Purpose
This study aimed to identify independent predictive factors for return to sports (RTS) after anterior cruciate ligament (ACL) reconstruction in competitive-level athletes and to determine ...optimal cut-off values for these factors at 6 months after surgery.
Methods
A total of 124 competitive athletes (50 males and 74 females; mean age, 17.0 years; preinjury Tegner activity scale > 7) who underwent primary ACL reconstruction were enrolled. Assessments at 6 months after surgery consisted of knee functional tests quadriceps index, hamstrings index, and single-leg hop for distance (SLH) and 2 self-report questionnaires IKDC subjective score and ACL-Return to Sport after Injury scale (ACL-RSI). At 1 year after surgery, athletes were classified into the RTS group (
n
= 101) or non-RTS group (
n
= 23) based on self-reported sports activities. After screening possible predictive factors of RTS, multivariate logistic regression and receiver operating characteristic curve analyses were performed to identify independent factors.
Results
Multivariate logistic regression analysis identified SLH (odds ratio, 2.861 per 10 unit increase;
P
< 0.001) and ACL-RSI (odds ratio, 1.810 per 10 unit increase;
P
= 0.001) at 6 months as independent predictors of RTS at 1 year after surgery. Optimal cut-off values of SLH and ACL-RSI were 81.3% (sensitivity = 0.891; specificity = 0.609) and 55 points (sensitivity = 0.693; specificity = 0.826), respectively.
Conclusion
In competitive athletes, SLH < 81% and ACL-RSI < 55 points at 6 months after surgery were associated with a greater risk of unsuccessful RTS at 1 year after surgery. SLH and ACL-RSI at 6 months could serve as screening tools to identify athletes who have difficulties with returning to sports after ACL reconstruction.
Level of evidence
III.
Background:
Many factors are involved in causing patellar instability or recurrent patellar dislocations. However, factors affecting the outcomes of anatomic medial patellofemoral ligament (MPFL) ...reconstruction have not been fully documented.
Purpose:
To evaluate the rate of recurrent patellar instability after isolated MPFL reconstruction and to elucidate factors affecting the outcomes of isolated MPFL reconstruction using multivariable statistics.
Study Design:
Case-control study; Level of evidence, 3.
Methods:
A total of 42 patients (44 knees) who underwent isolated, anatomic MPFL reconstruction using a semitendinosus autograft without any additional patellar stabilization procedures for treating recurrent patellar dislocations were included in this study. All patients were followed for more than 2 years; the mean follow-up period was 3.2 years (range, 2-9 years). Postoperative patellofemoral instability was diagnosed when the patient complained of recurrent patellar subluxations or dislocations or had a positive apprehension sign during follow-up. Preoperative radiographic findings were obtained using plain radiography and computed tomography. Femoral tunnel positions were assessed on postoperative radiographs. The strength of the relationship between postoperative patellofemoral instability and potential risk factors such as preoperative age, sex, body mass index, patellar type, sulcus angle, congruence angle, lateral tilt angle, patellar height, tibial tubercle–trochlear groove (TT-TG) distance, degree of trochlear dysplasia, and femoral bone tunnel position were evaluated by univariate and multivariate logistic regression analyses.
Results:
At follow-up, 2 knees had experienced a redislocation (4.5%). A positive apprehension sign was still evident in 8 knees (18.2%). Three factors, including the sulcus angle, the congruence angle, and trochlear dysplasia, were extracted by single linear regression analysis. Univariate logistic regression analysis showed that the sulcus angle (odds ratio OR, 1.11; 95% CI, 1.01-1.22; P = .04) and trochlear dysplasia (OR, 3.04; 95% CI, 1.39-6.63; P = .01) were associated with postoperative patellofemoral instability. Trochlear dysplasia was independently associated with postoperative patellofemoral instability by multivariable logistic regression analysis (P < .05). An increased TT-TG distance exerted a significant effect on the outcomes of MPFL reconstruction, particularly in patients with type D trochlea.
Conclusion:
Severe trochlear dysplasia is the most important predictor of residual patellofemoral instability after isolated MPFL reconstruction. In addition, an increased TT-TG distance affected the outcomes in patients with type D trochlea. Additional patellar stabilization procedures should be considered for patients with severe trochlear dysplasia and an increased TT-TG distance.
Background:
Articular cartilage has limited healing capacity, owing in part to poor vascularity and innervation. Once injured, it cannot be repaired, typically leading to high risk for developing ...osteoarthritis. Thus, cell-based and/or tissue-engineered approaches have been investigated; however, no approach has yet achieved safety and regenerative repair capacity via a simple implantation procedure.
Purpose:
To assess the safety and efficacy of using a scaffold-free tissue-engineered construct (TEC) derived from autologous synovial membrane mesenchymal stem cells (MSCs) for effective cartilage repair.
Study Design:
Case series; Level of evidence, 4.
Methods:
Five patients with symptomatic knee chondral lesions (1.5-3.0 cm2) on the medial femoral condyle, lateral femoral condyle, or femoral groove were included. Synovial MSCs were isolated from arthroscopic biopsy specimens and cultured to develop a TEC that matched the lesion size. The TECs were then implanted into chondral defects without fixation and assessed up to 24 months postoperatively. The primary outcome was the safety of the procedure. Secondary outcomes were self-assessed clinical scores, arthroscopy, tissue biopsy, and magnetic resonance image–based estimation of morphologic and compositional quality of the repair tissue.
Results:
No adverse events were recorded, and self-assessed clinical scores for pain, symptoms, activities of daily living, sports activity, and quality of life were significantly improved at 24 months after surgery. Secure defect filling was confirmed by second-look arthroscopy and magnetic resonance imaging in all cases. Histology of biopsy specimens indicated repair tissue approaching the composition and structure of hyaline cartilage.
Conclusion:
Autologous scaffold-free TEC derived from synovial MSCs may be used for regenerative cartilage repair via a sutureless and simple implantation procedure.
Registration:
000008266 (UMIN Clinical Trials Registry number).
Background:
Open reduction and internal fixation (ORIF) has been widely performed because the osteochondral component of the osteochondritis dissecans (OCD) lesion is the most suitable for ...reconstructing the joint structure.
Purpose:
To evaluate radiological healing in terms of reconstructed bony structure after ORIF with bone graft by computed tomography (CT), to identify preoperative prognostic factors for failure, and to determine the cutoff value of radiological healing for risk of failure.
Study Design:
Case-control study; Level of evidence, 3.
Methods:
A retrospective cohort study of 42 patients (44 knees) who underwent internal fixation with bone graft for OCD lesions of the knee from 2004 to 2018 was conducted. All patients were evaluated 6 months postoperatively, and if not healed 6 months after surgery, they were evaluated by CT periodically thereafter. Radiological healing was judged according to the following 3 criteria: (1) reossification of the OCD lesion, (2) bony continuity between the OCD lesion and basal floor, and (3) reconstructed bony surface of the femoral condyle reconstructed to match the normal joint. Then, the percentage of the radiological healing area was calculated as the ratio of the healing length to the total lesion length. The nonhealing area was calculated by multiplying the sum of the total nonhealing length. Clinical failure was defined as any definitive reoperation for the same OCD lesion, such as fragment excision, or a cartilage restoration procedure. After 6 months, all eligible patients underwent arthroscopy to check for protrusion of the absorbable pin into the joint; the removal of an absorbable pin protruding into the joint was not considered a failure.
Results:
Clinical failure was recorded for 4 cases (9.1%). The mean overall percentage of the radiological healing area of OCD 6 months after ORIF with bone graft was 79.5% ± 24.4%, and the mean overall nonhealing area at 6 months was 87.8 ± 107.9 mm2. The percentages of radiological healing area of stable (International Cartilage Regeneration & Joint Preservation Society OCD II) lesions and femoral condylar (lateral femoral condyle + medial femoral condyle) lesions were significantly lower than unstable lesions and femoral groove lesions, respectively (P = .01 and P = .03, respectively). On receiver operating characteristic curve analysis, the cutoff points for predicting a significantly increased risk of failure were 33.9% (sensitivity, 100%; specificity, 100%; area under the curve, 1) for the percentage of radiological healing area and 222.9 mm2 (sensitivity, 95%; specificity, 100%; area under the curve, 0.956) for the nonhealing area 6 months postoperatively.
Conclusion:
A stable lesion and a femoral condylar lesion were the predictors of poor radiological healing on CT images 6 months after ORIF with bone graft. The risk of failure was increased significantly in cases with only approximately one-third of the lesion healed or in cases with large nonhealing areas at 6 months postoperatively.
Although anatomical anterior cruciate ligament reconstruction (ACLR) can provide satisfactory outcomes, little is known about how this procedure impacts patellar height. Since harvesting ...bone-patellar tendon-bone (BTB) autografts is a potential risk factor for decreased patellar height, we examined changes in patellar height after anatomical ACLR with BTB autograft with a focus on the size of the harvested graft.
Subjects were 84 patients (49 males, 35 females; mean age, 23 years) who underwent primary anatomical ACLR with central third BTB autograft. Preoperative to postoperative Caton-Deschamps index (CDI) ratio was calculated using lateral knee radiographs before and 6 months after surgery. The length and cross-sectional area (CSA) of the graft were measured intraoperatively, and the CSA of the contralateral patellar tendon was measured by ultrasound 6 months postoperatively. The difference in graft CSA relative to the contralateral tendon CSA, expressed as a percentage (gCSA:ctCSA percentage), was also calculated.
Patellar height decreased slightly after surgery (preoperative CDI: 0.856 ± 0.113; postoperative CDI: 0.841 ± 0.113), with a mean difference between preoperative and postoperative CDIs of -0.015 (range: -0.293 to 0.101). Although the CDI of male subjects significantly decreased after surgery (preoperative: 0.852 ± 0.117; postoperative: 0.827 ± 0.115), no significant changes were noted in female subjects (preoperative: 0.862 ± 0.108; postoperative: 0.861 ± 0.108). Graft length and CSA did not significantly impact the CDI ratio (r = -0.138 and r = -0.038, respectively). Moreover, no significant relationship was observed between the gCSA:ctCSA percentage and CDI ratio (r = 0.118).
Although patellar height slightly, but significantly, decreased at 6 months after anatomical ACLR with BTB autograft, it was not affected by the length and CSA of harvested grafts. The decrease in postoperative patellar height was observed only in male subjects, suggesting the potential importance of sex differences in soft tissue healing during the postoperative period.
Purpose
This study aimed to retrospectively compare the enlargement and migration of the femoral tunnel aperture after anatomic rectangular tunnel anterior cruciate ligament (ACL) reconstruction with ...a bone–patella tendon–bone (BTB) or hamstring tendon (HT) graft using three-dimensional (3-D) computer models.
Methods
Thirty-two patients who underwent ACL reconstruction and postoperative computed tomography (CT) at 3 weeks and 6 months were included in this study. Of these, 20 patients underwent ACL reconstruction with a BTB graft (BTBR group), and the remaining 12 with an HT graft (HTR group). The area of the femoral tunnel aperture was extracted and measured using a 3-D computer model generated from CT images. Changes in the area and migration direction of the femoral tunnel aperture during this period were compared between the two groups.
Results
In the HTR group, the area of the femoral tunnel aperture was significantly increased at 6 months compared to 3 weeks postoperatively (
P
< 0.05). The average area of the femoral tunnel aperture at 6 months postoperatively was larger by 16.0 ± 12.4% in the BTBR group and 41.9 ± 22.2% in the HTR group, relative to that measured at 3 weeks postoperatively (
P
< 0.05). The femoral tunnel aperture migrated in the anteroinferior direction in the HTR group, and only in the inferior direction in the BTBR group.
Conclusions
The femoral tunnel aperture in the HTR group was significantly more enlarged and more anteriorly located at 6 months after ACL reconstruction, compared to the BTBR group.
Level of evidence
IV.
In a previous study, the utility of a single-leg loading (SLL) test after acute lateral ankle sprain (LAS) was reported. However, whether the severity level assessed by the SLL test is associated ...with the time to jog and return to sports (RTS) remains unclear. Therefore, this study aimed to examine whether the time to jog and RTS differ depending on the severity level. A total of 240 athletes after sustaining acute LAS were included in this study. The SLL test was performed at the first visit, and the patients were classified into four levels (Levels 1–4). The Steel–Dwass multiple comparison method and multiple regression analysis was performed to verify whether the SLL test can predict the time to jog and RTS. On examining the relationship between the severity levels assessed by the SLL test and time to jog and RTS, significant differences were found among almost all the severity levels. Moreover, the multiple regression analysis revealed that only the SLL test showed a significant correlation with both the time to jog and RTS. This study suggested that the time to jog and RTS can be predicted by conducting the SLL test for acute LAS and dividing the severity into four levels.
In young athletes, radial tear of the midbody on the semilunar lateral meniscus in stable knees is most common. Conventionally, for this type of tear, meniscectomy has been considered as a first-line ...treatment. However, meniscectomy does not prevent degenerative change. Therefore, repair is another treatment option for a full radial tear, though this type of tear can be difficult to repair because of the lack of a vascular supply. Compared with conventional transcapsular suture techniques (e.g., inside-out/outside-in techniques or all-inside techniques with implants), all-inside suture (AIS) repair techniques can avoid bunching of the meniscus to the capsule. AIS is considered suitable for restoration of normal structure and movement of the meniscus after repair, which can be advantageous for meniscal healing. However, AIS repair for an isolated radial tear at the midbody of the lateral meniscus has rarely been reported. Therefore, we applied the AIS repair technique for isolated radial tear at the midbody of the semilunar lateral meniscus using a QuickPass SutureLasso with 2-0 FiberWire. This procedure is easier and less invasive, shortening the gap by drawing each stump of the meniscus in the direction of the circumference.
Purpose
In animal studies after ACL reconstruction (ACL-R) using the bone-patellar tendon-bone (BTB), the graft-healing pattern was found to depend on the relationship between bone plug and the ...tunnel wall. This difference of graft-healing pattern could influence the postoperative morphological changes of the tunnel. However, no study has assessed the relationship between bone plug position and the change of tunnel morphology. Therefore, the main purpose of this study was to investigate the relationship between the bone plug position within femoral or tibial tunnel and morphological changes of each tunnel aperture in ACL-R using computed tomography.
Methods
Subjects were 30 consecutive patients (six females and 24 males; mean age, 20.4 ± 5.4 years) who underwent primary ACL-R using BTB. The distance from the tunnel aperture to the tendon-bone junction (TBJ) at 2 weeks postoperatively, and tunnel aperture enlargement and tunnel wall migration from 2 weeks to 6 months postoperatively, were evaluated.
Results
The distance from the femoral tunnel aperture to the TBJ in most cases was less than 2 mm, whereas the TBJ was located within the tibial tunnel. Femoral tunnel aperture was significantly enlarged (17.0 ± 11.7%) distally, and the tibial tunnel aperture was significantly enlarged (19.6 ± 12.5%) posterolaterally. Only the position at distal portion of femoral bone plug was correlated with femoral tunnel aperture enlargement (
r
= 0.454,
p
= 0.0015).
Conclusion
Both femoral and tibial tunnel aperture were significantly enlarged distally and posterolaterally 6 months postoperatively. Only correlation between the position at distal portion of femoral bone plug and femoral tunnel enlargement were found, suggesting the deep plug position in the tunnel is a risk factor for femoral tunnel enlargement, highlighting the importance of accurately locating the TBJ just at the femoral tunnel aperture. Another option is to deviate the harvest site in the patellar tendon to match the shape of the TBJ and the tunnel aperture.
Level of evidence
4 (case series).
Second-look arthroscopy is invasive but still one of the most useful postoperative evaluation methods since graft morphology including graft tension, graft tear, and synovial coverage can be directly ...evaluated. However, only a few studies have evaluated transplanted posterior cruciate ligament (PCL) grafts. This study aimed to clarify the PCL graft morphology and chondral damages at second-look arthroscopy after double-bundle PCL reconstruction (PCLR) and to investigate the effects of patient age on these arthroscopic findings.
This study retrospectively included 26 patients who underwent second-look arthroscopy at the time of hardware removal 14 months after double-bundle PCLR for isolated PCL injury from January 2007 to December 2020. The patients were divided into two groups: group A, 39 years or younger (n = 14); and group B, 40 years or older (n = 12). At second-look arthroscopy, the grafts were evaluated based on tension (taut, graft tension as tense as a normal PCL; lax, graft tension looser than a normal PCL, unclassified, completely torn graft), tear (one or more tendon strands torn), and synovial coverage (good, synovial coverage greater than 80% around the graft; fair, synovial coverage greater than 50%; and poor, synovial coverage less than 50%). The chondral damages were evaluated using the Outerbridge classification system. Radiographic posterior tibial translation with gravity sag view as well as clinical outcomes were also evaluated.
Anterolateral (AL) graft tension was lax in 8% of the patients, whereas posteromedial (PM) graft tension was lax or unclassified in 24% (p = 0.043). Graft tear was observed only in the PM graft of 19% patients (p = 0.022). Synovial coverage of AL grafts was good or fair in all cases, whereas that of PM grafts was poor in 28% cases (p < 0.001). Regarding the effect of patient age, the synovial coverage of PM grafts was significantly poorer in group B (p = 0.033), but no statistical difference in graft tension or tear was found. The chondral damages were significantly advanced in group B (p ≤ 0.01), except for the trochlear groove and lateral femoral condyle. No patients had residual subjective posterior instability, knee swelling, or loss of extension exceeding 5° or flexion exceeding 10°. All patients had improved from grade II or III preoperatively to grade I or grade II in the posterior drawer test. The posterior tibial translation significantly improved from 10.0 ± 3.6 mm preoperatively to 3.6 ± 2.1 mm at second-look arthroscopy. No significant differences in the postoperative clinical outcomes were observed between the two groups.
The morphology of the PM grafts at second-look arthroscopy after double-bundle PCLR was poorer than that of the AL grafts. Patient age negatively affected the postoperative graft synovial coverage and chondral status but did not affect the clinical outcomes.
•Second-look arthroscopy is a direct evaluation of the transplanted graft.•There are very few studies of second-look arthroscopy of transplanted PCL grafts.•Arthroscopic findings in the PM graft were inferior to those in the AL graft.•Poorer synovial coverage in the PM graft was observed in the patients ≥40 years.
PDF
