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Kemler B, Coladonato C, Sonnier JH, Campbell MP, Darius D, Erickson BJ, Tjoumakaris FP, Freedman KB. Evaluation of Failed ACL Reconstruction: An Updated Review. Open Access J Sports Med 2024; 15:29-39. [PMID: 38586217 PMCID: PMC10998505 DOI: 10.2147/oajsm.s427332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 03/23/2024] [Indexed: 04/09/2024] Open
Abstract
Failure rates among primary Anterior Cruciate Ligament Reconstruction (ACLR) range from 3.2% to 11.1%. Recently, there has been increased focus on surgical and anatomic considerations which predispose patients to failure, including excessive posterior tibial slope (PTS), unaddressed high-grade pivot shift, and improper tunnel placement. The purpose of this review was to provide a current summary and analysis of the literature regarding patient-related and technical factors surrounding revision ACLR, rehabilitation considerations, overall outcomes and return to sport (RTS) for patients who undergo revision ACLR. There is a convincingly higher re-tear and revision rate in patients who undergo ACLR with allograft than autograft, especially amongst the young, athletic population. Unrecognized Posterior Cruciate Ligament (PLC) injury is a common cause of ACLR failure and current literature suggests concurrent operative management of high-grade PLC injuries. Given the high rates of revision surgery in young active patients who return to pivoting sports, the authors recommend strong consideration of a combined ACLR + Anterolateral Ligament (ALL) or Lateral extra-articular tenodesis (LET) procedure in this population. Excessive PTS has been identified as an independent risk factor for ACL graft failure. Careful consideration of patient-specific factors such as age and activity level may influence the success of ACL reconstruction. Additional technical considerations including graft choice and fixation method, tunnel position, evaluation of concomitant posterolateral corner and high-grade pivot shift injuries, and the role of excessive posterior tibial slope may play a significant role in preventing failure.
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Affiliation(s)
- Bryson Kemler
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | - Carlo Coladonato
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | | | - Michael P Campbell
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | - Danielle Darius
- Department of Education, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Brandon J Erickson
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | | | - Kevin B Freedman
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
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Usami S, Kimura Y, Matsuzaka M, Sasaki Y, Sasaki S, Sasaki E, Tsuda E, Ishibashi Y. A new neural network model that detects graft ruptures and contralateral anterior cruciate ligament injuries. Knee Surg Sports Traumatol Arthrosc 2024; 32:872-880. [PMID: 38461400 DOI: 10.1002/ksa.12123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 02/19/2024] [Accepted: 02/22/2024] [Indexed: 03/11/2024]
Abstract
PURPOSE The purpose of this study was to develop a neural network model for predicting second anterior cruciate ligament (ACL) injury risk following ACL reconstruction using patient features from medical records. METHODS Of 486 consecutive patients who underwent primary unilateral ACL reconstruction, 386 patients (198 women, 188 men) with a mean age of 25.1 ± 11.6 years were included in this study. Fifty-eight features, including demographic data, surgical, preoperative and postoperative data, were retrospectively collected from medical records, and features with an incidence of less than 5% were excluded. Finally, 14 features were used for the analysis. The multilayer perceptron was composed of four hidden layers with a rectified linear unit as activation and was trained to maximise the area under the receiver-operating characteristic curve (auROC). Subsequently, validation was carried out through a rigorous threefold cross-validation process. To ascertain the most efficacious combination of features with the highest auROC, a single feature with the least impact on auROC maximisation was systematically eliminated from the comprehensive variable set, ultimately resulting in the retention of a mere two variables. RESULTS The median follow-up period was 50.5 (24-142) months. Fifty-seven knees had a second ACL injury, with a graft rupture rate of 7.7% and a contralateral injury rate of 6.9%. The maximum auROC for predicting graft rupture was 0.81 with two features: young age and hamstring graft. Meanwhile, the maximum auROC for predicting contralateral ACL injury was 0.74 with seven features, including young age, presence of medial meniscus tear, small body mass index, hamstring graft, female sex and medial meniscus repair or treatment. CONCLUSION A neural network model with patient features from medical records detected graft ruptures and contralateral ACL injuries with acceptable accuracy. This model can serve as a new, useful tool in clinical practice to inform decisions about ACL reconstruction and retuning to sports postoperatively. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Shintaro Usami
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuka Kimura
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Masashi Matsuzaka
- Department of Medical Informatics, Hirosaki University Hospital, Hirosaki, Japan
| | - Yoshihiro Sasaki
- Department of Medical Informatics, Hirosaki University Hospital, Hirosaki, Japan
| | - Shizuka Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Eiji Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Eiichi Tsuda
- Department of Rehabilitation Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Xerogeanes J. Editorial Commentary: Quadriceps Tendon Is a Better Graft Than Hamstring for Anterior Cruciate Ligament Reconstruction. Arthroscopy 2024; 40:1245-1246. [PMID: 38231145 DOI: 10.1016/j.arthro.2023.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 09/26/2023] [Indexed: 01/18/2024]
Abstract
Over the last 12 years identification of specific risk factors (age, activity level, and laxity) for failure of anterior cruciate ligament (ACL) reconstruction have led to comparisons of the patellar tendon (PT) and hamstring (HS) tendon grafts. The PT has proved superior in most of these studies. During this same time period, there has been increased clinical/research interest in the quadriceps tendon autograft for ACL reconstruction. This has led to direct comparison to the HS and QT autografts. Again, the HS tendon appears inferior in measured outcomes to the quadriceps tendon. Increased laxity measurements seem to correlate with the decreased evidence of radiographic healing on magnetic resonance imaging. If this is the case, it may indeed be the final nail in the coffin for HS graft use in young at-risk athletic populations.
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Quinn M, Byrne RA, Albright JA, Testa E, Ahn B, Lemme N, Petit L, Blankenhorn B, Owens BD. Peroneus Longus Tendon Autograft May Present a Viable Alternative for Anterior Cruciate Ligament Reconstruction: A Systematic Review. Arthroscopy 2024; 40:1366-1376.e1. [PMID: 37898307 DOI: 10.1016/j.arthro.2023.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 10/04/2023] [Accepted: 10/10/2023] [Indexed: 10/30/2023]
Abstract
PURPOSE To examine the available literature to better understand the objective and patient-reported outcomes using peroneus longus tendon (PLT) autograft compared with more commonly used autografts, such as the quadrupled hamstring tendons (HT), in patients undergoing primary for anterior cruciate ligament reconstruction (ACLR). METHODS A comprehensive search of published literature in PubMed, Web of Science, Cochrane Library, Ovid, and EMBASE databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria included patients undergoing ACLR with PLT autograft, inclusion of patient-recorded outcome measures, and availability in English language. Publications that included only biomechanical analysis or ACLR with use of allograft or combination grafts were excluded. RESULTS A total of 16 studies (Level of Evidence range: I-IV) met inclusion criteria, with follow-up ranging from 3 months to 5 years. In the available case series, patient-reported outcomes ranged from Lysholm = 80.7 to 95.1, International Knee Documentation Committee 78.1 to 95.7. In prospective cohorts and randomized controlled trials, PLT performance was comparable with HT autografts (PLT/HT: Lysholm = 88.3-95.1/86.5-94.9, International Knee Documentation Committee = 78.2-92.5/87.4-93.4). The majority of PLT grafts diameters were equal or greater than HT counterparts with a mean of >8 mm (PLT/HT: 7.0-9.0 mm/7.65-8.5 mm). There was minimal donor-site morbidity associated with PLT harvest. CONCLUSIONS Although limitations exist within the available literature, existing evidence suggests that PLT autograft routinely produces adequately sized grafts with comparable early outcomes to HT autograft and low risk of donor-site morbidity. However, the PLT autograft is yet to demonstrate superiority to any of the more-traditional autograft selections. LEVEL OF EVIDENCE Level IV, systematic review of Level I-IV studies.
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Affiliation(s)
- Matthew Quinn
- Department of Orthopaedic Surgery, Alpert Medical School, Brown University, Providence, Rhode Island, U.S.A..
| | - Rory A Byrne
- Department of Orthopaedic Surgery, Alpert Medical School, Brown University, Providence, Rhode Island, U.S.A
| | - J Alex Albright
- Department of Orthopaedic Surgery, Alpert Medical School, Brown University, Providence, Rhode Island, U.S.A
| | - Edward Testa
- Department of Orthopaedic Surgery, Alpert Medical School, Brown University, Providence, Rhode Island, U.S.A
| | - Benjamin Ahn
- Department of Orthopaedic Surgery, Alpert Medical School, Brown University, Providence, Rhode Island, U.S.A
| | - Nicholas Lemme
- Department of Orthopaedic Surgery, Alpert Medical School, Brown University, Providence, Rhode Island, U.S.A
| | - Logan Petit
- Department of Orthopaedic Surgery, Alpert Medical School, Brown University, Providence, Rhode Island, U.S.A
| | - Brad Blankenhorn
- Department of Orthopaedic Surgery, Alpert Medical School, Brown University, Providence, Rhode Island, U.S.A
| | - Brett D Owens
- Department of Orthopaedic Surgery, Alpert Medical School, Brown University, Providence, Rhode Island, U.S.A
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Solie BS, Tollefson LV, Doney CP, O'Keefe JMJ, Thompson WC, LaPrade RF. Return to the Pre-Injury Level of Sport after Anterior Cruciate Ligament Reconstruction: A Practical Review with Medical Recommendations. Int J Sports Med 2024. [PMID: 38527465 DOI: 10.1055/a-2270-3233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
Returning to sport after anterior cruciate ligament reconstruction (ACLR) can be a challenging and complex process for the athlete, with the rate of return to the pre-injury level of sport observed to be less than athlete expectations. Of the athletes that do return to sport (RTS), knee re-injury rates remain high, and multiple studies have observed impaired athletic performance upon RTS after ACLR as well as reduced playing time, productivity, and career lengths. To mitigate re-injury and improve RTS outcomes, multiple RTS after ACLR consensus statements/clinical practice guidelines have recommended objective RTS testing criteria to be met prior to medical clearance for unrestricted sports participation. While the achievement of RTS testing criteria can improve RTS rates after ACLR, current criteria do not appear valid for predicting safe RTS. Therefore, there is a need to review the various factors related to the successful return to the pre-injury level of sport after ACLR, clarify the utility of objective performance testing and RTS criteria, further discuss safe RTS decision-making as well as present strategies to reduce the risk of ACL injury/re-injury upon RTS. This article provides a practical review of the current RTS after ACLR literature, as well as makes medical recommendations for rehabilitation and RTS decision-making after ACLR.
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Affiliation(s)
- Braidy S Solie
- Physical Therapy, Training HAUS, Twin Cities Orthopedics, Eagan, MN, United States
- Research, Twin Cities Orthopedics, Edina, MN, United States
| | | | - Christopher P Doney
- Physical Therapy, Training HAUS, Twin Cities Orthopedics, Eagan, MN, United States
| | - Jeremy M J O'Keefe
- Physical Therapy, Training HAUS, Twin Cities Orthopedics, Eagan, MN, United States
| | - Will C Thompson
- Sports Science, Training HAUS, Twin Cities Orthopedics, Eagan, MN, United States
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Yang JS, Prentice HA, Reyes CE, Lehman CR, Maletis GB. Risk of Revision and Reoperation After Quadriceps Tendon Autograft ACL Reconstruction Compared With Patellar Tendon and Hamstring Autografts in a US Cohort of 21,973 Patients. Am J Sports Med 2024; 52:670-681. [PMID: 38284229 DOI: 10.1177/03635465231222267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
BACKGROUND The use of quadriceps tendon (QT) autografts has increased in the past 10 years. However, there remains a dearth of large studies examining the effects of graft selection on anterior cruciate ligament reconstruction (ACLR) that includes QT grafts. PURPOSE To evaluate the risk of subsequent surgical outcomes, including revision and reoperation, for a large cohort of patients with primary ACLR according to autograft selection. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Data from a US health care system ACLR registry were used to conduct a cohort study. Primary isolated autograft ACLRs were identified (2012-2021). The exposure of interest was autograft type: QT, bone-patellar tendon-bone (BPTB), and hamstring tendon (HT). Multivariable Cox regression models were used to evaluate the risk of aseptic revision (defined as a subsequent surgery where removal and replacement of the original graft for noninfectious reasons was required) and risk of aseptic reoperation (defined as any subsequent surgery for noninfectious reasons where the graft was left intact) according to autograft selection. RESULTS The study sample comprised 21,973 ACLRs performed by 290 surgeons at 53 hospitals. QT, BPTB, and HT autografts were used in 1103 (5.0%), 9519 (43.3%), and 11,351 (51.7%) ACLRs, respectively. In adjusted models, no significant differences were observed in revision risk (hazard ratio [HR], 1.06; 95% CI, 0.60-1.89; P = .837) or reoperation risk (HR, 1.00; 95% CI, 0.70-1.43; P = .993) within 4 years of follow-up when comparing QT ACLR with BPTB ACLR. Additionally, no differences in 4-year revision (HR, 0.62; 95% CI, 0.34-1.12; P = .111) or reoperation (HR, 1.24; 95% CI, 0.85-1.80; P = .262) risks were observed when comparing QT ACLR with HT ACLR. HT ACLRs were noted to have a higher risk of revision (HR, 1.52; 95% CI, 1.25-1.84; P < .001) compared with BPTB ACLRs but a lower risk of reoperation (HR, 0.86; 95% CI, 0.75-0.98; P = .024). CONCLUSION In this large multicenter study using data from an ACLR registry, the authors found no difference in the risk of revision or reoperation when QT was compared with BPTB or HT autograft with the numbers available, but they did find a 1.5 times higher risk of revision when HT autograft was compared with BPTB autograft. Surgeons may use this information when choosing the appropriate graft for ACLR in their patients.
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Affiliation(s)
- Justin S Yang
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Los Angeles, California, USA
| | - Heather A Prentice
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, California, USA
| | - Chelsea E Reyes
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, California, USA
| | - Christopher R Lehman
- Department of Orthopedic Surgery, Permanente Medical Group, South San Francisco, California, USA
| | - Gregory B Maletis
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Baldwin Park, California, USA
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Ferrel JR, Conley CE, Johnson DL. Routine Use of Suture Tape Augmentation for Primary Anterior Cruciate Ligament Reconstruction Surgery Is Not Justified. Arthroscopy 2024:S0749-8063(24)00157-9. [PMID: 38417641 DOI: 10.1016/j.arthro.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/01/2024]
Abstract
High rates of graft failure after primary ACLR and the need for revision ACLR continue to be a challenge. Multiple studies demonstrate graft failure rates and the need for revision ACLR in 10% to 15% of young patients participating in pivot sporting activities. There's currently a wide range of strategies to mitigate this problem being investigated, including extraarticular augmentation (with modified lateral extra-articular tenodesis or anterolateral ligament reconstruction) and intraarticular fixation (that aim for primary ACL healing or augmentation of an ACL reconstruction with suture tape). While the early data on suture tape augmentation of primary ACLR seems optimistic, it does not justify its routine use.
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Affiliation(s)
- Jason R Ferrel
- Orthopedic Surgery Sports Medicine Fellow, University of Kentucky School of Medicine, Kentucky Clinic, Dept. of Orthopaedic Surgery, 740 S. Limestone, Suite K401, Lexington, Ky. 40536-0284.
| | - Caitlin E Conley
- Assistant Professor, University of Kentucky School of Medicine, Kentucky Clinic, Dept. of Orthopaedic Surgery, 740 S. Limestone, Suite K401, Lexington, Ky. 40536-0284
| | - Darren L Johnson
- Professor of Orthopedic Surgery, Director and Chief: Sports Medicine, University of Kentucky School of Medicine, Kentucky Clinic, Dept. of Orthopaedic Surgery, 740 S. Limestone, Suite K401, Lexington, Ky. 40536-0284
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Daniel AV, Smith PA. Less Subsequent Revision Anterior Cruciate Ligament (ACL) Reconstruction Following Primary Bone-Patellar Tendon-Bone ACL Reconstruction with Suture Tape Augmentation-A Retrospective Comparative Therapeutic Trial With 5-Year Follow-up. Arthroscopy 2024:S0749-8063(24)00063-X. [PMID: 38311269 DOI: 10.1016/j.arthro.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 01/03/2024] [Accepted: 01/08/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE To investigate patient outcomes, including revision rate, following primary bone patellar-tendon bone autograft (BPTB) anterior cruciate ligament reconstruction (ACLR) with and without suture tape augmentation (STA) in a young and active cohort. METHODS All eligible patients who received primary BPTB ACLR with a minimum of 2-year follow-up were included in this retrospective cohort study. All patients receiving STA were augmented with the same device. Patients completed the following patient-reported outcome measures (PROMs): the visual analog scale, the Single Assessment Numeric Evaluation, the Knee Injury and Osteoarthritis Outcome Score subscales, and the Tegner activity scale. Anteroposterior knee laxity was assessed using a KT-1000 arthrometer preoperatively and 1-year postoperatively. Posterior tibial slope, femoral tunnel angle, and tibial tunnel placement were calculated for all patients. Subsequent surgical interventions and return to sport (RTS) were obtained from each patient. RESULTS One hundred fourteen patients (52 BPTB ACLR with STA, 62 traditional BPTB ACLR) with a mean patient age <19 years and a mean final follow-up of ≥5 years were included. Compared with the control group, the STA group demonstrated significantly less subsequent revision ACLR (0 vs. 5, P = .036). All PROMs and KT-1000 measurements improved at final follow-up (P < .001) and were comparable between groups. There were no differences seen in either posterior tibial slope or graft tunnel placement between groups. More than 85% of the patients were able to return to the sport that led to their injury at full capacity with no differences seen in RTS rate, time to RTS, or level of competition between groups. CONCLUSIONS Compared with traditional BPTB ACLR, additional STA appeared to safely and effectively lead to less subsequent revision ACLR while maintaining acceptable PROMs and objective joint laxity measurements in a young and active patient population. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Adam V Daniel
- Columbia Orthopaedic Group, Columbia, Missouri, U.S.A..
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Martin RK, Marmura H, Wastvedt S, Pareek A, Persson A, Moatshe G, Bryant D, Wolfson J, Engebretsen L, Getgood A. External validation of the Norwegian anterior cruciate ligament reconstruction revision prediction model using patients from the STABILITY 1 Trial. Knee Surg Sports Traumatol Arthrosc 2024; 32:206-213. [PMID: 38226736 DOI: 10.1002/ksa.12031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/10/2023] [Accepted: 12/05/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE A machine learning-based anterior cruciate ligament (ACL) revision prediction model has been developed using Norwegian Knee Ligament Register (NKLR) data, but lacks external validation outside Scandinavia. This study aimed to assess the external validity of the NKLR model (https://swastvedt.shinyapps.io/calculator_rev/) using the STABILITY 1 randomized clinical trial (RCT) data set. The hypothesis was that model performance would be similar. METHODS The NKLR Cox Lasso model was selected for external validation owing to its superior performance in the original study. STABILITY 1 patients with all five predictors required by the Cox Lasso model were included. The STABILITY 1 RCT was a prospective study which randomized patients to receive either a hamstring tendon autograft (HT) alone or HT plus a lateral extra-articular tenodesis (LET). Since all patients in the STABILITY 1 trial received HT ± LET, three configurations were tested: 1: all patients coded as HT, 2: HT + LET group coded as bone-patellar tendon-bone (BPTB) autograft, 3: HT + LET group coded as unknown/other graft choice. Model performance was assessed via concordance and calibration. RESULTS In total, 591/618 (95.6%) STABILITY 1 patients were eligible for inclusion, with 39 undergoing revisions within 2 years (6.6%). Model performance was best when patients receiving HT + LET were coded as BPTB. Concordance was similar to the original NKLR prediction model for 1- and 2-year revision prediction (STABILITY: 0.71; NKLR: 0.68-0.69). Concordance 95% confidence interval (CI) ranged from 0.63 to 0.79. The model was well calibrated for 1-year prediction while the 2-year prediction demonstrated evidence of miscalibration. CONCLUSION When patients in STABILITY 1 who received HT + LET were coded as BPTB in the NKLR prediction model, concordance was similar to the index study. However, due to a wide 95% CI, the true performance of the prediction model with this Canadian and European cohort is unclear and a larger data set is required to definitively determine the external validity. Further, better calibration for 1-year predictions aligns with general prediction modelling challenges over longer periods. While not a large enough sample size to elicit the true accuracy and external validity of the prediction model when applied to North American patients, this analysis provides more support for the notion that HT plus LET performs similarly to BPTB reconstruction. In addition, despite the wide confidence interval, this study suggests optimism regarding the accuracy of the model when applied outside of Scandinavia. LEVEL OF EVIDENCE Level 3, cohort study.
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Affiliation(s)
- R Kyle Martin
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Orthopaedic Surgery, CentraCare, Saint Cloud, Minnesota, USA
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
| | - Hana Marmura
- Department of Orthopaedic Surgery, University of Western Ontario, London, Ontario, Canada
| | - Solvejg Wastvedt
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ayoosh Pareek
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Andreas Persson
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
- Orthopaedic Clinic, Oslo University Hospital Ullevål, Oslo, Norway
| | - Gilbert Moatshe
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
- Orthopaedic Clinic, Oslo University Hospital Ullevål, Oslo, Norway
| | - Dianne Bryant
- School of Physical Therapy, University of Western Ontario, London, Ontario, Canada
| | - Julian Wolfson
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lars Engebretsen
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
- Orthopaedic Clinic, Oslo University Hospital Ullevål, Oslo, Norway
| | - Alan Getgood
- Department of Orthopaedic Surgery, University of Western Ontario, London, Ontario, Canada
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van der Wal WA, Meijer DT, Hoogeslag RAG, LaPrade RF. The Iliotibial Band is the Main Secondary Stabilizer for Anterolateral Rotatory Instability and both a Lemaire Tenodesis and Anterolateral Ligament Reconstruction Can Restore Native Knee Kinematics in the Anterior Cruciate Ligament Reconstructed Knee: A Systematic Review of Biomechanical Cadaveric Studies. Arthroscopy 2024; 40:632-647.e1. [PMID: 37207919 DOI: 10.1016/j.arthro.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 05/09/2023] [Accepted: 05/09/2023] [Indexed: 05/21/2023]
Abstract
PURPOSE To obtain a comprehensive overview of comparative biomechanical cadaveric studies investigating the effect of both the iliotibial band (ITB) and anterolateral ligament (ALL) on anterolateral rotatory instability (ALRI) in anterior cruciate ligament (ACL)-injured knees, and the effect of lateral extra-articular tenodesis (LET) versus ALL reconstruction (ALLR) in ACL-reconstructed knees. METHODS An electronic search was performed in the Embase and MEDLINE databases for the period between January 1, 2010, and October 1, 2022. All sectioning studies comparing the role of both the ITB and ALL on ALRI and all studies comparing the effect of both LET and ALLR were included. Articles were assessed for methodological quality according to the Quality Appraisal for Cadaveric Studies scale. RESULTS Data of 15 studies were included, representing the mean values of biomechanical data collected from 203 cadaveric specimens, with sample sizes ranging from 10 to 20 specimens. All 6 sectioning studies reported that the ITB acts as a secondary stabilizer to the ACL and helps resist internal knee rotation, whereas in only 2 of 6 sectioning studies the ALL contributed significantly to tibial internal rotation (IR). Most reconstruction studies reported that both a modified Lemaire tenodesis and an ALLR could significantly reduce the residual ALRI in isolated ACL-reconstructed knees and were able to restore IR stability/IR stability during the pivot shift. CONCLUSIONS The ITB acts as the main secondary stabilizer to the ACL in resisting IR/IR during pivot shift and an anterolateral corner (ALC) reconstruction with either a modified Lemaire tenodesis and ALLR can improve residual knee rotatory laxity in ACL reconstructed knees. CLINICAL RELEVANCE This systematic review provides insight in the biomechanical function of the ITB and ALL and emphasizes the importance of adding an ALC reconstruction to ACL reconstruction.
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Wallace GJ, Thompson JD, Diekfuss JA, Champagne AA, Myer GD, Kaiser J, Lamplot JD. Suture Augmentation of a Four-Strand Semitendinosus Graft Improves Time-Zero Biomechanical Properties. Arthroscopy 2024; 40:124-132. [PMID: 37355190 DOI: 10.1016/j.arthro.2023.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/05/2023] [Accepted: 06/12/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE To compare the time-zero biomechanical properties of hamstring graft preparations with or without suture augmentation for anterior cruciate ligament reconstruction (ACLR) in a full-construct cadaveric model. METHODS Hamstring grafts were harvested from 24 fresh frozen human cadavers and prepared in 1 of 3 ways: quadrupled SemiTendinosus (SemiT), and quadrupled SemiT with suture augmentation (SemiT+2.0-mm tape or SemiT+1.3-mm tape; n = 8 per group). Adjustable loop suspensory implants and cortical buttons were used for fixation on a porcine tibia and acrylic block. Testing included force-controlled cyclic loading at 250 N and 400 N followed by load to failure. RESULTS The 2 suture augmentation groups had less total elongation and increased stiffness compared to the nonsuture-augmented group (P = .025). The SemiT+2.0-mm tape group had 36% less total elongation and 34% increased stiffness compared to SemiT+1.3mm tape (P < .001). CONCLUSIONS Suture augmentation improves construct biomechanics at time zero following hamstring tendon ACLR. Augmentation with 2.0-mm tape suture improves construct biomechanics compared to 1.3-mm tape suture. CLINICAL RELEVANCE Independent suture augmentation of a quadrupled SemiT graft improves ACLR construct biomechanics. Outcomes were improved with augmentation using 2.0-mm tape suture compared to 1.3-mm tape suture.
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Affiliation(s)
- Garrett J Wallace
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - J Daniel Thompson
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jed A Diekfuss
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia, USA; Emory Sports Performance and Research Center (SPARC), Flowery Branch, Georgia, U.S.A
| | - Allen A Champagne
- Department of Orthopedic Surgery, Queen's University, Kingston, Ontario, Canada; School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Gregory D Myer
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia, USA; Emory Sports Performance and Research Center (SPARC), Flowery Branch, Georgia, U.S.A.; Emory Sports Medicine Center, Atlanta, Georgia, U.S.A.; The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, U.S.A
| | - Jarred Kaiser
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia, USA
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Darville GL, Young BL, Lamplot JD, Xerogeanes JW. Arthroscopic-Assisted Lateral Extra-Articular Tenodesis With Knotless Anchor Fixation. Arthrosc Tech 2023; 12:e2257-e2264. [PMID: 38196854 PMCID: PMC10772996 DOI: 10.1016/j.eats.2023.07.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/30/2023] [Indexed: 01/11/2024] Open
Abstract
Recent studies have reported the biomechanical and clinical advantages of lateral extraarticular augmentation procedures including the modified lateral extra-articular tenodesis (LET) in the setting of anterior cruciate ligament reconstruction. LET has been shown to significantly decrease re-rupture rates in high-risk patients and decrease anterior cruciate ligament graft forces during pivoting loads and instrumented anterior laxity testing. Many variations of the modified LET approaches have been described. However, concerns including lateral hematoma, wound-healing complications, and increased operative time exist. This minimally invasive, arthroscopic-assisted approach using a knotless, all-suture anchor allows for direct visualization through a 2-cm incision and inherently decreases the morbidity associated with traditional LET techniques.
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Affiliation(s)
- Gregory L. Darville
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Bradley L. Young
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Joseph D. Lamplot
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - John W. Xerogeanes
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, U.S.A
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Pyrz K, Wood A, Campbell C, Brabston E, Evely T, Casp A, Momaya A. Anterior Cruciate Ligament Reconstruction With Quadriceps Tendon Autograft: Surgical Technique Using Augmentation With a Biocomposite Scaffold. Arthrosc Tech 2023; 12:e2335-e2341. [PMID: 38196875 PMCID: PMC10773234 DOI: 10.1016/j.eats.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 08/07/2023] [Indexed: 01/11/2024] Open
Abstract
Anterior cruciate ligament (ACL) reconstruction augmentation continues to be widely studied. Both biologic and synthetic augments have been employed to enhance ACL healing and provide early protection. The BioBrace is a biocomposite scaffold that both mechanically reinforces the graft while biologically enhancing graft healing. The purpose of this article is to describe augmentation of an ACL reconstruction with BioBrace.
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Affiliation(s)
- Kaitlin Pyrz
- Augusta University/University of Georgia Medical Partnership, Athens, Georgia, U.S.A
| | - Audria Wood
- Department of Orthopaedics, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Collier Campbell
- Department of Orthopaedics, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Eugene Brabston
- Department of Orthopaedics, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Thomas Evely
- Department of Orthopaedics, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Aaron Casp
- Department of Orthopaedics, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Amit Momaya
- Department of Orthopaedics, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
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14
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Jildeh TR, Bowen E, Bedi A. Revision Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients. J Am Acad Orthop Surg 2023; 31:e920-e929. [PMID: 37364250 DOI: 10.5435/jaaos-d-23-00288] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 05/27/2023] [Indexed: 06/28/2023] Open
Abstract
Revision anterior cruciate ligament (ACL) reconstruction in the skeletally immature patient is a challenging procedure for pediatric patients with recurrent instability after primary ACL reconstruction. The pediatric population presents unique technical challenges and complications secondary to open physes compared with the adult population. Complications can include growth disturbances, recurrent graft failure, instability, and secondary chondral and/or meniscal injury. Moreover, identifying the etiology of graft failure is critical for a successful revision. Patients should undergo a complete history and physical examination with a focus on patient physiologic age, physeal status, mechanical axis, tibial slope, collagen status, injury mechanism, concomitant injuries, and previous surgical procedures. The surgeon must be adept at reconstruction with various grafts as well as socket or tunnel preparation and fixation, including over-the-top, all-epiphyseal, transphyseal, extra-articular augmentation, and staging approaches. Reported rates of return to sport are lower than those of primary reconstruction, with higher rates of cartilage and meniscal degeneration. Future research should focus on optimizing surgical outcomes and graft survivorship after primary ACL reconstruction with minimized trauma to the physis.
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Affiliation(s)
- Toufic R Jildeh
- From the Department of Orthopaedics, Michigan State University, East Lansing, MI (Jildeh), the Weill Cornell Medical College, New York, NY (Bowen), and the NorthShore Medical Group, Skokie, IL (Bedi)
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15
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de Geofroy B, Trescos F, Ghabi A, Choufani C, Peras M, Barbier O, de Landevoisin E, Jouvion AX. Anterior Cruciate Ligament Reconstruction in French Army: Return to Prior Level of Running on Selected Military Tests. Mil Med 2023:usad406. [PMID: 37864821 DOI: 10.1093/milmed/usad406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/11/2023] [Accepted: 09/29/2023] [Indexed: 10/23/2023] Open
Abstract
INTRODUCTION Anterior cruciate ligament (ACL) rupture is frequently encountered in athletes as well as in military personnel. In civilian population, many studies have looked at the return to sport, but return to duty in Army is a topic that requires further research.The purpose of this study was to determine through annual military fitness tests in real conditions, the return to sport in soldiers after ACL reconstruction and factors influencing failure. MATERIALS AND METHODS This was a retrospective comparative study. Patients were all soldiers and had followed up in a Military Hospital. The SUCCESS group was military personnel who obtained a result of the specific aptitude test greater than or equal to this same test carried out before reconstruction of the ACL, the FAILURE group comprised the others. Results of the annual specific aerobic fitness tests were collected before and after ACL reconstruction. Preoperative epidemiological data, intraoperative information, and isokinetic test results were collected. RESULTS One hundred forty four soldiers were included between January 2011 and December 2017 (94.9% of men with a median age of 27.6 years); 40.3% obtained a result greater than or equal to the preoperative fitness test after ACL reconstruction. Among the soldiers who did not regain their performance, 24.3% were declared unfit or discharged. In the FAILURE group, we found patients with a higher body mass index (25.5 vs. 24.4; P = .04), less patients with isokinetic deficit < 30% on the knee flexors and extensors (26.6% vs. 62.9%; P < .01), more long sick leave (39.5% vs. 13.7%; P < .01), and late resumption of military activities (10.5 vs. 8.9 months; P < .01). CONCLUSION Rupture of ACL has a significant impact on the operational capacity of the French army. The proportion of return to the same level in annual specific fitness tests after ACL reconstruction is 40% among soldiers. Several variables are important to consider in the follow-up of these patients to optimize their recovery of sports performance and therefore their operational capacity.
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Affiliation(s)
- Bernard de Geofroy
- Department of Orthopaedic and Trauma Surgery, HIA Laveran, Marseille, 13013, France
| | - Florent Trescos
- Department of Physical Medicine and Rehabilitation of the Injured, HIA Laveran, Marseille, 13013, France
| | - Ammar Ghabi
- Department of Orthopaedic and Trauma Surgery, HIA Laveran, Marseille, 13013, France
| | - Camille Choufani
- Department of Orthopaedic Surgery and Traumatology, HIA Sainte Anne, Toulon, 83000, France
| | - Mathieu Peras
- Department of Orthopaedic Surgery and Traumatology, HIA Sainte Anne, Toulon, 83000, France
| | - Olivier Barbier
- Department of Orthopaedic Surgery and Traumatology, HIA Sainte Anne, Toulon, 83000, France
| | | | - Arnaud-Xavier Jouvion
- Department of Physical Medicine and Rehabilitation of the Injured, HIA Laveran, Marseille, 13013, France
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Borim FM, Jubert NJ, Vinaixa MMR, Portas-Torres I, Bueno JP, Mayayo RS, Peiró JVA, Feliu EC, Monyart JM. Good rates of return-to-sport in athletes after revision anterior cruciate ligament reconstruction using autologous patellar tendon and lateral extra-articular tenodesis: a 2-year follow-up prospective study. Eur J Orthop Surg Traumatol 2023; 33:3125-3133. [PMID: 37039899 PMCID: PMC10504162 DOI: 10.1007/s00590-023-03544-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/03/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Most athletes who undergo revision of the anterior cruciate ligament reconstruction (ACLR) aim to return to their preinjury sport at a similar level of performance while minimizing the risk for reinjury. Additional lateral extra-articular tenodesis (LET) has recently been correlated with improved outcomes and low complication rate. Yet, there are few series evaluating return-to-sport (RTS) and clinical outcomes after revision ACLR using bone-patellar tendon-bone (BPTB) and LET in athletes. METHODS The study cohort consisted of 19 eligible athletes who had undergone their first revision ACLR using BPTB and LET (modified Lemaire) between January 2019 and 2020. Patients were prospectively followed and interviewed in a sports activity survey during a 2-year follow-up. RESULTS Despite all patients returning to sports after revision ACLR surgery, 52.6% resumed playing at their preinjury level. Furthermore, patient-reported functional outcomes improved significantly following revision surgery, as evidenced by improvements in IKDC [64.4 (± 12) to 87.8 (± 6)], Lysholm [71.27 (± 12) to 84.2 (± 9.7)], and SF-12 scales [Physical: 53.3 (± 3) 57 (± 1.2); Mental: 50.2 (± 3.3) to 52.7 (± 2.4)]. One case (5.3%) experienced persistent pain and underwent reoperation for a partial meniscectomy. CONCLUSION After revision ACLR using autologous BPTB and LET, all active individuals are expected to RTS, similar to primary ACLR. The difference comes down to returning to the preinjury level, where the levels are lower depending on the sport and initial level of play. Good mid-term functional outcomes with a low complication rate can be expected in most cases. STUDY DESIGN Case series; Level of evidence IV. ETHICAL COMMITTEE APPROVAL NUMBER PR(ATR)79/2021 and HCB/2023/0173.
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Affiliation(s)
- Felipe Moreira Borim
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellaterra, Barcelona, Spain.
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
- Bioengineering, Cell Therapy and Surgery in Congenital Malformations - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Nayana Joshi Jubert
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellaterra, Barcelona, Spain
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Maria Mercedes Revertè Vinaixa
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellaterra, Barcelona, Spain
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Knee Surgery Unit, Clínica Corachan, Carrer de Buïgas, 19, 08017, Barcelona, Spain
| | - Irene Portas-Torres
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Joan Pijoan Bueno
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellaterra, Barcelona, Spain
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Knee Surgery Unit, Clínica Corachan, Carrer de Buïgas, 19, 08017, Barcelona, Spain
| | - Raquel Sevil Mayayo
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Knee Surgery Unit, Clínica Corachan, Carrer de Buïgas, 19, 08017, Barcelona, Spain
| | - José Vicente Andrés Peiró
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellaterra, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Knee Surgery Unit, Clínica Corachan, Carrer de Buïgas, 19, 08017, Barcelona, Spain
| | - Enric Castellet Feliu
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellaterra, Barcelona, Spain
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Joan Minguell Monyart
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellaterra, Barcelona, Spain.
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain.
- Knee Surgery Unit, Clínica Corachan, Carrer de Buïgas, 19, 08017, Barcelona, Spain.
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Zhao D, Pan JK, Lin FZ, Luo MH, Liang GH, Zeng LF, Huang HT, Han YH, Xu NJ, Yang WY, Liu J. Risk Factors for Revision or Rerupture After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med 2023; 51:3053-3075. [PMID: 36189967 DOI: 10.1177/03635465221119787] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The rerupture or need for revision after anterior cruciate ligament reconstruction (ACLR) is a serious complication. Preventive strategies that target the early identification of risk factors are important to reduce the incidence of additional surgery. PURPOSE To perform a systematic review and meta-analysis to investigate risk factors for revision or rerupture after ACLR. STUDY DESIGN Systematic review and meta-analysis; Level of evidence, 4. METHODS Literature searches were performed in PubMed, Embase, and Web of Science from database inception to November 2021 and updated in January 2022. Quantitative, original studies reporting potential adjusted risk factors were included. Odds ratios (ORs) were calculated for potential risk factors. RESULTS A total of 71 studies across 13 countries with a total sample size of 629,120 met the inclusion criteria. Fifteen factors were associated with an increase in the risk of revision or rerupture after ACLR: male sex (OR, 1.27; 95% CI, 1.14-1.41), younger age (OR, 1.07; 95% CI, 1.05-1.08), lower body mass index (BMI) (OR, 1.03; 95% CI, 1.00-1.06), family history (OR, 2.47; 95% CI, 1.50-4.08), White race (OR, 1.32; 95% CI, 1.08-1.60), higher posterolateral tibial slope (OR, 1.15; 95% CI, 1.05-1.26), preoperative high-grade anterior knee laxity (OR, 2.30; 95% CI, 1.46-3.64), higher baseline Marx activity level (OR, 1.07; 95% CI, 1.02-1.13), return to a high activity level/sport (OR, 2.03; 95% CI, 1.15-3.57), an ACLR within less than a year after injury (OR, 2.05; 95% CI, 1.81-2.32), a concomitant medial collateral ligament (MCL) injury (OR, 1.62; 95% CI, 1.31-2.00), an anteromedial portal or transportal technique (OR, 1.36; 95% CI, 1.22-1.51), hamstring tendon (HT) autografts (vs bone-patellar tendon-bone [BPTB] autografts) (OR, 1.60; 95% CI, 1.40-1.82), allografts (OR, 2.63; 95% CI, 1.65-4.19), and smaller graft diameter (OR, 1.21; 95% CI, 1.05-1.38). The other factors failed to show an association with an increased risk of revision or rerupture after ACLR. CONCLUSION Male sex, younger age, lower BMI, family history, White race, higher posterolateral tibial slope, preoperative high-grade anterior knee laxity, higher baseline Marx activity level, return to a high activity level/sport, an ACLR within less than a year from injury, a concomitant MCL injury, an anteromedial portal or transportal technique, HT autografts (vs BPTB autografts), allografts, and smaller graft diameter may increase the risk of revision or rerupture after ACLR. Raising awareness and implementing effective preventions/interventions for risk factors are priorities for clinical practitioners to reduce the incidence of revision or rerupture after ACLR.
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Affiliation(s)
- Di Zhao
- The Second Clinical School of Guangzhou University of Chinese Medicine, Guangzhou, China
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Jian-Ke Pan
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
- Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Fang-Zheng Lin
- The Second Clinical School of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ming-Hui Luo
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
- Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Gui-Hong Liang
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
- Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ling-Feng Zeng
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
- Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - He-Tao Huang
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
- Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yan-Hong Han
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
- Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Nan-Jun Xu
- The Second Clinical School of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wei-Yi Yang
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
- Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jun Liu
- Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Guangdong Second Traditional Chinese Medicine Hospital (Guangdong Province Engineering Technology Research Institute of Traditional Chinese Medicine), Guangzhou, China
- The Fifth Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
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Deichsel A, Oeckenpöhler S, Raschke MJ, Grunenberg O, Peez C, Briese T, Herbst E, Kittl C, Glasbrenner J. Recurrent Instability Rate and Subjective Knee Function following Accelerated Rehabilitation after ACL Reconstruction in Comparison to a Conservative Rehabilitation Protocol. J Clin Med 2023; 12:4567. [PMID: 37510682 PMCID: PMC10380741 DOI: 10.3390/jcm12144567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/06/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
INTRODUCTION The Purpose of the present study was to assess the outcome of anterior cruciate ligament reconstruction (ACLR) with an accelerated rehabilitation protocol and to compare it to a conservative rehabilitation protocol. It was hypothesized that an accelerated rehabilitation protocol, including brace-free early weight bearing, would result in a higher rate of recurrent instability and revision surgery compared to a conservative rehabilitation protocol. METHODS From 2016 to 2017, two different rehabilitation protocols for isolated ACLR were used at a high-volume knee surgery center. A total of 65 consecutive patients with isolated hamstring ACLR, of whom n = 33 had been treated with an accelerated (AccRehab) and n = 32 with a conservative rehabilitation protocol (ConRehab), were retrospectively included in the study. Patients were evaluated for recurrent instability, revision surgery, and other complications at a mean follow-up period of 64 ± 7.4 months. In addition, Tegner Activity Scale, Lysholm Score, and IKDC-subjective Score were evaluated. Statistical comparison between the two groups was performed utilizing Fisher's exact test and Student's t-test. RESULTS Mean age (29.3 vs. 26.6 years) and preoperative Tegner Score (6.4 vs. 5.9) were comparable between both groups. At 64 ± 7.4 months after ACLR, six cases of recurrent instability were reported in the AccRehab group (18%) in comparison to three cases (9%) in the ConRehab group (p = n.s.). There was no significant difference regarding revision surgery and further complications. Furthermore, no significant difference was found between both groups regarding Tegner (5.5 ± 1.9 vs. 5.5 ± 1.2), Lysholm (93.6 ± 6.3 vs. 89.3 ± 10.7), and IKDC score (89.7 ± 7.9 vs. 86.7 ± 12.1). CONCLUSION No significant disadvantage of an accelerated rehabilitation protocol following ACLR was found in terms of recurrent instability rate, revision surgery, or patient-reported outcome. However, a trend towards a higher reinstability rate was found for an accelerated rehabilitation protocol. Future level one trials evaluating brace-free early weight bearing following ACLR are desirable.
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Affiliation(s)
- Adrian Deichsel
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Münster, Germany
| | - Simon Oeckenpöhler
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Münster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Münster, Germany
| | - Ole Grunenberg
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Münster, Germany
| | - Christian Peez
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Münster, Germany
| | - Thorben Briese
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Münster, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Münster, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Münster, Germany
| | - Johannes Glasbrenner
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Münster, Germany
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Lowenstein NA, Altwies ME, Hoang V, Anthony T, Matzkin EG. Technique for All-Inside Anterior Cruciate Ligament Reconstruction Using Quadrupled Semitendinosus and Gracilis Autograft. Arthrosc Tech 2023; 12:e1083-e1089. [PMID: 37533919 PMCID: PMC10390822 DOI: 10.1016/j.eats.2023.02.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/21/2023] [Indexed: 08/04/2023] Open
Abstract
Anterior cruciate ligament (ACL) injuries are common to athletes and non-athletes alike. Whereas the literature has historically supported bone-patellar tendon-bone as the gold standard for active patients who elect to undergo ACL reconstruction, other studies have suggested that soft-tissue grafts do not increase the risk of rerupture. Because graft diameter has a direct effect on revision rates, we share a technique for all-inside ACL reconstruction using quadrupled semitendinosus and gracilis autograft that allows for a predictable, robust graft. Reproducible steps of graft harvesting, tunnel preparation, graft passage, and fixation are shared to achieve a robust anatomic reconstruction.
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Affiliation(s)
- Natalie A. Lowenstein
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Madison E. Altwies
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Victor Hoang
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Taylor Anthony
- College of Osteopathic Medicine, Touro University Nevada, Henderson, Nevada, U.S.A
| | - Elizabeth G. Matzkin
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
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20
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Vari N, Marot V, Cavaignac M, Vieira TD, Bérard É, Cavaignac E. Factors Affecting Graft Remodeling and Anterior Cruciate Ligament Reconstruction: MRI Study of 180 Knees. Am J Sports Med 2023; 51:2073-2078. [PMID: 37249129 DOI: 10.1177/03635465231171947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Several factors affect the retear rate after anterior cruciate ligament (ACL) reconstruction, but there are few data on which factors affect graft remodeling. PURPOSE To determine which factors are associated with the remodeling of an ACL graft. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS A retrospective longitudinal study was conducted to investigate the relationship between various exposure factors and the occurrence of an "event": graft remodeling measured with the signal-to-noise quotient (SNQ). Data were collected prospectively and analyzed retrospectively for this study. The endpoint was the SNQ on magnetic resonance imaging at postoperative 1 year. The effect of the following parameters on SNQ was investigated: sex, smoking habits, age at surgery, body mass index, time to surgery, time to return to sports, type of sport (in-line, pivot, contact), type of graft (free semitendinosus [ST] or attached ST), and addition of lateral tenodesis. RESULTS An overall 180 patients were enrolled (90 with each technique). The following factors were significantly and independently associated with the SNQ: attached ST graft (β = -2.624668; P < .001), age at the time of surgery (β = -0.7948476; P = .012), and time elapsed between the injury event and surgery (β = -0.7137424; P = .046). CONCLUSION Leaving the ST graft attached distally, being older at the time of surgery, and having more time elapse between the injury event and ACL reconstruction surgery were significantly associated with better graft remodeling.
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Affiliation(s)
- Nicolas Vari
- Musculoskeletal Institute, Hôpital Pierre Paul Riquet, CHU Toulouse, Toulouse, France
| | - Vincent Marot
- Orthopaedics Unit, Hospital Nostra Senyora de Meritxell, Escaldes-Engordany, Andorra
| | | | - Thais Dutra Vieira
- Centre Orthopedique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Émilie Bérard
- Department of Epidemiology, Health Economics and Public Health, UMR 1295 CERPOP, University of Toulouse, INSERM, UPS, Toulouse University Hospital, Toulouse, France
| | - Etienne Cavaignac
- Musculoskeletal Institute, Hôpital Pierre Paul Riquet, CHU Toulouse, Toulouse, France
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Marx RG, Hsu J, Fink C, Eriksson K, Vincent A, van der Merwe WM. Graft choices for paediatric anterior cruciate ligament reconstruction: State of the art. J ISAKOS 2023; 8:145-152. [PMID: 36646171 DOI: 10.1016/j.jisako.2023.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/15/2022] [Accepted: 01/03/2023] [Indexed: 01/15/2023]
Abstract
The paediatric population is at particularly high risk for anterior cruciate ligament (ACL) injuries due to high rates of sports participation. Other risk factors for ACL injuries in children include but are not limited to being female, generalised ligamentous laxity, a high body mass index (BMI), and poor neuromuscular control. ACL reconstruction (ACLR) is commonly done to treat ACL injuries and allow for return to sports and daily activities. ACL repair is another option with ongoing techniques being developed. The high rates of graft failure in children reported in recent publications on ACL repair are very concerning. Special consideration must be taken in ACLR in the skeletally immature patient due to the risk of growth-related complications, such as limb deformity or growth arrest, that can arise from drilling across or disrupting the physis. Graft choices for paediatric ACLR include iliotibial band (ITB) over the top and over the front, hamstring autograft, bone patellar tendon bone (BTB) autograft, quadriceps tendon autograft, and allograft. Factors for each graft choice to consider include graft size, graft failure rates, donor site morbidity, requirement for bony tunnels, the post-op rehabilitation process, and return to sport outcomes. Each graft has its benefits and disadvantages for the individual patient, depending on age, skeletal maturity, and goals for recovery. Lateral extra-articular tenodesis (LET) is another option to consider with paediatric ACLR because LET has been shown to decrease the re-rupture rate in adult ACLR. After surgery, patient follow-up until at least the growth plates are closed is important. This article aims to provide an overview and comparison of the various graft types to aid in the graft choice decision making process for paediatric ACLR.
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Affiliation(s)
- Robert G Marx
- Sports Medicine Institute, Hospital for Special Surgery, New York, 10021, USA; Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, 10021, USA.
| | - Janet Hsu
- Sports Medicine Institute, Hospital for Special Surgery, New York, 10021, USA
| | - Christian Fink
- Gelenkpunkt-Sports and Joint Surgery, Innsbruck, 6020, Austria; Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), UMIT, Hall in Tirol, 6060, Austria
| | - Karl Eriksson
- Orthopaedic Surgery, Stockholm South Hospital, Karolinska Institutet, Stockholm, 17177, Sweden
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Nuelle CW, Shubert D, Leary E, Pringle LC. Two-Dimensional Magnetic Resonance Imaging in Preparation for Autograft Anterior Cruciate Ligament Reconstruction Demonstrates Quadriceps Tendon Is Thicker Than Patellar Tendon. Arthrosc Sports Med Rehabil 2023; 5:e783-e791. [PMID: 37388871 PMCID: PMC10300585 DOI: 10.1016/j.asmr.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/13/2023] [Indexed: 07/01/2023] Open
Abstract
Purpose The purpose of this study was to assess patellar tendon (PT) and quadriceps tendon (QT) thickness on preoperative magnetic resonance imaging (MRI), in both the sagittal and axial planes, at multiple points along each tendon, and to correlate these findings to anthropometric patient data before anterior cruciate ligament (ACL) surgery. Methods Patients who underwent PT or QT autograft ACL reconstruction between 2020 and 2022 and who had preoperative MRIs with adequate visualization of the proximal QT and distal PT were retrospectively identified. Patient demographics were recorded (age, height, weight, sex, injury side). Preoperative MRI measurements were performed by 3 independent examiners using standardized protocol. Preoperative MRI measurements were the QT anterior-posterior (AP) thickness at 1, 2, and 4 cm from the proximal patella on axial and sagittal MRI images at the central aspect of the tendon, as well as PT AP thickness at 1, 2, and 4 cm from the distal patella on axial and sagittal MRI images at the central aspect of the tendon. Results Forty-one patients (21 females, 20 males) were evaluated, with a mean age of 33.4 years. The quadriceps tendon was significantly thicker than the patellar tendon at all measured locations (P < .0001) with average QT versus PT thickness (in mm) at each level sagittal 1 cm (7.13 vs 4.35), sagittal 2 cm (7.41 vs 4.44), sagittal 4 cm (7.26 vs 4.81), axial 1 cm (7.35 vs 4.50), axial 2 cm (7.63 vs 4.47), axial 4 cm (7.46 vs 4.62), respectively. There were no significant correlations between tendon size and patient body mass index. Conclusions The quadriceps tendon is significantly thicker than the patellar tendon at 1, 2, and 4 cm from the patella in both males and females based on preoperative MRI before ACL surgery. Clinical relevance Investigating the thickness of the tendons available for autograft harvest before surgery will give us a better understanding of tendon anatomy in the setting of ACL reconstruction.
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Affiliation(s)
- Clayton W. Nuelle
- University of Missouri Hospitals, Columbia, Missouri
- Mizzou Joint Preservation Center, Missouri Orthopaedic Institute, Columbia, Missouri
| | | | - Emily Leary
- University of Missouri Hospitals, Columbia, Missouri
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Baker HP, Bowen E, Sheean A, Bedi A. New Considerations in ACL Surgery: When Is Anatomic Reconstruction Not Enough? J Bone Joint Surg Am 2023; Publish Ahead of Print:00004623-990000000-00808. [PMID: 37205735 DOI: 10.2106/jbjs.22.01079] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
➤ Clinicians should be careful to assess for associated injuries including anterolateral complex and medial meniscal ramp lesions or lateral meniscal posterior root tears.➤ Consideration of lateral extra-articular augmentation should be given for patients with >12° of posterior tibial slope.➤ Patients with preoperative knee hyperextension (>5°) or other nonmodifiable risk factors, including high-risk osseous geometry, may benefit from a concomitant anterolateral augmentation procedure to improve rotational stability.➤ Meniscal lesions should be addressed at the time of anterior cruciate ligament reconstruction with meniscal root or ramp repair.
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Affiliation(s)
- Hayden P Baker
- Department of Orthopaedic Surgery, University of Chicago, Chicago, Illinois
| | | | - Andrew Sheean
- San Antonio Military Medical Center, San Antonio, Texas
| | - Asheesh Bedi
- Northshore University Health System, Skokie, Illinois
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24
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Ina JG, Megerian MF, Knapik DM, Calcei JG, Rimnac CM, Voos JE. Smaller diameter femoral tunnel biocomposite interference screws provide adequate fixation strength in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2023:10.1007/s00167-023-07421-z. [PMID: 37115230 DOI: 10.1007/s00167-023-07421-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 04/14/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the effect of bioabsorbable interference screw diameter on the pullout strength and failure mode for femoral tunnel fixation in primary anterior cruciate ligament reconstruction (ACLR) at time zero fixation using bone-patellar tendon-bone (BTB) autograft in a cadaveric model. METHODS Twenty-four fresh-frozen cadaveric knees were obtained from 17 different donors. Specimens were allocated to three different treatment groups (n = 8 per group) based on interference screw diameter: 6 mm, 7 mm, or 8 mm biocomposite interference screw. All specimens underwent dual energy X-ray absorptiometry (DEXA) scanning prior to allocation to ensure no difference in bone mineral density among groups (n.s.). All specimens underwent femoral-sided ACLR with BTB autograft. Specimens subsequently underwent mechanical testing under monotonic loading conditions to failure. The load to failure and failure mechanism were recorded. RESULTS The mean pullout force (N) at time zero for each group was 309 ± 213 N, 518 ± 313 N, and 541 ± 267 N for 6 mm, 7 mm, and 8 mm biocomposite interference screw diameter, respectively (n.s.). One specimen in the 6 mm group, two specimens in the 7 mm group, and one specimen in the 8 mm group failed by screw pullout. The remainder in each group failed by graft failure (n.s.). CONCLUSION Biocomposite interference screw diameter did not have a significant influence on fixation pullout strength or failure mode following femoral tunnel fixation using BTB autograft at time zero. A 6 mm interference screw can improve preservation of native bone stock, increase potential for biologic healing, and decrease the risk of damage to the graft during insertion without significantly compromising fixation strength. This study supports the use of smaller 6 mm interference screw diameter options for femoral tunnel fixation in ACLR.
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Affiliation(s)
- Jason G Ina
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, 11101 Euclid Ave, Cleveland, OH, 44106, USA.
| | - Mark F Megerian
- Case Western Reserve University School of Medicine, Cleveland, USA
| | - Derrick M Knapik
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, 11101 Euclid Ave, Cleveland, OH, 44106, USA
| | - Jacob G Calcei
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, 11101 Euclid Ave, Cleveland, OH, 44106, USA
| | - Clare M Rimnac
- Department of Mechanical and Aerospace Engineering, Case Western Reserve University, Cleveland, USA
| | - James E Voos
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, 11101 Euclid Ave, Cleveland, OH, 44106, USA
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25
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Delaloye JR, Hartog C, Blatter S, Schläppi M, Müller D, Schwenke T, Murar J, Koch PP. Biomechanical Comparison of Anterior Cruciate Ligament Reconstruction Using a Single-Bundle Round or Ribbon-like Hamstring Tendon Graft. Am J Sports Med 2023; 51:1162-1170. [PMID: 36917792 DOI: 10.1177/03635465231159069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Persistent instability of the knee is reported in up to 30% of patients after anterior cruciate ligament (ACL) reconstruction. Based on anatomic findings showing that ACL is a flat ribbon-like structure that twists during knee flexion, a new surgical ACL reconstruction technique using a ribbon-like graft has been developed. However the effect of this surgical technique on knee kinematics has not yet been evaluated. PURPOSE To compare the anteroposterior and rotational stability of the knee after ACL reconstruction using single-bundle (SB) round and ribbon-like grafts in anterolateral-intact/deficient knees. STUDY DESIGN Controlled laboratory study. METHODS Twelve human fresh-frozen cadaveric knees were tested with a 6 degrees of freedom robotic system. Internal rotation and anterior translation of the knee were recorded from 0° to 90° of flexion. A full kinematic assessment was performed in each of the following conditions: (1) intact knee, (2) after sectioning of the ACL, (3) after ACL reconstruction using a SB hamstring tendon graft in a round configuration and a ribbon-like configuration, and (4) after sectioning of the anterolateral structures. One-way analysis of variance and post hoc Tukey tests were used for statistical analyses. RESULTS When compared with the intact knee, the ACL-deficient knee demonstrated a mean ± SD increase in anterior translation and internal rotation of 6.3 ± 2.5 mm (P < .01) and 5.8°± 2.3° (P < .01), respectively. After ACL reconstruction using a SB ribbon-like graft, the mean difference in anterior translation and internal rotation as compared with the intact knee was -0.1 ± 1.5 mm (P = .842) and 0.0°± 1.1° (P = .999). These differences from the intact knee were also not significant after ACL reconstruction using a round graft (-0.1 ± 1.3 mm, P = .999; -0.5°± 1.5°, P = .401). In the ACL-reconstructed knee using either a ribbon-like or round graft, sectioning of the anterolateral structures did not induce a significant increase of anterior translation and internal rotation of the knee. CONCLUSION ACL reconstruction using a SB ribbon-like or round graft restored the kinematics of the intact knee at time zero. Secondary sectioning of the anterolateral structures in the ACL-reconstructed knee using both types of graft did not significantly affect the anterior translation and internal rotation of the knee. CLINICAL RELEVANCE This is the first biomechanical study on the new ACL reconstruction technique using a ribbon-like graft.
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Affiliation(s)
- Jean-Romain Delaloye
- Clinic of Orthopaedics and Traumatology, Department of Surgery, Kantonsspital, Winterthur, Switzerland
| | - Christoph Hartog
- Clinic of Orthopaedics and Traumatology, Department of Surgery, Kantonsspital, Winterthur, Switzerland
| | - Samuel Blatter
- Clinic of Orthopaedics and Traumatology, Department of Surgery, Kantonsspital, Winterthur, Switzerland
| | - Michel Schläppi
- Clinic of Orthopaedics and Traumatology, Department of Surgery, Kantonsspital, Winterthur, Switzerland
| | | | | | - Jozef Murar
- Twin Cities Orthopedics, Edina, Minnesota, USA
| | - Peter P Koch
- Clinic of Orthopaedics and Traumatology, Department of Surgery, Kantonsspital, Winterthur, Switzerland
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26
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Sonnier JH, Paul RW, Sando HE, Hall AT, Tjoumakaris FP, Cohen SB, Freedman KB. Patient Decision Making in Anterior Cruciate Ligament Reconstruction: A Discrete Choice Experiment Examining Graft Preference. Orthop J Sports Med 2023; 11:23259671221144983. [PMID: 36756168 PMCID: PMC9900657 DOI: 10.1177/23259671221144983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/26/2022] [Indexed: 02/05/2023] Open
Abstract
Background Bone-patellar tendon-bone (BTB) and hamstring autografts are the most common grafts used for anterior cruciate ligament (ACL) reconstruction. Patient preferences should be accounted for as a part of shared decision making. Purpose/Hypothesis The purpose of this study was to perform a discrete choice experiment that evaluated patient preferences toward ACL autografts. We hypothesized that there would be no difference in patient preferences between groups. Study Design Cross-sectional study. Methods Patients aged 18 to 25 years who underwent shoulder arthroscopy at a single institution between 2013 and 2019 were included in the study as a proxy for healthy controls. Patients with a history of ACL tear were excluded. A discrete choice experiment was developed from a literature search and used the following data points as they pertain to BTB or hamstring autograft: risk of developing a significant complication, return-to-play rate, risk of anterior knee pain with kneeling, and risk of additional surgery due to graft failure. Included patients completed a custom survey in which they were asked to choose between "surgery A" (hamstring) and "surgery B" (BTB). Results A total of 107 participants were included in the analysis. Of these participants, 39 (36.5%) chose surgery A (hamstring) and 68 (63.6%) chose surgery B (BTB). When comparing the hamstring group with the BTB group, there was no significant difference in age, sex, body mass index, race, level of education, or employment status. However, 80.5% of self-reported athletes preferred BTB (P = .008). When controlling for age, sex, and body mass index, patients in the BTB group were more likely to rate return to sport (risk ratio [RR] = 1.49 [95% CI, 1.18-1.98]; P = .001) and the risk of requiring additional surgery due to graft failure (RR = 1.26 [95% CI, 1.02-1.58]; P = .037) as highly important. Conversely, they were less likely than patients in the hamstring group to rate pain while kneeling (RR = 0.65 [95% CI, 0.98-1.05]; P < .001) and complication risk (RR = 0.75 [95% CI, 0.59-0.94]; P = .013) as important. Conclusion The study hypothesis was rejected, as patient values did affect ACL graft choice preference. Utilizing patient-selected values in a quantifiable way can benefit the shared decision-making process before ACL reconstruction.
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Affiliation(s)
| | - Ryan W. Paul
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania,
USA
| | - Hayden E. Sando
- Drexel University College of Medicine, Philadelphia, Pennsylvania,
USA
| | - Anya T. Hall
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania,
USA
| | | | - Steven B. Cohen
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania,
USA
| | - Kevin B. Freedman
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania,
USA.,Kevin B. Freedman, MD, Rothman Orthopaedics at Thomas Jefferson
University, 825 Old Lancaster Road, Suite 200, Bryn Mawr, PA 19010, USA (
) (Twitter: @RothmanOrtho)
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Minguell Monyart J, Moreira Borim F, Revertè Vinaixa MM, Portas-Torres I, Pijoan Bueno J, Castellet Feliu E, Joshi Jubert N. Allografts and lateral extra-articular tenodesis for revision anterior cruciate ligament reconstruction: enhanced rotational stability and improved functional outcomes. Eur J Orthop Surg Traumatol 2023:10.1007/s00590-023-03475-4. [PMID: 36708388 PMCID: PMC10368563 DOI: 10.1007/s00590-023-03475-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/18/2023] [Indexed: 01/29/2023]
Abstract
PURPOSE Multiple studies have shown higher failure rate and patient-reported outcomes to be significantly worse following revision anterior cruciate ligament reconstructive (ACLR) surgery, especially using allografts. One of the reasons being rotational instability. Because of this, augmentation with lateral extra-articular tenodesis (LET) is often considered. Good short-term results in regards to functional and perceived scores and low complication rate can be expected in revision ACLR using allografts in combination with LET. METHODS Between 2014 and 2021, 46 patients were registered for revision ACLR using allografts and extra-articular augmentation (modified Lemaire) and included in this prospective study. Patients' demographic and clinical data were collected preoperatively, postoperatively, and during the follow-up period of 12 months. RESULTS Patient-reported functional outcomes were statistically significant for IKDC, Lysholm, and SF-12 physical scale (p < 0.05). Tegner score showed a decreased number of patients who were able to return to sport at their previous level (p = 0.001). Stability examination tests (Lachman and pivot-shift) showed significant improvements. Concomitant lesions were present in 76.1% of patients. Ten patients (21.7%) presented major complications, including six cases of anteroposterior instability, three cases of knee pain and one graft re-rupture. CONCLUSION Revision procedures are inherently challenging with a high number of associated chondral and meniscus lesions. However, good short-term functional outcomes and enhanced rotational stability with an acceptable complication rate can be expected in most cases where revision ACLR using allografts is augmented with LET. STUDY DESIGN Prospective; Case series; Level of evidence IV.
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Affiliation(s)
- Joan Minguell Monyart
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellatera, Barcelona, Spain
- Orthopaedic Surgery Department, Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Felipe Moreira Borim
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellatera, Barcelona, Spain.
- Orthopaedic Surgery Department, Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
- Bioengineering, Cell Therapy and Surgery in Congenital Malformations - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Maria Mercedes Revertè Vinaixa
- Orthopaedic Surgery Department, Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Irene Portas-Torres
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Joan Pijoan Bueno
- Orthopaedic Surgery Department, Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Enric Castellet Feliu
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellatera, Barcelona, Spain
- Orthopaedic Surgery Department, Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Nayana Joshi Jubert
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellatera, Barcelona, Spain.
- Orthopaedic Surgery Department, Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain.
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Rizvanovic D, Waldén M, Forssblad M, Stålman A. 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; 31:475-86. [PMID: 35896755 DOI: 10.1007/s00167-022-07057-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [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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du Moulin W, Bourne M, Diamond LE, Konrath J, Vertullo C, Lloyd D, Saxby DJ. Shape differences in the semitendinosus following tendon harvesting for anterior cruciate ligament reconstruction. J Orthop Res 2023; 41:44-53. [PMID: 35434842 PMCID: PMC10084140 DOI: 10.1002/jor.25337] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 02/12/2022] [Accepted: 03/31/2022] [Indexed: 02/04/2023]
Abstract
Following hamstring autograft anterior cruciate ligament reconstruction (ACLR), muscle length, cross-sectional area, and volume are reduced. However, these discrete measures of morphology do not account for complex three-dimensional muscle shape. The primary aim of this study was to determine between-limb semitendinosus (ST) shape and regional morphology differences in young adults following tendon harvest for ACLR and to compare these differences with those in healthy controls. In this cross-sectional study, magnetic resonance imaging was performed on 18 individuals with unilateral ACLR and 18 healthy controls. Bilaterally, ST muscles were segmented, and shape differences assessed between limbs and compared between groups using Jaccard index (0-1) and Hausdorff distance (mm). Length (cm), peak cross-sectional area (cm2 ), and volume (cm3 ) were measured for the entire muscle and proximal, middle, and distal regions, and compared between limbs and groups. Compared to healthy controls, the ACLR group had significantly (p < 0.001, Cohen's d = -2.33) lower bilateral ST shape similarity and shape deviation was significantly (p < 0.001, d = 2.12) greater. Shape deviation was greatest within the distal region of the ACLR (Hausdorff: 23.1 ± 8.68 mm). Compared to both the uninjured contralateral limb and healthy controls, deficits in peak cross-sectional area and volume in ACLR group were largest in proximal (p < 0.001, d = -2.52 to -1.28) and middle (p < 0.001, d = -1.81 to -1.04) regions of the ST. Overall, shape analysis provides unique insight into regional adaptations in ST morphology post-ACLR. Findings highlight morphological features in distal ST not identified by traditional discrete morphology measures. Clinical significance: Following ACLR, risk of a secondary knee or primary hamstring injury has been reported to be between 2-to-5 times greater compared to those without ACLR. Change in semitendinosus (ST) shape following ACLR may affect force transmission and distribution within the hamstrings and might contribute to persistent deficits in knee flexor and internal rotator strength.
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Affiliation(s)
- William du Moulin
- Griffith Centre of Biomedical and Rehabilitation Engineering (GCORE), Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Matthew Bourne
- Griffith Centre of Biomedical and Rehabilitation Engineering (GCORE), Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Laura E Diamond
- Griffith Centre of Biomedical and Rehabilitation Engineering (GCORE), Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Jason Konrath
- Griffith Centre of Biomedical and Rehabilitation Engineering (GCORE), Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia.,Principia Technology, Crawley, Western Australia, Australia
| | - Christopher Vertullo
- Griffith Centre of Biomedical and Rehabilitation Engineering (GCORE), Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia.,Knee Research Australia, Gold Coast, Queensland, Australia
| | - David Lloyd
- Griffith Centre of Biomedical and Rehabilitation Engineering (GCORE), Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - David J Saxby
- Griffith Centre of Biomedical and Rehabilitation Engineering (GCORE), Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
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Carter T, Norton A. A Prospective, Double-Blind Evaluation of Anterior Cruciate Ligament Reconstruction With Tibialis Tendon Allograft: Donor Age Does Not Alter Outcomes. Arthrosc Sports Med Rehabil 2023; 5:e267-72. [PMID: 36866298 DOI: 10.1016/j.asmr.2022.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 11/20/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose To evaluate the effect of graft donor age on outcomes of anterior cruciate ligament (ACL) reconstruction with nonirradiated, fresh-frozen tibialis tendon allografts. Methods This prospective, randomized, double-blind, single surgeon, 2-year follow-up study enrolled 40 patients (28 female, 12 male who underwent ACL reconstruction with tibialis tendon allografts. Results were compared with historical outcomes for allografts from donors aged 18 to 70 years. Analysis was determined by Group A (<50 years) and Group B (>50 years). Objective and subjective International Knee Documentation Committee (IKDC) forms, KT-1000 testing, and Lysholm scores were used for the evaluation. Results Follow-up on average of 24 months was completed in 37 patients (92.5%; Group A = 17, Group B = 20). Average patient age at surgery for Group A was 42.1 years (range 27-54) and Group B was 41.7 years (range 24-56). None of the patients required additional surgery during the initial 2-year follow-up. At 2-year follow-up, there were no significant differences in subjective outcomes. IKDC objective ratings for Group A were A-15 and B-2, and Group B were A-19 and B-1 (P = .45). Average IKDC subjective scores for Group A were 86.1 (± 16.2) and Group B were 84.1 (± 15.6) (P = .70). KT-1000 side to side differences for Group A were 0-4, 1-10, and 2-2, and Group B were 0-2, 1-10, 2-6 (P = .28). Average Lysholm scores for Group A were 91.4 (± 16.7) and Group B were 88.1 (± 12.3) (P = .49). Conclusions Donor age was not associated with clinical outcomes after ACL reconstruction using nonirradiated, fresh-frozen tibialis tendon allografts. Level of Evidence II, prospective prognostic trial.
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Hopper GP, Pioger C, Philippe C, El Helou A, Campos JP, Gousopoulos L, Carrozzo A, Vieira TD, Sonnery-Cottet B. Risk Factors for Anterior Cruciate Ligament Graft Failure in Professional Athletes: An Analysis of 342 Patients With a Mean Follow-up of 100 Months From the SANTI Study Group. Am J Sports Med 2022; 50:3218-3227. [PMID: 36177758 DOI: 10.1177/03635465221119186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) injuries are among the most common knee injuries sustained in elite sport, and athletes generally undergo ACL reconstruction (ACLR) to facilitate their return to sport. ACL graft rupture is a career-threatening event for elite athletes. PURPOSE/HYPOTHESIS The purpose of this study was to determine the risk factors for graft failure in professional athletes undergoing ACLR. It was hypothesized that athletes who underwent combined ACLR with a lateral extra-articular procedure (LEAP) would experience significantly lower rates of graft rupture in comparison with those who underwent isolated ACLR. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Professional athletes who underwent primary ACLR with a minimum follow-up of 2 years were identified from the Santy database. Patients were excluded if they underwent major concomitant procedures, including multiligament reconstruction surgery or osteotomy. Further ipsilateral knee injury, contralateral knee injury, and any other reoperations or complications after the index procedure were identified by interrogation of the database and review of the medical notes. RESULTS A total of 342 athletes with a mean follow-up of 100.2 ± 51.9 months (range, 24-215 months) were analyzed. Graft failures totaling 31 (9.1%) were reported, requiring revision surgery because of symptomatic instability. The rate of graft failure was significantly higher when ACLR was not combined with a LEAP (15.5% vs 6.0%; P = .0105) and in athletes aged 21 years or younger (13.8% vs 6.6%; P = .0290). A multivariate analysis was performed using the Cox model and demonstrated that athletes undergoing an isolated ACLR were at >2-fold risk of ACL graft rupture (hazard ratio [HR], 2.678 [1.173; 4.837], P = .0164) when compared with those undergoing a combined ACLR with a LEAP. Additionally, athletes aged ≤21 years were also at >2-fold risk of graft failure (HR, 2.381 [1.313; 5.463]; P = .0068) than those aged >21 years. Sex, sport, and graft type were not found to be significant risk factors for graft failure. CONCLUSION Professional athletes undergoing isolated ACLR and aged ≤21 years are at >2-fold greater risk of graft failure. Orthopaedic surgeons treating elite athletes should combine an ACLR with a LEAP to improve ACL graft survivorship.
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Affiliation(s)
- Graeme P Hopper
- NHS Glasgow and Clyde South Glasgow University Hospitals NHS Trust Glasgow, Glasgow, UK.,Centre Orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Charles Pioger
- Centre Orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France.,Hôpital Ambroise-Paré, Department of Orthopedic Surgery, Boulogne-Billancourt, Île-de-France, France
| | - Corentin Philippe
- Centre Orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Abdo El Helou
- Centre Orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Joao Pedro Campos
- Centre Orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Lampros Gousopoulos
- Centre Orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Alessandro Carrozzo
- Centre Orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France.,University of Rome La Sapienza, Orthopaedics and Traumatology Rome, Lazio, Italy
| | - Thais Dutra Vieira
- Centre Orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
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Allahabadi S, Mittal A, Coughlan MJ, Kim AE, Hung NJ, Pandya NK. Outcomes, Including Graft Tears, Contralateral Anterior Cruciate Ligament Tears, and All-Cause Ipsilateral Knee Operations, are Similar for Adult-type, Transphyseal, and Partial Transphyseal Anterior Cruciate Ligament Reconstruction Using Hamstring Autograft in Pediatric and Adolescent Patients. Arthrosc Sports Med Rehabil 2022; 4:e1465-e1474. [PMID: 36033172 PMCID: PMC9402463 DOI: 10.1016/j.asmr.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 05/22/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Sachin Allahabadi
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco
| | - Ashish Mittal
- San Francisco Orthopedic Residency Program, St. Mary’s Medical Center, San Francisco
| | - Monica J. Coughlan
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco
| | - Arin E. Kim
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco
| | - Nicole J. Hung
- Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles
| | - Nirav K. Pandya
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco
- Benioff Children’s Hospital Oakland, University of California, San Francisco, Oakland, California, U.S.A
- Address correspondence to Nirav K. Pandya, M.D., Department of Orthopaedic Surgery, Benioff Children’s Hospital Oakland, University of California, San Francisco, 747 52nd St., Oakland, CA 94609.
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Crutchfield CR, Zhong JR, Lee NJ, Fortney TA, Ahmad CS, Lynch TS. Operative Time Less Than 1.5 Hours, Male Sex, Dependent Functional Status, Presence of Dyspnea, and Reoperations Within 30 days Are Independent Risk Factors for Readmission After ACLR. Arthrosc Sports Med Rehabil 2022; 4:e1305-e1313. [PMID: 36033184 PMCID: PMC9402418 DOI: 10.1016/j.asmr.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 03/10/2022] [Accepted: 04/12/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose The purposes of this study are to use a large, patient-centered database to describe the 30-day readmission rate and to identify predictive risk factors for readmission after elective isolated ACLR. Methods The National Surgical Quality Improvement Program Database was retrospectively queried for isolated ACLR procedures between 2011 and 2017. Current Procedural Terminology (CPT) codes were used to identify isolated ACLR patients. Those undergoing additional procedures such as meniscectomy or multi-ligamentous reconstruction were excluded. Readmissions were analyzed against demographic variables with bivariate analysis. Multivariate logistic regression was used to find independent risk factors for 30-day readmissions after ACLR. Results A total of 11,060 patients (37.2% female) were included with an average age of 32.2 ± 10.6 years and mean body mass index (BMI) of 27.9 ± 6.5 kg/m2 (29.2% were >30). The overall readmission rate was 0.59%. The most reported reason for readmission was infection 0.22 (24 out of 11,060). The following variables were associated with significantly higher readmission rates: male sex (P = .001), history of severe chronic obstructive pulmonary disease (COPD) (P = .025), cardiac comorbidity (P = .034), operative time >1.5 hours (P <.001), partially dependent functional health status (P = .002), high preoperative creatinine (P = .009), normal preoperative albumin (P = .020), hypertension (P = .034), and reoperations (P < .001). Operative time >1.5 hours, male sex, dependent functional status, the presence of dyspnea, and undergoing a reoperation were identified as independent risk factors for 30-day readmissions (P < .05 for all). Conclusions Isolated ACLR is associated with low 30-day readmission rates. Operative time >1.5 hours, male sex, dependent functional status, the presence of dyspnea, and 30-day reoperations are independent risk factors for readmission that should be considered in patient selection and addressed with preoperative counseling. Level of Evidence Level III, retrospective cohort study.
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Ptasinski AM, Dunleavy M, Adebayo T, Gallo RA. Returning Athletes to Sports Following Anterior Cruciate Ligament Tears. Curr Rev Musculoskelet Med 2022; 15:616-28. [PMID: 35881327 DOI: 10.1007/s12178-022-09782-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss treatment options, rehabilitation protocols, return-to-play criteria, and expected outcomes after non-operative and operative treatment of anterior cruciate ligament (ACL) tears among an athletic population. RECENT FINDINGS Non-operative treatment may be a viable option for some athletes with an ACL tears but can be difficult to predict "copers," and those that resume to sports return at lower performance level and/or less intense activities. Most studies assessing function after ACL reconstruction demonstrate favorable outcomes using patient-reported outcome studies. However, return-to-play and graft re-rupture rates vary substantially based on patient characteristics and level and type of athletic activity. Grafts used to reconstruct ACL produce similar objective outcomes and favorable patient-reported outcomes but have variable re-rupture rates depending on study and differ largely on morbidity associated with graft harvest. Various treatment methods including non-operative and operative techniques have been demonstrated to be efficacious in returning athletes to athletic activity depending on patient age and level of activity. Adherence to fundamental rehabilitation principles and accepted return-to-play guidelines can optimize outcomes and limit re-injury to the injured or contralateral limb.
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Sim K, Rahardja R, Zhu M, Young SW. Optimal Graft Choice in Athletic Patients with Anterior Cruciate Ligament Injuries: Review and Clinical Insights. Open Access J Sports Med 2022; 13:55-67. [PMID: 35800660 PMCID: PMC9255990 DOI: 10.2147/oajsm.s340702] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/23/2022] [Indexed: 12/03/2022] Open
Abstract
Anterior cruciate ligament (ACL) rupture is a common sporting-related knee injury with a potentially detrimental impact on the athlete’s career, yet there is no formal consensus on the optimal graft choice for reconstructing the ruptured ACL in this specific population. Options for reconstruction include autograft, allograft, and artificial grafts. However, each has associated failure risk and donor site morbidity. Our operational definition of the athlete is a skeletally mature individual participating in high level activity with the expectation to return to pre-injury level of activity. The athlete has unique injury characteristics, post-operative expectations, and graft demands that differ to the general population. Long-term outcomes are of particular importance given on-going mechanical demands on the reconstructed knee. Therefore, the purpose of this review is to consolidate current literature on the various ACL reconstruction graft options, with a focus on the optimal graft for returning the athlete to activity with the lowest rate of re-injury.
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Affiliation(s)
- Katarina Sim
- Department of Orthopaedics, North Shore Hospital, Auckland, New Zealand
- Correspondence: Katarina Sim, Department of Orthopaedics, North Shore Hospital, 124 Shakespeare Road, Takapuna, Auckland, 0620, New Zealand, Email
| | - Richard Rahardja
- Department of Orthopaedics, North Shore Hospital, Auckland, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Mark Zhu
- Department of Orthopaedics, North Shore Hospital, Auckland, New Zealand
| | - Simon W Young
- Department of Orthopaedics, North Shore Hospital, Auckland, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
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Seijas R, Ferré-aniorte A, Rius M, Laiz P, Cugat R. Evolution of the patellar tendon size after Bone-Patelar tendon-Bone ACL reconstruction. Apunts Sports Medicine 2022; 57:100386. [DOI: 10.1016/j.apunsm.2022.100386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Polousky J. CORR Insights®: The Knee Injury and Osteoarthritis Outcome Score Does Not Have Adequate Structural Validity for Use With Young, Active Patients With ACL Tears. Clin Orthop Relat Res 2022; 480:1351-1353. [PMID: 35420553 PMCID: PMC9191324 DOI: 10.1097/corr.0000000000002217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 03/28/2022] [Indexed: 01/31/2023]
Affiliation(s)
- John Polousky
- Division Director of Orthopedic Sports Medicine at Akron Children's Hospital, Akron, OH, USA
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Lamplot JD. Regarding "No Difference in Complication Rates or Patient-Reported Outcomes Between Bone-Patellar Tendon-Bone and Quadriceps Tendon Autograft for Anterior Cruciate Ligament Reconstruction". Arthroscopy 2022; 38:1758-61. [PMID: 35660172 DOI: 10.1016/j.arthro.2022.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/13/2022] [Indexed: 02/02/2023]
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Hughes JD, Gibbs CM, Almast A, Atte A, Sansone M, Karlsson J, Musahl V. More anatomic tunnel placement for anterior cruciate ligament reconstruction by surgeons with high volume compared to low volume. Knee Surg Sports Traumatol Arthrosc 2022; 30:2014-2019. [PMID: 35092445 DOI: 10.1007/s00167-022-06875-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/13/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Correct placement of the femoral and tibial tunnels in the anatomic footprint during anterior cruciate ligament reconstruction (ACLR) is paramount for restoring rotatory knee stability. Recent studies have looked at surgeon volume and its outcomes on procedures such as total knee arthroplasty and infection rates, but only few studies have specifically examined tunnel placement after ACLR based on surgeon volume. The purpose of this study was to compare the placement of femoral and tibial tunnels during ACLR between high-volume and low-volume surgeons. It was hypothesized that high-volume surgeons would have more anatomic tunnel placement compared with low-volume surgeons. METHODS A retrospective review of all ACLR performed between 2015 and 2019 at an integrated health care system consisting of both academic and community hospitals with 68 orthopaedic surgeons was conducted. Surgeon volume was categorized as less than 35 ACLR per year (low volume) and 35 or more ACLR per year (high volume). Femoral tunnel placement for each patient was determined using an exact strict lateral radiograph (less than 6 mm of offset between the posterior halves of the medial and lateral condyles) taken after the primary ACLR using the quadrant method. The centre of the femoral tunnel was measured in relation to the posterior-anterior (PA) and proximal-distal (PD) dimensions (normal centre of anatomic footprint: PA 25% and PD 29%). Tibial tunnel placement for each patient was determined on the same lateral radiographs by measuring the mid-sagittal tibial diameter and the centre of the tibial attachment area of the ACL from the anterior tibial margin (normal centre of anatomic footprint: 43%). Each lateral radiograph was reviewed by one of two blinded reviewers. RESULTS A total of 4500 patients were reviewed, of which 645 patients met all the inclusion/exclusion criteria and were included in the final analysis. There were 228 patients in the low-volume group and 417 patients in the high-volume group. Low-volume surgeons performed a mean of 5 ACLRs per year, whereas surgeons in the high-volume group performed a mean of 40 ACLRs per year. In the PA dimension, the low-volume group had significantly more anterior femoral tunnel placement compared with the high-volume group (32 ± 10% vs 28 ± 9%, p < 0.01). In the PD dimension, the low-volume group had statistically significant more proximal femoral tunnel placement compared to the high-volume group (32 ± 9% vs 35 ± 9%, p < 0.01). For the tibial tunnel, the low-volume group had significantly more posterior tibial tunnel placement compared with the high-volume group (41 ± 10% vs 38 ± 7%, p < 0.01). CONCLUSION Low-volume surgeons placed their femoral tunnels significantly more anterior and proximal (high) during ACLR, and placed their tibial tunnels significantly more posterior, compared with high-volume surgeons. Prior research has indicated that anatomic placement of the femoral and tibial tunnels during ACLR leads to improved rotatory knee stability. The findings of this study demonstrate the importance of surgical volume and experience during ACLR. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh Medical Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, USA.
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Christopher M Gibbs
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh Medical Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, USA
| | - Anmol Almast
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Akere Atte
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh Medical Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, USA
| | - Mikael Sansone
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jon Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh Medical Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, USA
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Marigi EM, Song BM, Wasserburger JN, Camp CL, Levy BA, Stuart MJ, Okoroha KR, Krych AJ. Anterior Cruciate Ligament Reconstruction in 107 Competitive Wrestlers: Outcomes, Reoperations, and Return to Play at 6-Year Follow-up. Orthop J Sports Med 2022; 10:23259671221092770. [PMID: 35547615 PMCID: PMC9083060 DOI: 10.1177/23259671221092770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/17/2021] [Indexed: 11/15/2022] Open
Abstract
Background Wrestling is a physically demanding sport, with young athletes prone to anterior cruciate ligament (ACL) injuries. There is a paucity of data evaluating the results of ACL reconstruction (ACLR) in this cohort. Purpose To assess return to sport (RTS), patient-reported outcomes, reoperation rates, and graft survival after ACLR in a large cohort of competitive wrestlers at midterm follow-up. Study Design Case series; Level of evidence, 4. Methods We identified all competitive wrestlers (club, high school, collegiate, or professional) with a history of an ACLR at a single institution between 2000 and 2019. Graft failure was defined as a retear (as determined via clinical or advanced imaging evaluation) and/or revision ACLR. All patients were contacted for determination of reinjury rates; current sport status; and pain visual analog scale, International Knee Documentation Committee, and Tegner activity scores. Results Included were 107 knees in 103 wrestlers, with a median follow-up time of 5.9 years (interquartile range [IQR], 3.9-10.3 years). The median age was 17 years (IQR, 15-18 years), with 106 (99%) male patients, and the distribution of bone-patellar tendon-bone (BTB) and hamstring tendon (HT) autografts was 64 (60%) and 43 (40%), respectively. At final follow-up, 80% of athletes were able to RTP at a median of 280 days (IQR, 212-381 days). Graft failure occurred in 14 (13%) knees at a median time of 1.8 years (IQR, 0.7-5.3 years) after the index ACLR. BTB autograft demonstrated a lower failure rate compared with HT autograft (8% vs 21%; P = .044) and was associated with better survival compared with HT autograft up to 15 years after the index ACLR (90.4% vs 76.3%; P = .030). When compared by graft diameter, HT autografts of at least 7.5 mm were not associated with a lower graft failure than BTB constructs of all sizes (P = .205). Conclusion Return to competitive wrestling was observed in 80% of athletes after ACLR, with 14% of wrestlers experiencing graft failure. BTB autograft was associated with better survival than HT autograft.
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Affiliation(s)
- Erick M. Marigi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bryant M. Song
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Bruce A. Levy
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J. Stuart
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kelechi R. Okoroha
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J. Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Aaron J. Krych, MD, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA () (Twitter: @DrKrych)
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van der Wal WA, Meijer DT, Hoogeslag RAG, LaPrade RF. Meniscal Tears, Posterolateral and Posteromedial Corner Injuries, Increased Coronal Plane, and Increased Sagittal Plane Tibial Slope All Influence Anterior Cruciate Ligament-Related Knee Kinematics and Increase Forces on the Native and Reconstructed Anterior Cruciate Ligament: A Systematic Review of Cadaveric Studies. Arthroscopy 2022; 38:1664-1688.e1. [PMID: 34883197 DOI: 10.1016/j.arthro.2021.11.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 10/27/2021] [Accepted: 11/29/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To obtain a comprehensive list of pathologies that cause increased anterior cruciate ligament (ACL) forces and pathologic knee kinematics to evaluate for in both primary and revision ACL reconstruction to decrease the risk of subsequent graft overload. METHODS An electronic search was performed in the Embase and MEDLINE databases for the period between January 1, 1990, and December 10, 2020. All articles investigating medial and lateral meniscal injury, (postero)lateral corner injury, (postero)medial corner/medial collateral ligament injury, valgus alignment, varus alignment, and tibial slope in relation to ACL (graft) force and knee kinematics were included. RESULTS Data of 43 studies were included. The studies reported that high-volume medial and lateral meniscectomies, peripheral meniscus tears, medial meniscus ramp tears, lateral meniscus root tears, posterolateral corner injuries, medial collateral ligament tears, increased tibial slope, and valgus and varus alignment were reported to have a significant impact on ACL (graft) force and related knee kinematics. CONCLUSIONS This systematic review on biomechanical cadaver studies provides a rationale to systematically identify and treat pathologies in ACL-injured knees, because when undiagnosed or left untreated, these specific concomitant pathologies could lead to ACL graft overload in both primary and revision ACL-reconstructed knees. CLINICAL RELEVANCE it is necessary that orthopaedic surgeons who treat ACL-injured knees understand the surgically relevant biomechanical consequences of additional pathologies and use this knowledge to optimize treatment in ACL-injured patients.
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Affiliation(s)
| | - Diederik T Meijer
- Department of Orthopedic Surgery, Amsterdam UMC, Amsterdam, The Netherlands
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Fukuda H, Ogura T, Asai S, Omodani T, Takahashi T, Yamaura I, Sakai H, Saito C, Tsuchiya A, Takahashi K. Bone-patellar tendon-bone autograft maturation is superior to double-bundle hamstring tendon autograft maturation following anatomical anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2022; 30:1661-1671. [PMID: 34424354 DOI: 10.1007/s00167-021-06653-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 07/01/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE The primary purpose of this study was to evaluate the second-look arthroscopic findings 1 year postoperatively and magnetic resonance imaging (MRI) findings 2 years after anterior cruciate ligament reconstruction (ACLR) using bone-patellar tendon-bone autograft (BTB) or hamstring tendon autograft (HT). Secondary purpose included clinical results from physical examination, including range of motion, Lachman test, pivot shift test, and knee anterior laxity evaluation, and the clinical score for subjective evaluations at 2 years after surgery. METHODS Between 2015 and 2018, 75 patients with primary ACL injuries were divided into either the BTB group (n = 30) or HT group (n = 45). When using HT, an anatomical double-bundle ACLR was performed. BTB was indicated for athletes with sufficient motivation to return to sporting activity. Graft maturation on second-look arthroscopy was scored in terms of synovial coverage and revascularization. All participants underwent postoperative MRI evaluation 2 years postoperatively. The signal intensity (SI) characteristics of the reconstructed graft were evaluated using oblique axial proton density-weighted MR imaging (PDWI) perpendicular to the grafts. The signal/noise quotient (SNQ) was calculated to quantitatively determine the normalized SI. For clinical evaluation, the Lachman test, pivot shift test, KT-2000 evaluation, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS) were used. RESULTS Arthroscopic findings showed that the graft maturation score in the BTB group (3.6 ± 0.7) was significantly greater than that in the anteromedial bundle (AMB; 2.9 ± 0.2, p = 0.02) and posterolateral bundle (PLB; 2.0 ± 0.9, p = 0.001) in the HT group. The mean MRI-SNQs were as follows: BTB, 2.3 ± 0.5; AMB, 2.9 ± 0.9; and PLB, 4.1 ± 1.1. There were significant differences between BTB, AMB, and PLB (BTB and AMB: p = 0.04, BTB and PLB: p = 0.003, AMB and PLB: p = 0.03). Second-look arthroscopic maturation score and MRI-SNQ value significantly correlated for BTB, AMB, and PLB. No significant differences were detected in clinical scores. There was a significant difference (p = 0.02) in the knee laxity evaluation (BTB: 0.9 ± 1.1 mm; HT: 2.0 ± 1.9 mm). CONCLUSION BTB maturation is superior to that of double-bundle HT based on morphological and MRI evaluations following anatomical ACLR, although no significant differences were found in clinical scores. Regarding clinical relevance, the advantages of BTB may help clinicians decide on using the autograft option for athletes with higher motivation to return to sporting activity because significant differences were observed in morphological evaluation, MRI assessment, and knee anterior laxity evaluation between BTB and double-bundle HT. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Hideaki Fukuda
- Funabashi Orthopaedic Hospital Sports Medicine Center, 1-833 Hazama Funabashi-shi, Chiba, 274-0822, Japan.
| | - Takahiro Ogura
- Sports Medicine and Joint Center, Funabashi Orthopaedic Hospital, 1-833 Hasama, Funabashi, Chiba, 274-0822, Japan
| | - Shigehiro Asai
- Sports Medicine and Joint Center, Funabashi Orthopaedic Hospital, 1-833 Hasama, Funabashi, Chiba, 274-0822, Japan
| | - Toru Omodani
- Sports Medicine and Joint Center, Funabashi Orthopaedic Hospital, 1-833 Hasama, Funabashi, Chiba, 274-0822, Japan
| | - Tatsuya Takahashi
- Sports Medicine and Joint Center, Funabashi Orthopaedic Hospital, 1-833 Hasama, Funabashi, Chiba, 274-0822, Japan
| | - Ichiro Yamaura
- Sports Medicine and Joint Center, Funabashi Orthopaedic Hospital, 1-833 Hasama, Funabashi, Chiba, 274-0822, Japan
| | - Hiroki Sakai
- Sports Medicine and Joint Center, Funabashi Orthopaedic Hospital, 1-833 Hasama, Funabashi, Chiba, 274-0822, Japan
| | - Chikara Saito
- Sports Medicine and Joint Center, Funabashi Orthopaedic Hospital, 1-833 Hasama, Funabashi, Chiba, 274-0822, Japan
| | - Akihiro Tsuchiya
- Sports Medicine and Joint Center, Funabashi Orthopaedic Hospital, 1-833 Hasama, Funabashi, Chiba, 274-0822, Japan
| | - Kenji Takahashi
- Sports Medicine and Joint Center, Funabashi Orthopaedic Hospital, 1-833 Hasama, Funabashi, Chiba, 274-0822, Japan
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Etzel CM, Nadeem M, Gao B, Boduch AN, Owens BD. Graft Choice for Anterior Cruciate Ligament Reconstruction in Women Aged 25 Years and Younger: A Systematic Review. Sports Health 2022; 14:829-841. [PMID: 35343326 PMCID: PMC9631041 DOI: 10.1177/19417381221079632] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
CONTEXT Although anterior cruciate ligament (ACL) tears are relatively common in athletic populations, few studies have systematically reviewed graft choice in young women. OBJECTIVE To quantitatively and qualitatively examine reported outcomes for graft choice in women aged 25 years and younger undergoing primary ACL reconstruction. DATA SOURCE A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. An electronic search in the PubMed (includes MEDLINE) and EMBASE databases was completed using a combination of key terms. STUDY SELECTION Studies were included if they reported graft choice outcomes in women aged 25 years and younger. STUDY DESIGN Systematic review. LEVEL OF EVIDENCE Level 4. DATA EXTRACTION The following information was extracted: title, author, year of publication, number of female patients and age, graft type, follow-up, and patient-reported outcome measures. The following outcome scores were identified as being reported or not reported by each study: graft failure, contralateral ACL (CACL) rupture, IKDC (International Knee Documentation Committee), graft survival (Kaplan-Meier), Lysholm, Tegner, KT-1000, kneeling pain, return to sport, and Lachman. RESULTS Of 1170 identified articles, 16 met inclusion criteria, reporting on 1385 female patients aged 25 years and younger. Comparison of 655 bone-patellar tendon-bone (BPTB) versus 525 hamstring tendon (HT) autografts showed significant differences in mean failure rate between BPTB autografts (6.13% ± 2.58%) and HT autografts (17.35% ± 8.19%), P = 0.001. No statistically significant differences in CACL failure rates were found between BPTB autografts and HT autografts (P = 0.25). Pooled results for IKDC were possible in 3 of the HT autograft studies, showing a mean score of 88.31 (95% CI 83.53-93.08). Pooled Lysholm score results were possible in 2 of the HT autograft studies, showing a mean score of 93.46 (95% CI 91.90-95.01). CONCLUSION In female patients aged 25 years and younger, BPTB autografts showed significantly less graft failure compared with HT autografts. However, BPTB autografts had comparable patient-reported outcomes compared with HT autografts with the available data. The overall state of evidence for graft choice in female patients aged 25 years and younger is low. Future studies should report statistics by age and sex to allow for further analysis of graft choice for this specific population that is known to be more vulnerable to ACL injury.
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Affiliation(s)
- Christine M Etzel
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Maheen Nadeem
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Burke Gao
- Department of Orthopedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Abigail N Boduch
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Brett D Owens
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Tanaka Y, Tachibana Y, Kinugasa K, Takao R, Kita K, Amano H, Yonetani Y, Shiozaki Y, Uchida R, Horibe S. Rectangular bone-patellar tendon bone grafts reduce early graft failure in chronic ACL-Deficient knees. J Orthop Sci 2022; 28:597-602. [PMID: 35314094 DOI: 10.1016/j.jos.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/25/2022] [Accepted: 02/27/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND The aim of this study was to assess early graft failure after anterior cruciate ligament (ACL) reconstruction according to chronicity of ACL deficiency (ACLD) and clarify predisposing factors. METHODS A total of 731 patients who underwent anatomic ACL reconstruction were divided into 3 groups based on chronicity of ACLD: <6 months (Group 1), 6 months to 2 years (Group 2), and >2 years (Group 3). Types of ACL grafts used included single-bundle hamstring tendon (HT), multiple-bundle HT, and rectangular bone-patellar tendon-bone (BTB) grafts. Preoperatively and immediately postoperatively, lateral radiographs in full extension were taken to examine anterior tibial subluxation (ATS). All ACL grafts were evaluated by MRI at 6 months to identify graft failure. The group with the highest failure rate was further examined to compare possible risk factors between the intact and failure subgroups, followed by multivariate logistic regression analysis to identify predisposing factors. RESULTS Early graft failure on MRI without any episode of postoperative trauma was observed in 7 (1.4%), 2 (1.8%), and 11 (9.2%) patients in Groups 1, 2, and 3, respectively, with a significantly higher rate in Group 3 (P < 0.001). Of the 119 patients in Group 3, significant differences were observed between intact and failure subgroups with regard to surgical procedure (P = 0.03), chondral lesions (P < 0.01), and preoperative ATS (P < 0.01). Multivariate logistic regression analysis revealed that surgical procedures (odds ratio, 3.8; 95%CI, 1.16-12.59) and preoperative ATS (odd ratio, 2.4; 95%CI, 1.26-4.38) were predisposing factors of early graft failure. CONCLUSION Patients with ACLD for >2 years experienced early graft failure with an incidence rate of 9.2%. Predisposing factors of early graft failure in these patients included the use of single-bundle HT grafts and preoperative ATS. The use of rectangular BTB grafts resulted in a lower graft failure rate. STUDY DESIGN Case Series.
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Affiliation(s)
- Yoshinari Tanaka
- Investigation Performed at Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, Osaka 583-8555, Japan.
| | - Yuta Tachibana
- Investigation Performed at Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, Osaka 583-8555, Japan
| | - Kazutaka Kinugasa
- Investigation Performed at Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, Osaka 583-8555, Japan
| | - Rikio Takao
- Investigation Performed at Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, Osaka 583-8555, Japan
| | - Keisuke Kita
- Investigation Performed at Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, Osaka 583-8555, Japan
| | - Hiroshi Amano
- Investigation Performed at Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, Osaka 583-8555, Japan
| | - Yasukazu Yonetani
- Investigation Performed at Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, Osaka 583-8555, Japan
| | - Yoshiki Shiozaki
- Investigation Performed at Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, Osaka 583-8555, Japan
| | - Ryohei Uchida
- Investigation Performed at Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, Osaka 583-8555, Japan
| | - Shuji Horibe
- Investigation Performed at Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, Osaka 583-8555, Japan
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Ma R, Guess T, Echelmeyer D, Stannard JP. Bench to Bedside: A Multidisciplinary Approach toward the Unknowns after ACL Injuries to Drive Individual Success. Mo Med 2022; 119:136-143. [PMID: 36036042 PMCID: PMC9339398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
ACL injury and surgery are increasing in prevalence. Several challenges exist that can be obstacles to an individual achieving success after ACL surgery. A knowledge of these risk factors alongside a multidisciplinary collaborative team approach can result in a greater likelihood of achieving individual success after ACL surgery.
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Affiliation(s)
- Richard Ma
- Gregory L. And Ann L. Hummel Distinguished Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, University of Missouri - Columbia School of Medicine (DOS UMC SOM) and with the Thompson Laboratory for Regenerative Orthopaedics (TLRO), Columbia, Missouri
| | - Trent Guess
- DOS UMC SOM and the Department of Physical Therapy, UMC SOM, Columbia, Missouri
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Firth AD, Bryant DM, Litchfield R, McCormack RG, Heard M, MacDonald PB, Spalding T, Verdonk PC, Peterson D, Bardana D, Rezansoff A, Getgood AM, Willits K, Birmingham T, Hewison C, Wanlin S, Pinto R, Martindale A, O’Neill L, Jennings M, Daniluk M, Boyer D, Zomar M, Moon K, Moon R, Fan B, Mohan B, Buchko GM, Hiemstra LA, Kerslake S, Tynedal J, Stranges G, Mcrae S, Gullett L, Brown H, Legary A, Longo A, Christian M, Ferguson C, Mohtadi N, Barber R, Chan D, Campbell C, Garven A, Pulsifer K, Mayer M, Simunovic N, Duong A, Robinson D, Levy D, Skelly M, Shanmugaraj A, Howells F, Tough M, Thompson P, Metcalfe A, Asplin L, Dube A, Clarkson L, Brown J, Bolsover A, Bradshaw C, Belgrove L, Milan F, Turner S, Verdugo S, Lowe J, Dunne D, McGowan K, Suddens CM, Declerq G, Vuylsteke K, Van Haver M. Predictors of Graft Failure in Young Active Patients Undergoing Hamstring Autograft Anterior Cruciate Ligament Reconstruction With or Without a Lateral Extra-articular Tenodesis: The Stability Experience. Am J Sports Med 2022; 50:384-395. [PMID: 35050817 PMCID: PMC8829733 DOI: 10.1177/03635465211061150] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstruction (ACLR) has higher failure rates in young active patients returning to sports as compared with older, less active individuals. Augmentation of ACLR with an anterolateral procedure has been shown to reduce failure rates; however, indications for this procedure have yet to be clearly defined. PURPOSE/HYPOTHESIS The purpose of this study was to identify predictors of ACL graft failure in high-risk patients and determine key indications for when hamstring ACLR should be augmented by a lateral extra-articular tenodesis (LET). We hypothesized that different preoperative characteristics and surgical variables may be associated with graft failure characterized by asymmetric pivot shift and graft rupture. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Data were obtained from the Stability 1 Study, a multicenter randomized controlled trial of young active patients undergoing autologous hamstring ACLR with or without a LET. We performed 2 multivariable logistic regression analyses, with asymmetric pivot shift and graft rupture as the dependent variables. The following were included as predictors: LET, age, sex, graft diameter, tear chronicity, preoperative high-grade knee laxity, preoperative hyperextension on the contralateral side, medial meniscal repair/excision, lateral meniscal repair/excision, posterior tibial slope angle, and return-to-sports exposure time and level. RESULTS Of the 618 patients in the Stability 1 Study, 568 with a mean age of 18.8 years (292 female; 51.4%) were included in this analysis. Asymmetric pivot shift occurred in 152 (26.8%) and graft rupture in 43 (7.6%). The addition of a LET (odds ratio [OR], 0.56; 95% CI, 0.37-0.83) and increased graft diameter (OR, 0.62; 95% CI, 0.44-0.87) were significantly associated with lower odds of asymmetric pivot shift. The addition of a LET (OR, 0.40; 95% CI, 0.18-0.91) and older age (OR, 0.83; 95% CI, 0.72-0.96) significantly reduced the odds of graft rupture, while greater tibial slope (OR, 1.15; 95% CI, 1.01-1.32), preoperative high-grade knee laxity (OR, 3.27; 95% CI, 1.45-7.41), and greater exposure time to sport (ie, earlier return to sport) (OR, 1.18; 95% CI, 1.08-1.29) were significantly associated with greater odds of rupture. CONCLUSION The addition of a LET and larger graft diameter were significantly associated with reduced odds of asymmetric pivot shift. Adding a LET was protective of graft rupture, while younger age, greater posterior tibial slope, high-grade knee laxity, and earlier return to sport were associated with increased odds of graft rupture. Orthopaedic surgeons should consider supplementing hamstring autograft ACLR with a LET in young active patients with morphological characteristics that make them at high risk of reinjury.
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Affiliation(s)
| | | | - Robert Litchfield
- London Health Sciences Centre, Western University, Fowler Kennedy Sport Medicine Clinic, London, Canada
| | | | | | | | - Tim Spalding
- University Hospitals Coventry Warwickshire NHS Trust, Coventry, UK
| | | | | | | | - Alex Rezansoff
- Sport Medicine Centre, University of Calgary, Calgary, Canada
| | | | - Alan M.J. Getgood
- Alan M.J. Getgood, MD, Fowler Kennedy Sport Medicine Clinic, Western University, 3M Centre, London, ON N6A 3K7, Canada () (Twitter: FKSMC_Getgood)
| | | | | | | | | | | | | | | | | | - Michal Daniluk
- London Health Sciences Centre, Western University, Fowler Kennedy Sport Medicine Clinic, London, Canada
| | | | | | | | | | | | - Bindu Mohan
- Fraser Orthopaedic Institute, New Westminster, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Michelle Mayer
- Sport Medicine Centre, University of Calgary, Calgary, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Mieke Van Haver
- Antwerp Orthopaedic Center, Ghent, Belgium,Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
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Curtis DM. Editorial Commentary: Identifying the Problem Is Only the First Step in Fixing Disparities in Anterior Cruciate Ligament Injury Care. Arthroscopy 2022; 38:595-6. [PMID: 35123723 DOI: 10.1016/j.arthro.2021.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 08/16/2021] [Indexed: 02/02/2023]
Abstract
Anterior cruciate ligament reconstruction (ACL-R) is one of the most commonly performed orthopaedic surgeries. Social determinants of health, including race, ethnicity, income, education, insurance, and employment status, are major nonmodifiable risk factors for worse outcomes and higher complication rates after ACL-R. Improved understanding of these variables can help surgeons assess risk and counsel their patients, but evidence-based solutions to improving access to care and outcomes after ACL-R in at-risk patients are needed.
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Devana SK, Solorzano C, Nwachukwu B, Jones KJ. Disparities in ACL Reconstruction: the Influence of Gender and Race on Incidence, Treatment, and Outcomes. Curr Rev Musculoskelet Med 2022; 15:1-9. [PMID: 34970713 PMCID: PMC8804118 DOI: 10.1007/s12178-021-09736-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW Anterior cruciate ligament (ACL) rupture is a common injury that has important clinical and economic implications. We aimed to review the literature to identify gender, racial and ethnic disparities in incidence, treatment, and outcomes of ACL injury. RECENT FINDINGS Females are at increased risk for ACL injury compared to males. Intrinsic differences such as increased quadriceps angle and increased posterior tibial slope may be contributing factors. Despite lower rates of injury, males undergo ACL reconstruction (ACLR) more frequently. There is conflicting evidence regarding gender differences in graft failure and ACL revision rates, but males demonstrate higher return to sport (RTS) rates. Females report worse functional outcome scores and have worse biomechanical metrics following ACLR. Direct evidence of racial and ethnic disparities is limited, but present. White athletes have greater risk of ACL injury compared to Black athletes. Non-White and Spanish-speaking patients are less likely to undergo ACLR after ACL tear. Black and Hispanic youth have greater surgical delay to ACLR, increased risk for loss to clinical follow-up, and less physical therapy sessions, thereby leading to greater deficits in knee extensor strength during rehabilitation. Hispanic and Black patients also have greater risk for hospital admission after ACLR, though this disparity is improving. Females have higher rates of ACL injury with inconclusive evidence on anatomic predisposition and ACL failure rate differences between genders. Recent literature has suggested inferior RTS and functional outcomes following ACLR in females. Though there is limited and mixed data on incidence and outcome differences between races and ethnic groups, recent studies suggest there may be disparities in those who undergo ACLR and time to treatment.
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Affiliation(s)
- Sai K. Devana
- Department of Orthopaedic Surgery, University of California, Los Angeles, USA
| | - Carlos Solorzano
- Department of Orthopaedic Surgery, University of California, Los Angeles, USA
| | - Benedict Nwachukwu
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, USA
| | - Kristofer J. Jones
- Department of Orthopaedic Surgery, University of California, Los Angeles, USA
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Winkler PW, Vivacqua T, Thomassen S, Lovse L, Lesniak BP, Getgood AMJ, Musahl V. Quadriceps tendon autograft is becoming increasingly popular in revision ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2022; 30:149-160. [PMID: 33591370 PMCID: PMC8800889 DOI: 10.1007/s00167-021-06478-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 01/25/2021] [Indexed: 01/26/2023]
Abstract
PURPOSE To evaluate trends in revision anterior cruciate ligament reconstruction (ACL-R), with emphasis on intra-articular findings, grafts, and concurrent procedures. It was hypothesized that revision ACL-Rs over time show a trend toward increased complexity with increased use of autografts over allografts. METHODS This was a two-center retrospective study including patients undergoing revision ACL-R between 2010 and 2020. Demographic and surgical data including intra-articular findings and concurrent procedures were collected and compared for the time periods 2010-2014 and 2015-2020. All collected variables were compared between three pre-defined age groups (< 20 years, 20-30 years, > 30 years), right and left knees, and males and females. A time series analysis was performed to assess trends in revision ACL-R. RESULTS This study included 260 patients with a mean age of 26.2 ± 9.4 years at the time of the most recent revision ACL-R, representing the first, second, third, and fourth revision ACL-R for 214 (82%), 35 (14%), 10 (4%), and 1 (< 1%) patients, respectively. Patients age > 30 years showed a significantly longer mean time from primary ACL-R to most recent revision ACL-R (11.1 years), compared to patients age < 20 years (2.2 years, p < 0.001) and age 20-30 years (5.5 years, p < 0.05). Quadriceps tendon autograft was used significantly more often in 2015-2020 compared to 2010-2014 (49% vs. 18%, p < 0.001). A high rate of concurrently performed procedures including meniscal repairs (45%), lateral extra-articular tenodesis (LET; 31%), osteotomies (13%), and meniscal allograft transplantations (11%) was shown. Concurrent LET was associated with intact cartilage and severely abnormal preoperative knee laxity and showed a statistically significant and linear increase over time (p < 0.05). Intact cartilage (41%, p < 0.05), concurrent medial meniscal repairs (39%, p < 0.05), and LET (35%, non-significant) were most frequently observed in patients aged < 20 years. CONCLUSION Quadriceps tendon autograft and concurrent LET are becoming increasingly popular in revision ACL-R. Intact cartilage and severely abnormal preoperative knee laxity represent indications for LET in revision ACL-R. The high rate of concurrent procedures observed demonstrates the high surgical demands of revision ACL-R. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Philipp W. Winkler
- grid.21925.3d0000 0004 1936 9000Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA 15203 USA ,grid.15474.330000 0004 0477 2438Department for Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Thiago Vivacqua
- grid.39381.300000 0004 1936 8884Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, 3M Centre, 1151 Richmond Street, London, ON N6A 3K7 Canada
| | - Stephan Thomassen
- grid.39381.300000 0004 1936 8884Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, 3M Centre, 1151 Richmond Street, London, ON N6A 3K7 Canada
| | - Lisa Lovse
- grid.39381.300000 0004 1936 8884Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, 3M Centre, 1151 Richmond Street, London, ON N6A 3K7 Canada
| | - Bryson P. Lesniak
- grid.21925.3d0000 0004 1936 9000Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA 15203 USA
| | - Alan M. J. Getgood
- grid.39381.300000 0004 1936 8884Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, 3M Centre, 1151 Richmond Street, London, ON N6A 3K7 Canada
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, 15203, USA.
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Marmura H, Bryant DM, Birmingham TB, Kothari A, Spindler KP, Kaeding CC, Spalding T, Getgood AMJ. Same knee, different goals: patients and surgeons have different priorities related to ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:4286-4295. [PMID: 33876273 DOI: 10.1007/s00167-021-06550-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 03/25/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The priorities of patients should be shared by those treating them. Patients and surgeons are likely to have different priorities surrounding anterior cruciate ligament reconstruction (ACLR), with implications for shared decision-making and patient education. The optimal surgical approach for ACLR is constantly evolving, and the magnitude of treatment effect necessary for evidence to change surgical practice is unknown. The aim of this study was to determine (1) the priorities of surgeons and patients when making decisions regarding ACLR and (2) the magnitude of reduction in ACLR graft failure risk that orthopaedic surgeons require before changing practice. METHODS This study followed a cross-sectional survey design. Three distinct electronic surveys were administered to pre-operative ACLR patients, post-operative ACLR patients, and orthopaedic surgeons. Patients and surgeons were asked about the importance of various outcomes and considerations pertaining to ACLR. Surgeons were asked scenario-based questions regarding changing practice for ACLR based on new research. RESULTS Surgeons were more likely to prioritize outcomes related to the surgical knee itself, whereas patients were more likely to prioritize outcomes related to their daily lifestyle and activities. Knee instability and risk of re-injury were unanimous top priorities among all three groups. A mean relative risk reduction in ACLR graft failure of about 50% was required by orthopaedic surgeons to change practice regardless of the type of change, or patient risk profile. CONCLUSION There are discrepancies between the priorities of surgeons and patients, and orthopaedic surgeons appear resistant to changing practice for ACLR. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Hana Marmura
- Faculty of Health Sciences, Western University, London, ON, Canada
- Fowler Kennedy Sport Medicine Clinic, London, ON, Canada
- Bone and Joint Institute, Western University, London, ON, Canada
- Lawson Research, London Health Sciences Centre, London, ON, Canada
| | - Dianne M Bryant
- Faculty of Health Sciences, Western University, London, ON, Canada
- Fowler Kennedy Sport Medicine Clinic, London, ON, Canada
- Bone and Joint Institute, Western University, London, ON, Canada
- Lawson Research, London Health Sciences Centre, London, ON, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, London, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Trevor B Birmingham
- Faculty of Health Sciences, Western University, London, ON, Canada
- Bone and Joint Institute, Western University, London, ON, Canada
- Wolf Orthopaedic Biomechanics Lab, Fowler Kennedy Sport Medicine Clinic, London, ON, Canada
| | - Anita Kothari
- Faculty of Health Sciences, Western University, London, ON, Canada
| | | | | | - Tim Spalding
- Department of Orthopaedics, University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Alan M J Getgood
- Faculty of Health Sciences, Western University, London, ON, Canada.
- Fowler Kennedy Sport Medicine Clinic, London, ON, Canada.
- Bone and Joint Institute, Western University, London, ON, Canada.
- Lawson Research, London Health Sciences Centre, London, ON, Canada.
- Department of Surgery, Schulich School of Medicine and Dentistry, London, ON, Canada.
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