American Academy of Orthopaedic Surgeons Clinical Practice Guideline Summary: Management of Anterior Cruciate Ligament Injuries

Gradual stabilization and narrowing of bone tunnels following primary anterior cruciate ligament reconstruction

PURPOSE

The purpose of this study is to dynamically assess variations in tunnel diameters following anterior cruciate ligament reconstruction (ACLR) and investigate correlations with patient-reported outcomes (PROs) and graft maturity based on signal-to-noise quotient (SNQ).

METHODS

Tunnel diameter and tunnel position were measured using three-dimensional models derived from computed tomography (CT) data. Postoperative graft maturity and integration were evaluated using magnetic resonance imaging (MRI). Clinical outcomes were assessed through PROs, which included the International Knee Documentation Committee Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Scores and Lysholm scores. The correlation between tunnel enlargement extent, PROs and SNQ values, as well as correlations between confounding factors, tunnel diameter differences and SNQ were analyzed.

RESULTS

A total of 73 participants underwent primary ACLR and scheduled follow-ups. At the segment of the articular aperture, the femoral tunnel was enlarged by 32.3% to 10.4 ± 1.6 mm (p < 0.05), and the tibial tunnel was widened by 17.2% to 9.6 ± 1.2 mm (p < 0.05) at the 6-month follow-up. At 1 year postoperatively, diameters at the articular aperture were not further increased on the femoral (n.s.) and tibial (n.s.) sides. In early postoperative follow-up, the femoral tunnel was anteriorly and distally shifted, coupled with posterior and lateral deviation involving the tibial side, exhibiting minimal migration at 1-year follow-up. The degree of tunnel widening was not correlated with PROs and SNQ values. Age, gender, body mass index (BMI), time from surgery to follow-up, concomitant injuries and autograft type were not correlated with tunnel diameter differences and SNQ.

CONCLUSIONS

The femoral and tibial bone tunnels exhibited eccentrical widening and gradually stabilized at 1 year following ACLR. Furthermore, the enlarged bone tunnels were not correlated with unsatisfied PROs and inferior graft maturity.

LEVEL OF EVIDENCE

Level IV.

Mid-term outcomes of moderate-severe cystocele repairing with autologous fascia lata harvested through a small incision

INTRODUCTION AND HYPOTHESIS

To investigate the mid-term outcomes of transvaginal repair for moderate-severe cystocele using autologous fascia lata harvested through a single small incision.

METHODS

Between February and October 2022, 35 patients with moderate to severe cystocele undergoing transvaginal repair with autologous fascia lata were included. Patient demographics and perioperative data were collected, with follow-ups through outpatient visits or phone calls. Patients were evaluated by subjective perception of vaginal bulging, physical examination, Pelvic Floor Distress Inventory (PFDI-20) Questionnaire, patient satisfaction, Patient Global Impression of Improvement (PGI-I) scores, regret rate, willingness to recommend, complications, and harvesting site issue.

RESULTS

The patient's mean age was 60.44 ± 6.01 years. Fascia lata harvesting took 32.92 ± 19.72 min, reconstruction surgery lasted 141.21 ± 37.89 min. Follow-up duration was 15.94 ± 2.46 months. 5.7% (2/35) of the patients reported a non-interfering vaginal bulge not requiring treatment. Objective recurrence rate was 4.26% (1/24, Aa or Ba>0) PFDI-20 was significantly improved (P < 0.0001). All 35 patients (100%) were highly satisfied, with PGI-I score very much improved or improved. No patient regretted. 97.14% (34/35) would recommend the procedure. One patient developed poor wound healing at the vaginal apex. One patient developed thromboembolic event. Harvest site: 2.86% (1/35) developed a non-bothersome thigh bulge, 17.14% (6/35) noted an impact on wound appearance, and 8.57% (3/35) reported mild paresthesia.

CONCLUSION

Autologous fascia lata for cystocele treatment shows promising mid-term outcomes, safely and effectively enhancing QoL with high satisfaction. Despite concerns about leg scarring, no patient regretted and would recommend the procedure. Long-term outcomes require larger follow-up studies.

Functional Outcomes of Bone-Patellar Tendon-Bone Versus Quadrupled Semitendinosus and Gracilis Autografts for Anterior Cruciate Ligament Reconstruction

Introduction Anterior cruciate ligament reconstruction (ACLR) with autografts has been available for decades; however, the choice of graft is still debated. Here, we compared the functional outcomes of the two most widely used autografts, bone-patella tendon-bone (BPTB) and quadruple-stranded semitendinosus/gracilis (ST/G) autografts, at six months following ACLR. Materials and methods This prospective study was performed in the Department of Orthopedics of Yenepoya Medical College and Hospital located in Mangalore, Karnataka, India, a tertiary care institute over a period of 18 months (November 2018 to April 2020). The study included 38 adult patients who underwent ACLR and were randomly divided into two groups: BPTB autograft (n=19) or ST/G autograft (N=19). The patients were followed up at one-, three-, and six months. Postoperatively, surgical morbidity, knee stability functional outcome on Lysholm score, and knee range of motion (ROM) were assessed. Results The groups were homogenous and comparable regarding age, sex, side of ACL affected, duration of tear to treatment, and muscle wasting (all p-values > 0.05). At six months, the majority of the patients had a tibial translation of 0-2 mm on the Lachman test and anterior drawer test, and the groups did not differ significantly (both p-values > 0.05). Additionally, at six months, both groups demonstrated a significant increase in mean Lysholm score and mean ROM (both p-values < 0.001). However, the groups did not differ in mean Lysholm score and mean ROM at baseline and any of the follow-up visits (all p-values > 0.05). Conclusion At six months, ACLR with BPTB and ST/G autografts produced significant and comparable knee stability, functional outcome, and ROM.

Investigation of the anatomic risk factors in acute anterior cruciate ligament ruptures to develop ramp lesions of the medial meniscus by quantitative MRI

OBJECTIVE

To investigate the anatomic risk factors of knee in patients with acute non-contact anterior cruciate ligament (aACL) ruptures to develop ramp lesions.

METHODS

A total of 202 subjects were retrospectively divided into three groups: (1) aACL ruptures combined with ramp lesions group (n = 76); (2) isolated ACL ruptures group (n = 56) and (3) normal controls group (n = 70). Quantitative morphological parameters on MRI were measured including: diameter of medial femoral condyle (MFC), anterior-posterior length and depth of medial tibial plateau (MTP AP length and depth), lateral posterior tibial slope (LPTS) and medial posterior tibial slope (MTPS), asymmetry of LPTS and MPTS (LMPTS), lateral meniscal slope (LMS), and medial meniscal slope (MMS).

RESULTS

The MTP AP length, MTP AP length/MFC diameter ratio, MTP depth, LPTS and the asymmetry of LMPTS showed significant differences among the three groups (p < 0.001). The risk factors associated with the ramp lesions including a longer MTP AP length (OR 1.17, 95% CI 1.00-1.44, p = 0.044), increased MTP depth (OR 1.91, 95% CI 1.22-3.00, p = 0.005) and lager ratio (OR 1.11, 95% CI 1.01-1.22, p = 0.036). The highest AUC was the MTP AP length/MFC diameter ratio (0.74; 95% CI, 0.66-0.82). The combination model increased higher accuracy (0.80; 95% CI, 0.72-0.88).

CONCLUSION

Several bony anatomic characteristics of the knee, especially the morphology of medial tibia plateau, are additional risk factors for aACL ruptures to develop ramp lesions.

CRITICAL RELEVANCE STATEMENT

Predictive anatomic risk factors of the knee for patients with acute non-contact anterior cruciate ligament (aACL) ruptures to develop ramp lesions, especially the morphology of medial tibia plateau, are detectable by MRI.

KEY POINTS

Ramp lesion development can complicate aACL ruptures and requires specific treatment. Longer AP length and increased MTP depth are risk factors for concurrent ramp lesions. Identification of ramp lesions allows for the most appropriate treatment.

Preferences in anterior cruciate ligament reconstruction: A survey among orthopedic surgeons in China

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.

Delaying anterior cruciate ligament reconstruction increases the rate and severity of medial chondral injuries

Aims

The aim of this study was to evaluate the association between chondral injury and interval from anterior cruciate ligament (ACL) tear to surgical reconstruction (ACLr).

Methods

Between January 2012 and January 2022, 1,840 consecutive ACLrs were performed and included in a single-centre retrospective cohort. Exclusion criteria were partial tears, multiligament knee injuries, prior ipsilateral knee surgery, concomitant unicompartmental knee arthroplasty or high tibial osteotomy, ACL agenesis, and unknown date of tear. A total of 1,317 patients were included in the final analysis, with a median age of 29 years (interquartile range (IQR) 23 to 38). The median preoperative Tegner Activity Score (TAS) was 6 (IQR 6 to 7). Patients were categorized into four groups according to the delay to ACLr: < three months (427; 32%), three to six months (388; 29%), > six to 12 months (248; 19%), and > 12 months (254; 19%). Chondral injury was assessed during arthroscopy using the International Cartilage Regeneration and Joint Preservation Society classification, and its association with delay to ACLr was analyzed using multivariable analysis.

Results

In the medial compartment, delaying ACLr for more than 12 months was associated with an increased rate (odds ratio (OR) 1.93 (95% confidence interval (CI) 1.27 to 2.95); p = 0.002) and severity (OR 1.23 (95% CI 1.08 to 1.40); p = 0.002) of chondral injuries, compared with < three months, with no association in patients aged > 50 years old. No association was found for shorter delays, but the overall dose-effect analysis was significant for the rate (p = 0.015) and severity (p = 0.026) of medial chondral injuries. Increased TAS was associated with a significantly reduced rate (OR 0.88 (95% CI 0.78 to 0.99); p = 0.036) and severity (OR 0.96 (95% CI 0.92 to 0.99); p = 0.017) of medial chondral injuries. In the lateral compartment, no association was found between delay and chondral injuries.

Conclusion

Delay was associated with an increased rate and severity of medial chondral injuries in a dose-effect fashion, in particular for delays > 12 months. Younger patients seem to be at higher risk of chondral injury when delaying surgery. The timing of ACLr should be optimally reduced in this population.