Background:
Anterior cruciate ligament (ACL) reconstruction (ACLR) using a hamstring tendon (HT) autograft is an effective and widespread method. Recent studies have identified a relationship between ...the graft diameter and revision ACLR.
Purpose:
To evaluate the influence of the graft diameter on revision ACLR and patient-reported outcomes in patients undergoing primary ACLR using HT autografts.
Study Design:
Cohort study; Level of evidence, 2.
Methods:
A prospective cohort study was conducted using the Swedish National Knee Ligament Register (SNKLR) involving all patients undergoing primary ACLR using HT autografts. Patients with graft failure who needed revision surgery (cases) were compared with patients not undergoing revision surgery (controls). The control group was matched for sex, age, and graft fixation method in a 3:1 ratio. Conditional logistic regression was performed to produce odds ratios and 95% CIs. Univariate linear regression analyses were performed for patient-related outcomes. The Knee injury and Osteoarthritis Outcome Score (KOOS) and EuroQol 5 dimensions questionnaire (EQ-5D) values were obtained.
Results:
A total of 2240 patients were included in which there were 560 cases and 1680 controls. No significant differences between the cases and controls were found for sex (52.9% male), mean age (21.7 years), and femoral and tibial fixation. The mean graft diameter for the cases was 8.0 ± 0.74 mm and for the controls was 8.1 ± 0.76 mm. In the present cohort, the likelihood of revision surgery for every 0.5-mm increase in the HT autograft diameter between 7.0 and 10.0 mm was 0.86 (95% CI, 0.75-0.99; P = .03). Univariate linear regression analysis found no significant regression coefficient for the change in KOOS or EQ-5D values.
Conclusion:
In a large cohort of patients after primary ACLR with HT autografts, an increase in the graft diameter between 7.0 and 10.0 mm resulted in a 0.86 times lower likelihood of revision surgery with every 0.5-mm increase. This study provides further evidence of the importance of the HT autograft size in intraoperative decision making.
Background
Residual rotational instability remains a controversial factor when analysing failure rates of anterior cruciate ligament (ACL) reconstruction. Anatomical and biomechanical studies have ...demonstrated a very important role of anterolateral structures for rotational control. Revision ACL is considered one of the main indications for a lateral extra-articular tenodesis (LET). Yet, few series evaluating these procedures are published.
Purpose
To perform a systematic review of studies that assessed outcomes in patients treated with revision ACL surgery associated with a lateral extra-articular procedure.
Study design
Systematic review.
Methods
A comprehensive literature search was performed in February 2018 using PubMed, Scopus, Web of Search and Cochrane. Inclusion criteria were series of ACL revision reconstructions associated with lateral extra-articular procedures. Clinical outcomes (Lysholm, subjective IKDC, KOOS, Cincinnati and WOMAC), joint stability measures (Lachman test, pivot-shift, arthrometer assessment and navigation assessment), graft type, reported chondral and meniscal injury, radiographic outcomes, complications and failures were recorded. Articles were assessed for level of evidence and methodology using a modification of the ACL Methodology Score (AMS) system.
Results
Twelve studies met the inclusion criteria out of the 231 abstracts; 9 retrospective evaluations, two prospective cohorts and one combination of two populations (a retrospective and prospective series). A total of 851 patients evaluated with a mean age of 28.8 years (range 16–68 years) and a weighted mean follow-up of 4.9 years (range 1–10 years). The mean time from primary ACL reconstruction to revision was 5.3 years (reported in 7 studies, including 710 patients). The Lysholm, IKDC, and KOOS scores indicated favorable results in studies that reported these outcomes. Objective evaluations reported 86% objective A and B IKDC results, 2.6 mm mean side-to-side arthrometric difference and 80% negative pivot-shift. About 74% of patients returned to their previous sport (evaluated in six studies). Few studies reported radiological evaluation. Fifty-nine complications (8.0%) and 24 failures (3.6%) were reported. The mean modified ACL Methodology Score was 55.5 (range 32–72).
Conclusion
Good mid-term results were obtained for combined revision ACL reconstruction and lateral extra-articular procedures. Despite the fact that in clinical practice LET are a common indication associated with revision ACL, there are no high-level studies supporting this technique.
Level of evidence
IV.
Background:
Increased postoperative rotatory knee laxity after anterior cruciate ligament (ACL) reconstruction may be associated with an increased risk of osteoarthritis and inferior subjective ...outcome, although long-term studies are lacking. In terms of anteroposterior knee laxity, this association has not yet been established.
Purpose/Hypothesis:
The purpose was to investigate whether postoperative knee laxity is associated with inferior long-term outcome in patients who have undergone ACL reconstruction. The hypothesis was that increased laxity would cause an inferior long-term clinical and radiographic outcome.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
A total of 193 patients underwent ACL reconstruction and were examined at both 2 and 16 years postoperatively. At the 2-year follow-up, knee laxity was tested by use of the Lachman test, the anterior drawer test, the pivot-shift test, and the KT-1000 arthrometer. Outcome variables examined at the 16-year follow-up involved a radiographic assessment of osteoarthritis, patient-reported outcome measurements, and the single-legged hop test.
Results:
At the long-term follow-up, 147 (76%) patients were examined. The mean follow-up period for the included patients was 16.4 ± 1.2 years. A negative Lachman test at 2 years resulted in a superior International Knee Documentation Committee (IKDC) score (76.3 ± 19.4 vs 67.8 ± 19.3, P < .05) and Lysholm score (85.2 ± 11.9 vs 76.9 ± 17.8, P < .05) at the 16-year follow-up. Correspondingly, a negative anterior drawer test at 2 years was associated with a superior IKDC score (75.3 ± 18.7 vs 62.9 ± 20.2, P < .05) and Lysholm score (84.1 ± 12.1 vs 72.6 ± 20.2, P < .05) at 16 years. A negative pivot-shift test resulted in a superior IKDC score (74.5 ± 18.8 vs 46.9 ± 17.8, P < .05), a superior Lysholm score (83.3 ± 13.4 vs 58.9 ± 23.0, P < .05), and an increased level of activity (Tegner activity scale, median range: 4 1-10 vs 3 0-5, P < .05). Osteoarthritis was overrepresented in patients with positive manual knee laxity tests, but the difference was not statistically significant. The KT-1000 arthrometer result was not correlated with any outcome variables assessed in this study.
Conclusion:
Increased manual anteroposterior and rotatory knee laxity 2 years after ACL reconstruction is associated with an inferior long-term subjective outcome.
Purpose The primary aim was to summarize and assess current evidence from randomized controlled trials (RCTs) on anterior cruciate ligament injuries, with special reference to graft type and surgical ...technique. The secondary aims were to identify the relative strengths and weaknesses of the selected studies, to resolve contradictions in the literature, and to evaluate the need for further studies. Methods A PubMed database search using the key words “anterior cruciate ligament” was performed. The search was limited to RCTs published in English between January 1995 and March 2009. Articles on the subject of graft type and surgical technique were identified. After initial screening and a subsequent quality appraisal based on the CONSORT (Consolidated Standards of Reporting Trials) Statement, a total of 39 articles were included in this review. Results There are no differences between the bone–patellar tendon–bone (BPTB) graft and the hamstring tendon (HT) graft in terms of laxity, clinical outcome, time to return to sports, patellofemoral crepitations, 1-leg hop test, range of motion, thigh muscle circumference, or anterior knee sensory deficit. The BPTB graft produces more anterior knee pain and kneeling pain than the HT graft, but the difference disappears with time. The harvest site affects muscle strength initially but not over time. There is a possible correlation between the development of osteoarthritis and the BPTB graft. The HT graft produces more tunnel widening than the BPTB graft, but there is no correlation between tunnel widening and clinical outcome or laxity. The semitendinosus and gracilis graft is associated with inferior knee flexion at higher angles, as compared with the semitendinosus graft. There are probably no differences between the BPTB graft and the bone-HT-bone graft in terms of laxity and clinical outcome. Semitendinosus and gracilis tendon harvesting probably reduces hamstring muscle strength for approximately 1 year. Double-bundle reconstruction produces less rotatory laxity than single-bundle reconstruction. Double-bundle reconstruction by use of an 8-strand HT graft probably produces less laxity than single-bundle reconstruction. There are no differences in clinical outcome when single-bundle and double-bundle anterior cruciate ligament reconstructions are compared. Conclusions In the quality assessment several weaknesses in the study design of the RCTs were found. This emphasizes the need for further high-quality studies, especially with long-term follow-up. Level of Evidence Level II, systematic review of randomized controlled trials.
Background:
Adult patients who succeed in returning to their preinjury levels of sport after anterior cruciate ligament (ACL) reconstruction have been characterized by a more positive psychological ...response. It is not known whether this relationship is valid for adolescent athletes.
Purpose:
To investigate psychological readiness to return to sport, knee-related self-efficacy, and motivation among adolescent (15-20 years old) and adult (21-30 years old) athletes after ACL reconstruction. A further aim was to compare athletes (15-30 years old) who had recovered their muscle function and returned to sport with athletes who had not.
Study Design:
Case-control study; Level of evidence, 3.
Methods:
Data were extracted from a rehabilitation-specific register 8 and 12 months after ACL reconstruction. Athletes previously involved in knee-strenuous sport who had undergone primary ACL reconstruction were included. Data comprised psychological patient-reported outcomes and results from 5 tests of muscle function. Comparisons were performed between age groups, between athletes who had and had not recovered their muscle function, and between patients who had returned to sport and not.
Results:
In all, 384 (50% females) and 271 athletes (52% females) were included at the 8- and 12- month follow-ups, respectively. Enhanced self-efficacy was reported at both follow-ups by adolescents and by athletes who had recovered their muscle function. Athletes who had recovered their muscle function reported higher (P = .0007) motivation to achieve their goals. Subgroup analyses on patient sex revealed findings similar to those in the main analyses for females but not for males. Moreover, adolescent and adult athletes who had returned to sport reported significantly higher levels on the Knee Self-Efficacy Scale and the ACL–Return to Sport After Injury scale at both follow-ups.
Conclusion:
Adolescent athletes, especially females, perceived enhanced self-efficacy, had a higher return-to-sport rate, and were more motivated to reach their goals after ACL reconstruction compared with adults. Regardless of age, athletes who had returned to sport and athletes with more symmetrical muscle function had a stronger psychological profile.
Injuries to the hamstring muscles are among the most common in sports and account for significant time loss. Despite being so common, the injury mechanism of hamstring injuries remains to be ...determined.
To investigate the hamstring injury mechanism by conducting a systematic review.
A systematic review following the PRISMA statement.
A systematic search was conducted using PubMed, EMBASE and the Cochrane Library. Studies 1) written in English and 2) deciding on the mechanism of hamstring injury were eligible for inclusion. Literature reviews, systematic reviews, meta-analyses, conference abstracts, book chapters and editorials were excluded, as well as studies where the full text could not be obtained.
Twenty-six of 2372 screened original studies were included and stratified to the mechanism or methods used to determine hamstring injury: stretch-related injuries, kinematic analysis, electromyography-based kinematic analysis and strength-related injuries. All studies that reported the stretch-type injury mechanism concluded that injury occurs due to extensive hip flexion with a hyperextended knee. The vast majority of studies on injuries during running proposed that these injuries occur during the late swing phase of the running gait cycle.
A stretch-type injury to the hamstrings is caused by extensive hip flexion with an extended knee. Hamstring injuries during sprinting are most likely to occur due to excessive muscle strain caused by eccentric contraction during the late swing phase of the running gait cycle.
Level IV.
Background:
There is insufficient knowledge about the way that concomitant injuries affect the short-term likelihood of a return to a knee-strenuous sport after anterior cruciate ligament (ACL) ...reconstruction.
Hypotheses/Purpose:
The purpose was to study whether patient characteristics, concomitant injuries, and graft choice at primary ACL reconstruction can predict return to sport (RTS) 1 year after surgery. The hypotheses were that younger age at the time of ACL reconstruction would positively affect RTS, while the presence of concomitant injuries would negatively affect RTS 1 year after surgery.
Study Design:
Case-control study; Level of evidence, 3.
Methods:
Data were extracted from a rehabilitation-specific register and the Swedish National Knee Ligament Register. Twelve months after surgery, all patients were evaluated for RTS via the Tegner Activity Scale. The primary outcome was a return to knee-strenuous sport, defined as a Tegner Activity Scale ≥6. Univariable and multivariable logistic regression analyses were performed with patient characteristics, concomitant knee injuries, and graft choice as independent variables.
Results:
A total of 272 patients (51% female) with a mean ± SD age of 25.0 ± 9.2 years were included. In the multivariable analysis, a favorable odds ratio (OR) for returning to sport was found for patients of male sex (OR, 2.58; 95% CI, 1.43-4.65; P = .0016), younger age at the time of ACL reconstruction (OR, 2.32; 95% CI, 1.59-3.33; P < .0001), a higher preinjury score on the Tegner Activity Scale (OR, 1.45; 95% CI, 1.13-1.87; P = .0038), and an absence of injury to the meniscus (OR, 1.92; 95% CI, 1.10-3.36; P = .023) and medial collateral ligament (OR, 7.61; 95% CI, 1.42-40.87; P = .018). In addition, the absence of cartilage injury was favorable in terms of RTS in the univariable analysis (OR, 2.48; 95% CI, 1.40-4.39; P = .0018).
Conclusion:
Positive predictors of a return to knee-strenuous sport 1 year after ACL reconstruction were male sex, younger age, a high preinjury level of physical activity, and the absence of concomitant injuries to the medial collateral ligament and meniscus.
Background:
Simultaneous meniscal tears are often present with anterior cruciate ligament (ACL) injuries, and in the acute setting, the lateral meniscus (LM) is more commonly injured than the medial ...meniscus.
Purpose:
To investigate how a concomitant LM injury, repaired, resected, or left in situ during primary ACL reconstruction (ACLR), affects the ACL revision rate and cartilaginous and meniscal status at the time of revision within 2 years after the primary ACLR.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
Data for 31,705 patients with primary ACLR, extracted from the Swedish National Knee Ligament Registry, were used. The odds of revision ACLR, and cartilaginous as well as meniscal injuries at the time of revision ACLR, were assessed between the unexposed comparison group (isolated ACLR) and the exposed groups of interest (ACLR + LM repair, ACLR + LM resection, ACLR + LM repair + LM resection, or ACLR + LM injury left in situ).
Results:
In total, 719 (2.5%) of the included 29,270 patients with 2 years follow-up data underwent revision ACLR within 2 years after the primary ACLR. No significant difference in revision rate was found between the groups. Patients with concomitant LM repair (OR, 3.56; 95% CI, 1.57-8.10; P = .0024) or LM resection (OR, 1.76; 95% CI, 1.18-2.62; P = .0055) had higher odds of concomitant meniscal injuries (medial or lateral) at the time of revision ACLR than patients undergoing isolated primary ACLR. Additionally, higher odds of concomitant cartilage injuries at the time of revision ACLR were found in patients with LM resection at index ACLR compared with patients undergoing isolated primary ACLR (OR, 1.73; 95% CI, 1.14-2.63; P = .010).
Conclusion:
The results of this study demonstrated higher odds of meniscal and cartilaginous injuries at the time of revision ACLR within 2 years after primary ACLR + LM resection and higher odds of meniscal injury at the time of revision ACLR within 2 years after primary ACLR + LM repair compared with isolated ACLR. Surgeons should be aware of the possibility of concomitant cartilaginous and meniscal injuries at the time of revision ACLR after index ACLR with concomitant LM injury, regardless of the index treatment type received.
Background:
Although comparable clinical and functional outcomes have been reported after nonsurgical and surgical anterior cruciate ligament (ACL) treatment, few studies have investigated the ...effects of early versus late ACL reconstruction with initial rehabilitation.
Purpose:
To determine patient-reported knee function in patients who initially undergo nonreconstructive treatment after an ACL injury but who later choose to undergo ACL reconstruction as compared with (1) patients undergoing ACL reconstruction close to the index injury and (2) patients treated nonreconstructively at 1 to 10 years of follow-up.
Study Design:
Cohort study; Level of evidence, 2.
Methods:
Results from the Knee injury and Osteoarthritis Outcome Score (KOOS) were extracted from the Swedish National Knee Ligament Registry for patients treated with nonreconstruction, early ACL reconstruction, and initial nonreconstruction but subsequent ACL reconstruction (crossover group). The KOOS4 (a mean of 4 KOOS subscales) was analyzed cross-sectionally at baseline and at the 1-, 2-, 5-, and 10-year follow-ups. Additionally, the Patient Acceptable Symptom State (PASS) was applied to all KOOS subscales from baseline to the 10-year follow-up.
Results:
A total of 1,074 crossover, 484 nonreconstruction, and 20,352 early ACL reconstruction cases were included. The crossover group reported lower KOOS4 values than the group undergoing early ACL reconstruction at baseline and at all follow-ups (mean difference 95% CI): baseline, −6.5 (−8.0 to −5.0); 1 year, −9.3 (−10.9 to −7.7); 2 years, −4.8 (−6.3 to −3.2); 5 years, −6.1 (−8.8 to −3.4); and 10 years, −10.9 (−16.3 to −5.2). Additionally, a smaller proportion of the crossover cohort achieved a PASS on KOOS subscales at baseline and through the 1-, 2-, 5-, and 10-year follow-ups as compared with the early ACL reconstruction cohort. No differences were observed between crossover and nonreconstruction cases on either the KOOS4 or the PASS at any follow-up.
Conclusion:
A greater proportion of patients treated with early ACL reconstruction reported acceptable knee function and superior overall knee function as compared with patients who decided to cross over from nonreconstructive treatment to ACL reconstruction.
Isolated and combined posterior cruciate ligament (PCL) injuries are associated with severe limitations in daily, professional, and sports activities as well as with devastating long-term effects for ...the knee joint. As the number of primary and recurrent PCL injuries increases, so does the body of literature, with high-quality evidence evolving in recent years. However, the debate about the ideal treatment approach such as; operative vs. non-operative; single-bundle vs. double-bundle reconstruction; transtibial vs. tibial inlay technique, continues. Ultimately, the goal in the treatment of PCL injuries is restoring native knee kinematics and preventing residual posterior and combined rotatory knee laxity through an individualized approach. Certain demographic, anatomical, and surgical risk factors for failures in operative treatment have been identified. Failures after PCL reconstruction are increasing, confronting the treating surgeon with challenges including the need for revision PCL reconstruction. Part 2 of the evidence-based update on the management of primary and recurrent PCL injuries will summarize the outcomes of operative and non-operative treatment including indications, surgical techniques, complications, and risk factors for recurrent PCL deficiency. This paper aims to support surgeons in decision-making for the treatment of PCL injuries by systematically evaluating underlying risk factors, thus preventing postoperative complications and recurrent knee laxity.
Level of evidence
V.
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