Anterior cruciate ligament (ACL) injuries are increasingly common in the United States. This may be related to the increase in high school sports participation, particularly in female athletes. A ...significant proportion of these injuries are caused by noncontact mechanisms. The incidence of these noncontact injuries may be significantly reduced by enrolling young athletes in jump-training programs. The diagnosis of ACL injuries involves a focused history and physical examination, which can provide a high index of suspicion. Although radiographs are important to rule out associated injuries, the gold standard for diagnosis of ACL injuries is MRI, which has shown excellent accuracy.
Purpose Our purpose was to determine patient-cited reasons for lack of return to sport after anterior cruciate ligament reconstruction. Methods All patients who underwent primary or revision anterior ...cruciate ligament reconstruction by 2 surgeons from 2007 to 2008 (N = 171) were contacted for a telephone interview. Patients who did not return to preinjury levels by self-assessment were then asked to cite contributing factors from a predetermined list. These included non–knee-related life events, persistent knee symptoms, fear of reinjury (kinesiophobia), and choice-related options (such as lack of interest or time). Results Of the 135 patients who completed the interview, 62 (46%) reported a return to preinjury activity levels (returners) whereas 73 (54%) did not (non-returners). Returners (26.4 ± 10.9 years) were younger than non-returners (30.0 ± 9.8 years) ( P = .04). Persistent knee symptoms (68%) and kinesiophobia (52%) were more commonly cited as reasons for not returning to sport than non–knee-related life events (29%), including children, job/education, or health problems ( P < .001 for symptoms and P = .004 for kinesiophobia). Among non-returners who cited knee symptoms, 50% concurrently cited kinesiophobia and 24% cited life events. Conclusions A lack of return to preinjury activity levels is common after anterior cruciate ligament reconstruction. A majority of patients who do not return to their preinjury activities cite persistent knee symptoms, particularly pain, as a contributing factor, and only a minority of patients cite job and family demands or a lack of interest. Finally, fear of reinjury was cited by half of the patients who did not return to sport. Level of Evidence Level III, retrospective comparative study.
To evaluate sex differences in incidence rates (IRs) of anterior cruciate ligament (ACL) injury by sport type (collision, contact, limited contact, and noncontact).
A systematic review was performed ...using the electronic databases PubMed (1969-January 20, 2017) and EBSCOhost (CINAHL, SPORTDiscus; 1969-January 20, 2017) and the search terms
AND
AND (
OR
OR
).
Studies were included if they provided the number of ACL injuries and the number of athlete-exposures (AEs) by sex or enough information to allow the number of ACL injuries by sex to be calculated. Studies were excluded if they were analyses of previously reported data or were not written in English.
Data on sport classification, number of ACL injuries by sex, person-time in AEs for each sex, year of publication, sport, sport type, and level of play were extracted for analysis.
We conducted IR and IR ratio (IRR) meta-analyses, weighted for study size and calculated. Female and male athletes had similar ACL injury IRs for the following sport types: collision (2.10/10 000 versus 1.12/10 000 AEs, IRR = 1.14,
= .63), limited contact (0.71/10 000 versus 0.29/10 000 AEs, IRR = 1.21,
= .77), and noncontact (0.36/10 000 versus 0.21/10 000 AEs, IRR = 1.49,
= .22) sports. For contact sports, female athletes had a greater risk of injury than male athletes did (1.88/10 000 versus 0.87/10 000 AEs, IRR = 3.00,
< .001). Gymnastics and obstacle-course races were outliers with respect to IR, so we created a sport category of fixed-object, high-impact rotational landing (HIRL). For this sport type, female athletes had a greater risk of ACL injury than male athletes did (4.80/10 000 versus 1.75/10 000 AEs, IRR = 5.51,
< .001), and the overall IRs of ACL injury were greater than all IRs in all other sport categories.
Fixed-object HIRL sports had the highest IRs of ACL injury for both sexes. Female athletes were at greater risk of ACL injury than male athletes in contact and fixed-object HIRL sports.
Purpose The purpose of this study was to evaluate the effect of graft size on patient-reported outcomes and revision risk after anterior cruciate ligament (ACL) reconstruction. Methods A ...retrospective chart review of prospectively collected cohort data was performed, and 263 of 320 consecutive patients (82.2%) undergoing primary ACL reconstruction with hamstring autograft were evaluated. We recorded graft size; femoral tunnel drilling technique; patient age, sex, and body mass index at the time of ACL reconstruction; Knee Injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee score preoperatively and at 2 years postoperatively; and whether each patient underwent revision ACL reconstruction during the 2-year follow-up period. Revision was used as a marker for graft failure. The relation between graft size and patient-reported outcomes was determined by multiple linear regression. The relation between graft size and risk of revision was determined by dichotomizing graft size at 8 mm and stratifying by age. Results After we controlled for age, sex, operative side, surgeon, body mass index, graft choice, and femoral tunnel drilling technique, a 1-mm increase in graft size was noted to correlate with a 3.3-point increase in the KOOS pain subscale ( P = .003), a 2.0-point increase in the KOOS activities of daily living subscale ( P = .034), a 5.2-point increase in the KOOS sport/recreation function subscale ( P = .004), and a 3.4-point increase in the subjective International Knee Documentation Committee score ( P = .026). Revision was required in 0 of 64 patients (0.0%) with grafts greater than 8 mm in diameter and 14 of 199 patients (7.0%) with grafts 8 mm in diameter or smaller ( P = .037). Among patients aged 18 years or younger, revision was required in 0 of 14 patients (0.0%) with grafts greater than 8 mm in diameter and 13 of 71 patients (18.3%) with grafts 8 mm in diameter or smaller. Conclusions Smaller hamstring autograft size is a predictor of poorer KOOS sport/recreation function 2 years after primary ACL reconstruction. A larger sample size is required to confirm the relation between graft size and risk of revision ACL reconstruction. Level of Evidence Level III, retrospective comparative study.
Background:
Elevated posterior tibial slope (PTS) has been identified as an important risk factor in anterior cruciate ligament (ACL) injuries and ACL graft failures. The cutoff value to recommend ...treatment with slope-reducing osteotomy remains unclear and is based on expert opinion and small case series.
Purpose:
(1) To determine whether there is a difference in PTS shown on lateral knee radiographs and magnetic resonance imaging (MRI) scans in a group of patients who experienced revision ACL graft failure versus a control group of patients who underwent successful revision ACL reconstruction, (2) to identify cutoff values of PTS measurements that predict risk of revision ACL graft failure, and (3) to examine whether there is a correlation between radiographic and MRI measurements of PTS.
Study Design:
Case-control study; Level of evidence, 3.
Methods:
A total of 38 patients who experienced revision ACL graft failure were identified from a revision ACL database. These patients were matched 1:1 by age, sex, and graft type to a group of 38 control patients who underwent revision ACL reconstruction with no evidence of graft failure at a minimum 2 years of follow-up. Medial and lateral PTS were measured by lateral knee radiographs and MRI scans of the affected limb. Demographics, surgical characteristics, and PTS were compared between the groups. The optimal cutoff values of medial and lateral PTS per radiographs and MRI scans for predicting increased risk of revision ACL graft failure were determined by receiver operating characteristic curves. Conditional multivariable logistic regression was used to assess the relative contribution of PTS cutoff values as a predictor of revision graft failure.
Results:
The mean PTS values in the failure group were significantly higher than those in the control group on radiographs (medial, 13.2°± 2.9° vs 10.3°± 2.9°; P < .001; lateral, 12.9°± 3.0° vs 9.8°± 2.8°; P < .001) and MRI scans (medial, 7.2°± 3.1° vs 4.8°± 2.9°; P < .001; lateral, 8.4 ± 3.1° vs 5.9 ± 3.0°; P < .001). A radiographic medial PTS ≥14° had the highest increased risk of revision ACL graft failure with sensitivity equal to 50% and specificity to 92.1% (odds ratio, 18.71; 95% CI, 2.0-174.9; P = .01).
Conclusion:
Elevated PTS was a significant risk factor for revision ACL graft failure. Patients with radiographic medial PTS ≥14° had 18.7-times increased risk of revision ACL failure.
Large registries and prospective cohorts are so expensive, time intensive, and tedious that one may wonder, “Are they worth it?” The answer lies in our core desire to do better. To continually ...improve the care of our patients and advance our field of orthopaedic surgery, research is required. Basic research is without doubt of great value, but essential to this advancement is quality clinical outcomes research. Without it, we are vulnerable to multiple missed turns and dead ends on our road to ever improving care of our patients.
Background:
Anterior cruciate ligament (ACL) reinjury results in worse outcomes and increases the risk of posttraumatic osteoarthritis.
Purpose:
To identify the risk factors for both ipsilateral and ...contralateral ACL tears after primary ACL reconstruction (ACLR).
Study Design:
Cohort study; Level of evidence, 3.
Methods:
Data from the Multicenter Orthopaedic Outcomes Network (MOON), a prospective longitudinal cohort, were used to identify risk factors for ACL retear. Subjects with primary ACLR, no history of contralateral knee surgery, and a minimum of 2-year follow-up data were included. Age, sex, Marx activity score, graft type, lateral meniscal tear, medial meniscal tear, sport played at index injury, and surgical facility were evaluated to determine their contribution to both ipsilateral retear and contralateral ACL tear.
Results:
A total of 2683 subjects with average age of 27 ± 11 years (1498 men; 56%) met all study inclusion/exclusion criteria. Overall there were 4.4% ipsilateral graft tears and 3.5% contralateral ACL tears. The odds of ipsilateral ACL retear were 5.2 times greater for an allograft (P < .01) compared with a bone–patellar tendon–bone (BTB) autograft; the odds of retear were not significantly different between BTB autograft and hamstring autograft (P = .12). The odds of an ipsilateral ACL retear decreased by 0.09 for every yearly increase in age (P < .01) and increased by 0.11 for every increased point on the Marx score (P < .01). These odds were not significantly influenced by sex, smoking status, sport played, medial or lateral meniscal tear, or consortium site (P > .05). The odds of a contralateral ACL tear decreased by 0.04 for every yearly increase in age (P = .04) and increased by 0.12 for every increased point on the Marx score (P < .01); these odds were not significantly different between sex, smoking status, sport played, graft type, medial meniscal tear, or lateral meniscal tear (P > .05).
Conclusion:
Younger age, higher activity level, and allograft graft type were predictors of increased odds of ipsilateral graft failure. Higher activity and younger age were found to be risk factors in contralateral ACL tears.
Background:
The long-term prognosis and risk factors for quality of life and disability after anterior cruciate ligament (ACL) reconstruction remain unknown.
Hypothesis/Purpose:
Our objective was to ...identify patient-reported outcomes and patient-specific risk factors from a large prospective cohort at a minimum 10-year follow-up after ACL reconstruction. We hypothesized that meniscus and articular cartilage injuries, revision ACL reconstruction, subsequent knee surgery, and certain demographic characteristics would be significant risk factors for inferior outcomes at 10 years.
Study Design:
Therapeutic study; Level of evidence, 2.
Methods:
Unilateral ACL reconstruction procedures were identified and prospectively enrolled between 2002 and 2004 from 7 sites in the Multicenter Orthopaedic Outcomes Network (MOON). Patients preoperatively completed a series of validated outcome instruments, including the International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), and Marx activity rating scale. At the time of surgery, physicians documented all intra-articular abnormalities, treatment, and surgical techniques utilized. Patients were followed at 2, 6, and 10 years postoperatively and asked to complete the same outcome instruments that they completed at baseline. The incidence and details of any subsequent knee surgeries were also obtained. Multivariable regression analysis was used to identify significant predictors of the outcome.
Results:
A total of 1592 patients were enrolled (57% male; median age, 24 years). Ten-year follow-up was obtained on 83% (n = 1320) of the cohort. Both IKDC and KOOS scores significantly improved at 2 years and were maintained at 6 and 10 years. Conversely, Marx scores dropped markedly over time, from a median score of 12 points at baseline to 9 points at 2 years, 7 points at 6 years, and 6 points at 10 years. The patient-specific risk factors for inferior 10-year outcomes were lower baseline scores; higher body mass index; being a smoker at baseline; having a medial or lateral meniscus procedure performed before index ACL reconstruction; undergoing revision ACL reconstruction; undergoing lateral meniscectomy; grade 3 to 4 articular cartilage lesions in the medial, lateral, or patellofemoral compartments; and undergoing any subsequent ipsilateral knee surgery after index ACL reconstruction.
Conclusion:
Patients were able to perform sports-related functions and maintain a relatively high knee-related quality of life 10 years after ACL reconstruction, although activity levels significantly declined over time. Multivariable analysis identified several key modifiable risk factors that significantly influence the outcome.
Background:
The time required to develop a secondary cartilage or meniscal injury in the medial compartment after anterior cruciate ligament (ACL) injury is not well understood.
Purpose:
To determine ...the association between time delay until ACL reconstruction and the presence of medial compartment Outerbridge grade 3 or 4 chondral injury or medial meniscal tear requiring treatment.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
A total of 609 patients underwent primary ACL reconstruction at a single institution at a median 46 days between injury and surgery (61.4% male; mean age, 26.5 years SD, 11.1). Chondral status was graded according to Outerbridge criteria at the time of surgery. Multivariate regression analysis was used to assess the relationship between time delay until surgery and medial compartment chondral injury or meniscal injury requiring treatment. Adjustment was performed as needed for patient demographics, sporting activity, and prior knee injuries. Time until surgery had a nonlinear association with medial compartment health and was more effectively described in discrete intervals rather than as a continuous variable. The optimal time intervals to predict medial compartment health were determined by comparison of Bayes information criterion values between fully adjusted regression models.
Results:
After controlling for relevant confounders, delay of surgery >8 weeks had an increased likelihood of a medial meniscal tear requiring partial meniscectomy (adjusted odds ratio aOR, 2.30; 95% CI, 1.04-5.12; P = .04) and a decreased likelihood of a meniscal tear requiring repair (aOR, 0.50; 95% CI, 0.32-0.76; P = .001). Delay of surgery >5 months had an increased likelihood of a medial Outerbridge grade ≥3 chondral defect (aOR, 3.11; 95% CI, 1.64-5.87; P = .001) or a grade 4 defect (aOR, 3.84; 95% CI, 1.75-8.45; P = .001).
Conclusion:
From the time of ACL injury, risk of an irreparable medial meniscal tear found at the time of ACL reconstruction is significantly increased by 8 weeks, and risk of high-grade medial chondral damage is increased by 5 months.
Purpose To assess the isokinetic, functional, and patient-reported outcomes of femoral nerve block (FNB) compared with traditional multimodal anesthesia for FNB in anterior cruciate ligament (ACL) ...reconstruction. Methods A systematic search of PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature, Cochrane Reviews, and Google Scholar was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Effects of FNB on quadriceps function were evaluated by isokinetic testing, functional scoring systems, range of motion, and patient self-report questionnaires. Heterogeneous reporting of outcomes precluded a formal meta-analysis. The methodologic merit of all studies included was evaluated by the Coleman Methodology Score. Results Six studies were identified with outcome measures reported between 7 days and 6 months postoperatively. At 6 months, 2 of 4 studies that reported isokinetic testing found significantly greater deficits among patients who received a nerve block; one of the remaining studies showed a deficit at 6 weeks but not 6 months. Limited data showed no significant differences in functional or patient-reported outcomes at 6 months after reconstruction, and data regarding the impact of FNB on return to sport were inconclusive. The mean Coleman Methodology Score for the included studies was 53, indicating poor overall methodologic quality of the available literature. Conclusions The limited data available suggest that FNB causes a measurable deficit in quadriceps isokinetic strength during the early postoperative period but has no effect on functional outcomes or return to sport at 6 months after ACL reconstruction. However, current clinical evidence is not sufficient to draw any valid or definitive conclusions regarding the effect of FNB on postoperative outcomes after ACL reconstruction. Level of Evidence Level IV, systemic review of Level I through IV studies.
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