V, de SA D. Anatomical anterior cruciate ligament reconstruction (ACLR) results in fewer rates of atraumatic graft rupture, and higher rates of rotatory knee stability: a meta-analysis. J ISAKOS 2020. [DOI: 10.1136/jisakos-2020-000476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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No difference in revision rates between anteromedial portal and transtibial drilling of the femoral graft tunnel in primary anterior cruciate ligament reconstruction: early results from the New Zealand ACL Registry. Knee Surg Sports Traumatol Arthrosc 2020; 28:3631-3638. [PMID: 32239269 DOI: 10.1007/s00167-020-05959-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 03/23/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE The use of an accessory anteromedial portal to drill the femoral graft tunnel in primary anterior cruciate ligament (ACL) reconstruction was introduced in the 2000s in an effort to achieve a more anatomic femoral tunnel position. However, some early studies reported an increase in revision ACL reconstruction compared to the traditional transtibial technique. The aim of this study was to analyse recent data recorded by the New Zealand ACL Registry to compare outcomes of ACL reconstruction performed using the anteromedial portal and transtibial techniques. METHODS Analysis was performed on primary isolated single-bundle ACL reconstructions recorded between 2014 and 2018 by the New Zealand ACL Registry. Patients were categorised into two groups according to whether an anteromedial portal or transtibial technique was used to drill the femoral graft tunnel. The primary outcome was revision ACL reconstruction and was compared between both groups through univariate and multivariate survival analyses. The secondary outcomes that were analysed included subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS) and Marx activity score. RESULTS Six thousand one hundred and eighty-eight primary single-bundle ACL reconstructions were performed using either the anteromedial portal or transtibial drilling techniques. The mean time of follow-up was 23.3 (SD ± 14.0) months. Similar patient characteristics such as mean age (29 years, SD ± 11), sex (males = 58% versus 57%) and time to surgery (median 4 months, IQR 5) were observed between both groups. The rate of revision ACL reconstruction was 2.6% in the anteromedial portal group and 2.2% in the transtibial group (n.s.). The adjusted risk of revision ACL reconstruction was 1.07 (95% CI 0.62-1.84, n.s.). Patients in the anteromedial portal group reported improved scores for subscales of the KOOS and higher Marx activity scores at 1-year post-reconstruction. CONCLUSION There was no difference in the risk of revision ACL reconstruction between the two femoral tunnel drilling techniques at short-term follow-up. We observed minor differences in patient-reported outcomes at 1-year follow-up favouring the anteromedial portal technique, which may not be clinically relevant. Surgeons can achieve good clinical outcomes with either drilling technique. LEVEL OF EVIDENCE III.
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Yari SS, El Naga AN, Patel A, Qadeer AA, Shah A. TightRope Versus Biocomposite Interference Screw for Fixation in Allograft ACL Reconstruction: Prospective Evaluation of Osseous Integration and Patient Outcomes. JB JS Open Access 2020; 5:e0057. [PMID: 33123662 PMCID: PMC7418916 DOI: 10.2106/jbjs.oa.19.00057] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Anterior cruciate ligament (ACL) reconstruction is a commonly performed procedure with many options regarding graft choice and graft fixation. The purpose of this study was to compare suspensory and aperture fixation in terms of femoral osseous integration of the bone block after ACL reconstruction with an Achilles tendon allograft. Methods After institutional review board approval and patient consent were obtained, 37 patients underwent ACL reconstruction with an Achilles tendon allograft. The patients were randomized according to the graft femoral fixation technique, which was with either a suspensory device (Arthrex TightRope) or aperture fixation by a biocomposite interference screw (Arthrex BioComposite Interference Screw or DePuy Mitek MILAGRO Interference Screw). Tibial fixation, performed with a biocomposite screw and knotless anchor, was identical in all patients. All patients underwent a computed tomography (CT) scan at 6 months to evaluate bone block incorporation of the femoral graft within the femoral tunnel, which was the study's primary outcome. Secondary outcome measures included a postoperative visual analogue scale (VAS) pain score, range-of-motion measures, and International Knee Documentation Committee scores. Demographic data were collected. Results Thirty-three patients (89%) completed the study's 6-month follow-up, at which time the femoral ossification score was significantly greater in the aperture fixation group (p = 0.025). There was no substantial difference between the 2 groups with regard to any other outcome measure. Conclusions Performing Achilles tendon allograft ACL reconstruction with femoral aperture fixation results in greater femoral bone block incorporation at 6 months postoperatively compared with what is seen after suspensory fixation. Level of Evidence Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Shahram Shawn Yari
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas
| | - Ashraf N El Naga
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Amar Patel
- Departments of Radiology (A.P.) and Orthopedic Surgery (A.S.), Kelsey-Seybold Clinic, Houston, Texas
| | - Ali Asaf Qadeer
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas
| | - Anup Shah
- Departments of Radiology (A.P.) and Orthopedic Surgery (A.S.), Kelsey-Seybold Clinic, Houston, Texas
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Shiwaku K, Suzuki T, Matsumura T, Takashima H, Otsubo H, Yamashita T. Bioabsorbable interference screws can be used with less tunnel widening in anatomic rectangular tunnel anterior cruciate ligament reconstruction with a bone-patellar-tendon-bone graft. Knee 2020; 27:1293-1299. [PMID: 33010741 DOI: 10.1016/j.knee.2020.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 04/18/2020] [Accepted: 06/30/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of this study was to investigate postoperative tunnel widening after rectangular tunnel bone-patellar-tendon-bone graft anterior cruciate ligament reconstruction using newer-generation bioabsorbable interference screws. METHODS Forty-six patients who had undergone primary rectangular tunnel bone-patellar-tendon-bone graft anterior cruciate ligament reconstruction using MILAGRO bioabsorbable interference screws (DePuy Synthes, Warsaw, IN, USA) for femoral fixation and for whom computed tomography was performed at two weeks and one year postoperatively were included in this prospective study. To assess the tunnel widening, the cross-sectional area of the femoral tunnel aperture (compared between two weeks and one year postoperatively) was assessed using computed tomography. Cyst formation, postoperative screw breakage, screw migration, and graft migration were also evaluated using computed tomography one year postoperatively. RESULTS Mean tunnel widening was 1.9%, and the cross-sectional area of the femoral tunnel aperture was not significantly different between two weeks and one year postoperatively. Postoperative cyst formation, screw breakage, screw migration, and graft migration were not observed in any patient. CONCLUSIONS After rectangular tunnel bone-patellar-tendon-bone graft anterior cruciate ligament reconstruction using bioabsorbable interference screws for femoral fixation, tunnel widening was not observed via computed tomography analysis at two weeks and one year postoperatively.
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Affiliation(s)
- Kousuke Shiwaku
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Tomoyuki Suzuki
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan.
| | - Takashi Matsumura
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hiroyuki Takashima
- Division of Radiology and Nuclear Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | | | - Toshihiko Yamashita
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
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Risk of Subsequent Knee Arthroplasty After Sports Medicine Procedures. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:e20.00125. [PMID: 32852917 PMCID: PMC7430232 DOI: 10.5435/jaaosglobal-d-20-00125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Approximately 10% of men and 13% of women older than the age of 60 are affected by symptomatic osteoarthritis of the knee. Anatomic repair or reconstruction after knee injury has been a central tenet of surgical treatment to reduce the risk of osteoarthritis. The purpose of this study was to examine common sports medicine procedures of the knee and determine the proportion of patients who subsequently undergo total knee arthroplasty (TKA). METHODS The MarketScan database was queried from the period of January 2007 through December 2016. Patients were identified, who underwent a procedure of the knee, as defined by Current Procedural Terminology codes relating to nonarthroplasty procedures of the knee. Patients in whom laterality could not be confirmed or underwent another ipsilateral knee procedure before TKA were excluded from this study. The primary outcome of this study was the overall rate of TKA after index knee surgery. Time from index procedure to TKA was a secondary outcome. A multivariate regression analysis was used to control for covariates such as age, sex, and comorbidity status. RESULTS A total of 843,749 patients underwent one of the 13 common sports medicine procedures of the knee. The procedure with the highest unadjusted rate of subsequent TKA was arthroscopic osteochondral allograft (5.81%), whereas anterior cruciate ligament (ACL) reconstruction with meniscus repair demonstrated the lowest rate of subsequent TKA (0.01%). When adjusting for confounding factors, the regression analysis identified meniscal transplantation (odds ratio [OR] = 3.06, P < 0.0001) as having the highest risk of subsequent TKA, followed by osteochondral autograft (OR = 1.74, P = 0.0424) and arthroscopic osteochondral allograft (OR = 1.49, P < 0.0001). ACL reconstruction with meniscus repair (OR = 0.02, P < 0.0001), ACL reconstruction alone (OR = 0.17, P < 0.0001), ACL with meniscectomy (OR = 0.20, P < 0.0001), and meniscal repair (OR = 0.65, P < 0.0001) had the lowest rate of subsequent TKA. ACL reconstruction with meniscus repair had the longest period from index procedure to TKA at 2827 days. CONCLUSION ACL reconstruction and meniscus preservation demonstrated an extremely low rate of conversion to TKA when compared with patients who needed salvage interventions such as meniscus and cartilage transplantation. None of the salvage interventions delayed the need for a TKA. Meniscal transplantation had the highest risk of all procedures of going on to a TKA.
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Kim SG, Nagao M, Nozawa M, Doi T. Optimal cutoff score for patient-reported outcome measures after anterior cruciate ligament reconstruction using load-displacement curve analysis. J Orthop Surg (Hong Kong) 2020; 27:2309499019887581. [PMID: 31793842 DOI: 10.1177/2309499019887581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
To assess psychological components after anterior cruciate ligament (ACL) injury, we developed a new patient-reported outcome measure, the Japanese anterior cruciate ligament injury questionnaire 25 (JACL-25), and demonstrated that the JACL-25 is valid, reliable, and sufficiently responsive to evaluate psychological factors that are associated with outcomes in individuals with ACL injuries. The purpose of this study was to identify the optimum cutoff score for the JACL-25 that indicates successful clinical outcomes, combining with the graphical data obtained using the KT-2000. We studied 30 patients who underwent primary ACL reconstruction with a patella tendon or hamstring tendon autograft. On the same day of the JACL-25 evaluation, anterior knee laxity tests were performed using the KT-2000 arthrometer. ACL stiffness was calculated on the graphs of the hysteresis, which can be used to measure side-to-side differences in anterior translation. Akaike's information criterion (AIC) was used to determine the most appropriate cutoff level for the JACL-25 score for the stiffness reduction ratio and anterior-posterior (AP) translation. The average JACL-25 score was 23.8 (standard deviation (SD) 18.4). The average side-to-side displacement difference in AP translation was 2.4 (SD 4.2) mm. The average stiffness reduction ratio was 24.4% (SD 31.8). The smallest AIC values for the cutoff level for the JACL-25 score, the stiffness reduction ratio, and side-to-side differences of the anterior translation were 9, 27%, and 1.1 mm, respectively. We determined the optimal cutoff score for the JACL-25 that identifies successful clinical outcomes.
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Affiliation(s)
- Sung-Gon Kim
- Department of Orthopaedic Surgery, Juntendo University Nerima Hospital, Nerima ku, Tokyo, Japan
| | - Masashi Nagao
- Department of Orthopaedic Surgery, Juntendo University Nerima Hospital, Nerima ku, Tokyo, Japan
| | - Masahiko Nozawa
- Department of Orthopaedic Surgery, Juntendo University Nerima Hospital, Nerima ku, Tokyo, Japan
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Reconstruction of the anterior cruciate- and anterolateral ligament deficient knee with a modified iliotibial graft reduces instability more than with an intra-articular hamstring graft. Knee Surg Sports Traumatol Arthrosc 2020; 28:2526-2534. [PMID: 32040678 DOI: 10.1007/s00167-020-05850-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 01/10/2020] [Indexed: 12/30/2022]
Abstract
PURPOSE To compare knee kinematics before and after anterior cruciate ligament ACL reconstruction (ACL-R) using hamstring graft (HG) and a double-stranded iliotibial tract graft attached to Gerdy's tubercle (providing an extra-articular anterolateral tenodesis) (named the modified iliotibial tract graft = MIT). METHOD Eighteen cadaveric knees were tested in a 6 degree of freedom kinematics rig. An optical tracking system recorded kinematics of the knee from 0 to 80 degrees of flexion applying no load, internal/external rotation (IR/ER), valgus/varus rotation (VGR/VRR), simulated pivot shift (SPS), anterior translation (AT) and posterior translation loads. The knee was tested before and after resection of the ACL and the anterolateral ligament (ALL), respectively; then after HG-ACL-R and MIT-ACL-R. Grafts were fixed at 20° of flexion. Results were compared to the intact knee. RESULTS ACL resection resulted in a significant increase in AT (p < 0.05) over the entire range of motion, peaking at 20° of flexion, mean difference 6.6 ± 2.25 mm (p = 0.0007). ACL-R with HG-ACL and MIT-ACL restored AT. Resection of the ALL increased IR in the fully extended knee, mean difference 2.4 ± 2.1° (p = 0.024). When compared to the intact knee and the knee after HG-ACL-R, MIT-ACL-R knee reduced IR/SPS significantly (p < 0.05) in deep flexion angles (60°-80°), peaking at 80° of flexion. The MIT-ACL-R caused significantly less VRR at 80° flexion (p = 0.02). CONCLUSION MIT-ACL-R restored AT equally to the HG-ACL-R. The MIT-ACL-R reduced IR and SPS in deep flexion, resulting in overconstraint. MIT-ACL-R can be used as an alternative to standard reconstruction methods.
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Biomechanical, histologic, and molecular characteristics of graft-tunnel healing in a murine modified ACL reconstruction model. J Orthop Translat 2020; 24:103-111. [PMID: 32775202 PMCID: PMC7390781 DOI: 10.1016/j.jot.2020.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 05/15/2020] [Accepted: 05/20/2020] [Indexed: 02/07/2023] Open
Abstract
Purpose The purpose of our study was to introduce and validate a metal-free, reproducible and reliable mouse model of anterior cruciate ligament (ACL) reconstruction (ACLR) surgery as an effective tool for a better understanding of molecular mechanisms of graft-tunnel healing after ACLR. Methods A total of 150 C57BL/6 mice were randomly allocated into five Groups: Group 1 (mice with intact ACL), Group 2–4 (mice underwent modified ACLR surgery and sacrificed 1-, 2-, and 4-weeks after surgery), and Group 5 (mice underwent unmodified ACLR surgery and sacrificed 4 weeks after surgery). Micro-computed tomography (CT), biomechanical histological as well as immunohistochemical (IHC) analyses were performed to characterize the modified ACLR. Results Micro-CT analysis demonstrated there is a non-significant increase in BV/TV and BMD of the bone tunnel during the tendon-to-bone healing following ACLR. Biomechanical tests showed that the mean load-to-failure forces of Group 3 and 4 are equal to 31.7% and 46.0% of that in Group 1, while the stiffness was 33.1% and 57.2% of that of Group 1, respectively. And no obvious difference in biomechanical parameters was found between Group 4 and 5. Histological analysis demonstrated that formation of fibrovascular tissue in the tibial tunnel and aperture in Groups 4 and 5 and direct junction appeared between tendon graft and tunnel both in Groups 4 and 5. IHC results showed that there are gradually enhanced expression of Patched1, Smoothened and Gli2 concomitant with decreased Gli3 protein in the tendon-bone interface during the tendon-bone healing process. Conclusion We introduced a metal-free, reproducible and reliable mouse model of ACLR compared to the unmodified ACLR procedure, and characterized the expression pattern of key molecules in Ihh signaling during the graft healing process. The translational potential of this article In the present study we introduced and validated, for the first time, a metal-free, reproducible and reliable ACLR mouse model, which could be used to investigate the detailed molecular mechanisms of graft-tunnel healing after ACLR. We also explored new strategies to promote the healing of tendon-to-bone integration.
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Key Words
- ACL, Anterior cruciate ligament
- ACLR, ACL reconstruction
- Anterior cruciate ligament
- BMD, Bone mineral density
- BV/TV, Bone volume/total volume
- CI, Confidence interval
- CT, Computed tomography
- Gli1, Glioma-associated oncogene homologue 1
- Gli2, Glioma-associated oncogene homologue 2
- Gli3, Glioma-associated oncogene homologue 3
- H&E, Haematoxylin-eosin
- Hedgehog signaling
- Ihh, Indian hedgehog
- Mouse model
- NS, Non-significant
- Ptch1, Patched1
- Smo, Smoothened
- Tendon-bone healing
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