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Charles S, Preston N. Osteoarthritis After Anterior Cruciate Ligament Reconstruction: A Systematic Review of Contributing Factors and Potential Treatments. Cureus 2024; 16:e71188. [PMID: 39525184 PMCID: PMC11549666 DOI: 10.7759/cureus.71188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2024] [Indexed: 11/16/2024] Open
Abstract
Anterior cruciate ligament (ACL) injuries result in abnormal knee motion and long-term joint degradation. ACL reconstruction (ACLR) is done with the aim of restoring normal knee kinematics and slowing the joint degradation process. It does appear that this inevitably happens and can be impacted by a multitude of factors. The aim of this review was to examine the factors that influence the progression of osteoarthritis (OA) after ACLR and examine possible treatments that can aid in slowing that progression. A systematic review was conducted by searching all levels of evidence for all studies in English that assessed risk factors for developing OA after ACL reconstruction, had a minimum follow-up of 10 years, and used radiographical outcomes to measure the presence of OA. Studies on trial treatments to reduce osteoarthritis after ACL reconstruction were also included. It was found that among the factors associated with an increased risk of post-ACLR OA are meniscal lesions, meniscectomy, increased age at the time of ACLR, increased time from injury to surgery, male sex, reduced range of motion, smaller thigh girth, graft complications, and failure. Additionally, in performing the ACLR, anteromedial femoral tunnel placement, higher graft tension, and following guidelines for performing anatomic ACLR have been shown to reduce the risk of OA as well. Patients should be adequately counselled on their risk pre-operatively for informed decision-making. Surgeons should also be aware of potential risk factors and how they can be mitigated.
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Affiliation(s)
- Shane Charles
- Sports and Exercise Medicine, University of South Wales, Wales, GBR
- Orthopaedics and Trauma, San Fernando General Hospital, San Fernando, TTO
| | - Nick Preston
- Department of Rehabilitation Medicine, The University of Leeds, Leeds, GBR
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Liukkonen R, Vaajala M, Mattila VM, Reito A. Prevalence of post-traumatic osteoarthritis after anterior cruciate ligament injury remains high despite advances in surgical techniques. Bone Joint J 2023; 105-B:1140-1148. [PMID: 37907079 DOI: 10.1302/0301-620x.105b11.bjj-2023-0058.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Aims The aim of this study was to report the pooled prevalence of post-traumatic osteoarthritis (PTOA) and examine whether the risk of developing PTOA after anterior cruciate ligament (ACL) injury has decreased in recent decades. Methods The PubMed and Web of Science databases were searched from 1 January 1980 to 11 May 2022. Patient series, observational studies, and clinical trials having reported the prevalence of radiologically confirmed PTOA after ACL injury, with at least a ten-year follow-up, were included. All studies were analyzed simultaneously, and separate analyses of the operative and nonoperative knees were performed. The prevalence of PTOA was calculated separately for each study, and pooled prevalence was reported with 95% confidence intervals (CIs) using either a fixed or random effects model. To examine the effect of the year of injury on the prevalence, a logit transformed meta-regression analysis was used with a maximum-likelihood estimator. Results from meta-regression analyses were reported with the unstandardized coefficient (β). Results The pooled prevalence of PTOA was 37.9% (95% CI 32.1 to 44) for operatively treated ACL injuries with a median follow-up of 14.6 years (interquartile range (IQR) 10.6 to 16.7). For nonoperatively treated ACL injuries, the prevalence was 40.5% (95% CI 28.9 to 53.3), with a median of follow-up of 15 years (IQR 11.7 to 20.0). The association between the year of operation and the prevalence of PTOA was weak and imprecise and not related to the choice of treatment (operative β -0.038 (95% CI -0.076 to 0.000) and nonoperative β -0.011 (95% CI -0.101 to 0.079)). Conclusion The initial injury, irrespective of management, has, by the balance of probability, resulted in PTOA within 20 years. In addition, the prevalence of PTOA has only slightly decreased during past decades. Therefore, further research is warranted to develop strategies to prevent the development of PTOA after ACL injuries.
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Affiliation(s)
- Rasmus Liukkonen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Matias Vaajala
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Ville M Mattila
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Aleksi Reito
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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Spatholt RJ, Minoughan CE, Gooch C, Harms SP, Taylor ML, Galloway MT, Shearn JT. Determine the vertical ground reaction forces and knee mechanics with different gait inclinations in the sheep model. J Orthop Res 2023; 41:779-786. [PMID: 35822352 DOI: 10.1002/jor.25416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 04/20/2022] [Accepted: 07/07/2022] [Indexed: 02/04/2023]
Abstract
Our current understanding of knee mechanics and anterior cruciate ligament (ACL) function is predominately based on data recorded during simulations of clinical examinations or the application of nonphysiologic loads and motions. These methodologies provide little information on knee and ACL mechanics during activities of daily living (ADLs). Additionally, researchers have not directly measured knee kinetics, knee contact pressures, and ACL forces, and it is unknown how these parameters change with different activities. This study quantified the effects of activity level on vertical ground reaction forces, knee kinematics, and joint and ligament forces during in vivo motions. Five female Suffolk sheep were walked twice weekly on a treadmill during level (0°), inclined (+6°), and declined (-6°) gait for 12 weeks. Electromagnetic (EM) trackers were surgically implanted onto the left distal femur and the left proximal tibia, and in vivo motions were recorded for all activities. Following sacrifice, the in vivo motions were applied to their respective knees using a serial robot with a multi-axis load cell. In vitro simulations were repeated to measure (a) total knee forces, (b) contact pressure maps, and (c) ACL-only forces. Declining the gait surface led to increased posterior translation during the swing phase and decreased flexion at hoof-strike, decreased medial contact pressure at push-off, decreased ACL force at hoof-strike and increased ACL force at push-off. This study established a system that can be used to examine knee mechanics and ACL forces during ADLs for different knee states to define design requirements for ACL reconstruction techniques.
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Affiliation(s)
- Rebecca J Spatholt
- Department of Biomedical Engineering, University of Cincinnati, Cincinnati, Ohio, USA
| | - Chelsea E Minoughan
- Department of Biomedical Engineering, University of Cincinnati, Cincinnati, Ohio, USA
| | - Cynthia Gooch
- Department of Biomedical Engineering, University of Cincinnati, Cincinnati, Ohio, USA
| | - Samuel P Harms
- Orthopaedic Associates of Duluth, Duluth, Minnesota, USA
| | - Michal L Taylor
- Rocky Mountain Associates in Orthopaedic Medicine, Denver, Colorado, USA
| | | | - Jason T Shearn
- Department of Biomedical Engineering, University of Cincinnati, Cincinnati, Ohio, USA
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Filbay SR, Skou ST, Bullock GS, Le CY, Räisänen AM, Toomey C, Ezzat AM, Hayden A, Culvenor AG, Whittaker JL, Roos EM, Crossley KM, Juhl CB, Emery C. Long-term quality of life, work limitation, physical activity, economic cost and disease burden following ACL and meniscal injury: a systematic review and meta-analysis for the OPTIKNEE consensus. Br J Sports Med 2022; 56:1465-1474. [PMID: 36171078 DOI: 10.1136/bjsports-2022-105626] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Determine the long-term health-related quality-of-life (HRQoL), work limitation, physical activity, health/economic cost and disease burden of traumatic ACL and/or meniscal injury. Findings will inform OPTIKNEE evidence-based consensus recommendations. DESIGN Random-effects meta-analysis evaluated HRQoL (SF-36/SF-12/VR-12 Physical Component Scores (PCS) and Mental Component Scores (MCS), EuroQol-5D (EQ-5D)) stratified by time postinjury, and pooled mean differences (95% CI) between ACL-injured and uninjured controls. Other outcomes were synthesised descriptively. Risk-of-bias (RoB) and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation) were assessed. DATA SOURCES MEDLINE, EMBASE, CENTRAL, SPORTDiscus, CINAHL searched inception: 22 November 2021. ELIGIBILITY Studies reporting HRQoL, work limitations, physical activity levels, health/economic costs or disease burden, ≥2 years post-ACL and/or meniscal injury. RESULTS Fifty studies were included (10 high-RoB, 28 susceptible-to-some-bias and 12 low-RoB). Meta-analysis (27 studies, very low certainty of evidence) estimated a pooled mean (95% CI) PCS of 52.4 (51.4 to 53.4) and MCS of 54.0 (53.0 to 55.0) 2-14 years post-ACL injury. Pooled PCS scores were worse >10 years (50.8 (48.7 to 52.9)) compared with 2-5 years (53.9 (53.1 to 54.7)) postinjury. Excluding high-RoB studies, PCS scores were worse in ACL-injured compared with uninjured controls (-1.5 (-2.9 to -0.1)). Six studies (low certainty of evidence) informed a pooled EQ-5D score of 0.83 (0.81 to 0.84). Some individuals experienced prolonged work absenteeism and modified activities ≥2 years post-ACL injury. ACL injury was associated with significant direct and indirect costs, and early ACL reconstruction may be less cost-effective than rehabilitation. Only three studies evaluated meniscal injury outcomes (all evaluated HRQoL). CONCLUSION There is a very-low certainty of evidence that PCS scores ≥2 years post-ACL injury are worse than uninjured controls and decline over time, whereas MCS scores remain high. ACL injury can result in prolonged work absenteeism and high health/economic costs. Further studies are needed to determine the long-term burden of traumatic meniscal injury.
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Affiliation(s)
- Stephanie Rose Filbay
- Department of Physiotherapy, University of Melbourne, Melbourne, Victoria, Australia
| | - Søren T Skou
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Slagelse, Denmark
| | - Garrett S Bullock
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Christina Y Le
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada.,Arthritis Research Canada, Richmond, British Columbia, Canada
| | - Anu M Räisänen
- Department of Physical Therapy Education, Oregon, Western University of Health Sciences College of Health Sciences, Northwest, Lebanon, Oregon, USA.,Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Clodagh Toomey
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,School of Allied Health, University of Limerick, Limerick, Ireland
| | - Allison M Ezzat
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Victoria, Australia.,Department of Physical Therapy, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Alix Hayden
- Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada
| | - Adam G Culvenor
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Victoria, Australia
| | - Jackie L Whittaker
- Arthritis Research Canada, Richmond, British Columbia, Canada.,Department of Physical Therapy, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Ewa M Roos
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Kay M Crossley
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Victoria, Australia
| | - Carsten Bogh Juhl
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Herlev-Gentofte, Copenhagen, Denmark
| | - Carolyn Emery
- Kinesiology, University of Calgary, Calgary, Alberta, Canada
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Iriuchishima T, Goto B. Systematic Review of Surgical Technique and Tunnel Target Points and Placement in Anatomical Single-Bundle ACL Reconstruction. J Knee Surg 2021; 34:1531-1538. [PMID: 32480416 DOI: 10.1055/s-0040-1710521] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this systematic review was to reveal the trend in surgical technique and tunnel targets points and placement in anatomical single-bundle anterior cruciate ligament (ACL) reconstruction. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, data collection was performed. PubMed, EMBASE, and Cochran Review were searched using the terms "anterior cruciate ligament reconstruction," "anatomic or anatomical," and "single bundle." Studies were included when they reported clinical results, surgical technique, and/or tunnel placement evaluation. Laboratory studies, technical reports, case reports, and reviews were excluded from this study. From these full article reviews, graft selection, method of creating the femoral tunnel, and femoral and tibial tunnel target points and placement were evaluated. In the 79 studies included for data evaluation, the selected grafts were: bone patella tendon bone autograft (12%), and hamstring autograft (83%). The reported methods of creating the femoral tunnel were: transportal technique (54%), outside-in technique (15%), and transtibial technique (19%). In the 60 studies reporting tunnel target points, the target point was the center of the femoral footprint (60%), and the center of the anteromedial bundle footprint (22%). In the 23 studies evaluating tunnel placement, the femoral tunnel was placed in a shallow-deep direction (32.3%) and in a high-low direction (30.2%), and the tibial tunnel was placed from the anterior margin of the tibia (38.1%). The results of this systematic review revealed a trend in anatomical single-bundle ACL reconstruction favoring a hamstring tendon with a transportal technique, and a tunnel target point mainly at the center of the ACL footprint. The level of evidence stated is Systematic review of level-III studies.
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Affiliation(s)
| | - Bunsei Goto
- Department of Orthopaedic Surgery, Kamimoku Spa Hospital, Minakami, Japan
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Thwin L, Ho SW, Tan TJL, Lim WY, Lee KT. Pre-operative MRI measurements versus anthropometric data: Which is more accurate in predicting 4-stranded hamstring graft size in anterior cruciate ligament reconstruction? ASIA-PACIFIC JOURNAL OF SPORT MEDICINE ARTHROSCOPY REHABILITATION AND TECHNOLOGY 2020; 22:5-9. [PMID: 32642442 PMCID: PMC7321968 DOI: 10.1016/j.asmart.2020.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/18/2020] [Accepted: 05/25/2020] [Indexed: 01/12/2023]
Abstract
Background/objective Graft diameter has been shown to play an important role in anterior cruciate ligament (ACL) autograft failure rates. The roles of pre-operative MRI measurement of graft size and anthropometric data have been studied in the prediction of hamstring graft size. Pre-operative knowledge of hamstring graft diameter allows surgeons to perform better surgical planning and provides an opportunity to discuss with patients on alternative graft options such as allografts should the need arises. The purpose of this study was to compare the accuracy of pre-operative anthropometric data and MRI measurements in the prediction of 4-stranded hamstring autograft size in anterior cruciate ligament reconstruction. Method This was a cohort study involving 141 subjects (115 males and 26 females) who underwent a single bundle ACL reconstruction utilising a 4-stranded hamstring graft by a single surgeon from 2008 to 2012. Pre-operatively, the height, weight, body mass index (BMI), age, gender and smoking status was recorded. The MRI scans used for diagnosis were utilized to measure the gracilis (GT) and semi-tendinosus (ST) cross sectional area (CSA). Result We found the strongest correlation between Combined (ST + GT) CSA and intra-operative graft size (r = 0.596, p < 0.001). This was followed by ST CSA (r = 0.570,p < 0.001), Body surface area (r = 0.507,p < 0.001), and GT CSA (r = 0.460,p < 0.001). No significant correlation was found between 2 anthropometric data (Age and BMI). There was also no significant difference between different strengths of MRIs (1.5T vs 3.0T) in determining the intra-operative graft size (p = 0.438). Conclusion We conclude that pre-operative MRI is superior to anthropometric variables in predicting the size of 4-stranded hamstring autografts used in ACL reconstruction.
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Affiliation(s)
- Lynn Thwin
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
| | - Sean Wl Ho
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
| | | | - Wei Yang Lim
- Department of Diagnostic Radiology, Tan Tock Seng Hospital, Singapore
| | - Keng Thiam Lee
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
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Rothrauff BB, Jorge A, de Sa D, Kay J, Fu FH, Musahl V. Anatomic ACL reconstruction reduces risk of post-traumatic osteoarthritis: a systematic review with minimum 10-year follow-up. Knee Surg Sports Traumatol Arthrosc 2020; 28:1072-1084. [PMID: 31471726 DOI: 10.1007/s00167-019-05665-2] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/05/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE To systematically review the literature for radiographic prevalence of osteoarthritis (OA) at a minimum of 10 years following anterior cruciate ligament (ACL) reconstruction (ACLR) with anatomic vs. non-anatomic techniques. It was hypothesized that the incidence of OA at long-term follow-up would be lower following anatomic compared to non-anatomic ACLR. METHODS A systematic review was performed by searching PubMed, MEDLINE, EMBASE, and the Cochrane Library, for studies reporting OA prevalence by radiographic classification scales at a minimum of 10 years following ACLR with autograft. Studies were categorized as anatomic if they met or exceeded a score of 8 according the Anatomic ACL Reconstruction Scoring Checklist (AARSC), while those with a score less than 8 were categorized as non-anatomic/non-specified. Secondary outcomes included graft failure and measures of knee stability (KT-1000, Pivot Shift) and functional outcomes [Lysholm, Tegner, subjective and objective International Knee Documentation Committee (IKDC) scores]. OA prevalence on all radiographic scales was recorded and adapted to a normalized scale. RESULTS Twenty-six studies were included, of which 5 achieved a score of 8 on the AARSC. Using a normalized OA classification scale, 87 of 375 patients (23.2%) had diagnosed OA at a mean follow-up of 15.3 years after anatomic ACLR and 744 of 1696 patients (43.9%) had OA at mean follow-up of 15.9 years after non-anatomic/non-specified ACLR. The AARSC scores were 9.2 ± 1.3 for anatomic ACLR and 5.1 ± 1.1 for non-anatomic/non-specified ACLR. Secondary outcomes were relatively similar between techniques but inconsistently reported. CONCLUSIONS This study showed that anatomic ACLR, defined as an AARSC score ≥ 8, was associated with lower OA prevalence at long-term follow-up. Additional studies reporting long-term outcomes following anatomic ACLR are needed, as high-level studies of anatomic ACLR are lacking. The AARSC is a valuable resource in performing and evaluating anatomic ACLR. Anatomic ACLR, as defined by the AARSC, may reduce the long-term risk of post-traumatic OA following ACL injury to a greater extent than non-anatomic ACLR. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Benjamin B Rothrauff
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, 15203, USA
| | - Ahmed Jorge
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, 15203, USA
| | - Darren de Sa
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, 15203, USA
| | - Jeffrey Kay
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Freddie H Fu
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, 15203, USA
| | - 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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Ishibashi Y, Adachi N, Koga H, Kondo E, Kuroda R, Mae T, Uchio Y. Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of anterior cruciate ligament injury - Secondary publication. J Orthop Sci 2020; 25:6-45. [PMID: 31843222 DOI: 10.1016/j.jos.2019.10.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 10/12/2019] [Accepted: 10/16/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND This clinical guideline presents recommendations for the management of patients with anterior cruciate ligament (ACL) injury, endorsed by the Japanese Orthopaedic Association (JOA) and Japanese Orthopaedic Society of Knee, Arthroscopy and Sports Medicine (JOSKAS). METHODS The JOA ACL guideline committee revised the previous guideline based on "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which proposed a desirable method for preparing clinical guidelines in Japan. Furthermore, the importance of "the balance of benefit and harm" was also emphasized. This guideline consists of 21 clinical questions (CQ) and 23 background questions (BQ). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design. RESULTS We evaluated the objectives and results of each study in order to make a decision on the level of evidence so as to integrate the results with our recommendations for each CQ. For BQ, the guideline committee proposed recommendations based on the literature. CONCLUSIONS This guideline is intended to be used by physicians, orthopedic surgeons, physical therapists, and athletic trainers managing ACL injuries. We hope that this guideline is useful for appropriate decision-making and improved management of ACL injuries.
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Affiliation(s)
- Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Japan.
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Eiji Kondo
- Centre for Sports Medicine, Hokkaido University Hospital, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
| | - Tatsuo Mae
- Department of Sports Medical Biomechanics, Osaka University Graduate School of Medicine, Japan
| | - Yuji Uchio
- Department of Orthopaedic Surgery, Shimane University School of Medicine, Japan
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9
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Lie MM, Risberg MA, Storheim K, Engebretsen L, Øiestad BE. What's the rate of knee osteoarthritis 10 years after anterior cruciate ligament injury? An updated systematic review. Br J Sports Med 2019; 53:1162-1167. [PMID: 30936063 DOI: 10.1136/bjsports-2018-099751] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND This updated systematic review reports data from 2009 on the prevalence, and risk factors, for knee osteoarthritis (OA) more than 10 years after anterior cruciate ligament (ACL) tear. METHODS We systematically searched five databases (PubMed, EMBASE, AMED, Cinahl and SPORTDiscus) for prospective and retrospective studies published after 1 August 2008. Studies were included if they investigated participants with ACL tear (isolated or in combination with medial collateral ligament and/or meniscal injuries) and reported symptomatic and/or radiographic OA at a minimum of 10 years postinjury. We used a modified version of the Downs and Black checklist for methodological quality assessment and narrative synthesis to report results. The study protocol was registered in PROSPERO. RESULTS Forty-one studies were included. Low methodological quality was revealed in over half of the studies. At inclusion, age ranged from 23 to 38 years, and at follow-up from 31 to 51 years. Sample sizes ranged from 18 to 780 participants. The reported radiographic OA prevalence varied between 0% and 100% >10 years after injury, regardless of follow-up time. The studies with low and high methodological quality reported a prevalence of radiographic OA between 0%-100% and 1%-80%, respectively. One study reported symptomatic knee OA for the tibiofemoral (TF) joint (35%), and one study reported symptomatic knee OA for the patellofemoral (PF) joint (15%). Meniscectomy was the only consistent risk factor determined from the data synthesis. CONCLUSION Radiographic knee OA varied between 0% and 100% in line with our previous systematic review from 2009. Symptomatic and radiographic knee OA was differentiated in two studies only, with a reported symptomatic OA prevalence of 35% for the TF joint and 15% for PF joint. Future cohort studies need to include measurement of symptomatic knee OA in this patient group. PROSPERO REGISTRATION NUMBER CRD42016042693.
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Affiliation(s)
- Marthe Mehus Lie
- Institute of Physiotherapy, OsloMet - Oslo Metropolitan University, Oslo, Norway
| | - May Arna Risberg
- Department of Sport Medicine, Norwegian School of Sport Sciences, Oslo, Norway.,Division of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Kjersti Storheim
- Institute of Physiotherapy, OsloMet - Oslo Metropolitan University, Oslo, Norway.,Research and Communication unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
| | - Lars Engebretsen
- Division of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway.,Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
| | - Britt Elin Øiestad
- Institute of Physiotherapy, OsloMet - Oslo Metropolitan University, Oslo, Norway
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10
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Filbay SR, Grindem H. Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture. Best Pract Res Clin Rheumatol 2019; 33:33-47. [PMID: 31431274 PMCID: PMC6723618 DOI: 10.1016/j.berh.2019.01.018] [Citation(s) in RCA: 214] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Anterior cruciate ligament (ACL) rupture occurs most commonly in young and active individuals and can have negative long-term physical and psychological impacts. The diagnosis is made with a combination of patient's history, clinical examination, and, if appropriate, magnetic resonance imaging. The objectives of management are to restore knee function, address psychological barriers to activity participation, prevent further injury and osteoarthritis, and optimize long-term quality of life. The three main treatment options for ACL rupture are (1) rehabilitation as first-line treatment (followed by ACL reconstruction (ACLR) in patients, who develop functional instability), (2) ACLR and post-operative rehabilitation as the first-line treatment, and (3) pre-operative rehabilitation followed by ACLR and post-operative rehabilitation. We provide practical recommendations for informing and discussing management options with patients, and describe patient-related factors associated with a worse ACL-rupture outcome. Finally, we define evidence-based rehabilitation and present phase-specific rehabilitation recommendations and criteria to inform return to sport decisions.
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Affiliation(s)
- Stephanie R Filbay
- Arthritis Research UK Centre for Sport, Exercise and Osteoarthritis, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, OX3 7LD, UK.
| | - Hege Grindem
- Oslo Sport Trauma Research Center, Department of Sports Medicine, Norwegian School of Sport Sciences, PB 4014 Ullevål Stadion, Oslo, 0806, Norway.
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11
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Winnisch M, Tiefenboeck TM, Steiger M, Komjati M, Hofbauer M, Kdolsky R. Long-term results after primary augmented repair of proximal tears of the anterior cruciate ligament with the Kennedy-LAD - Does it work? Knee 2018; 25:1115-1121. [PMID: 30193977 DOI: 10.1016/j.knee.2018.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 05/10/2018] [Accepted: 08/13/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of this study was to objectively evaluate the clinical functionality of the knee joint 30 years after surgical augmentation of the ACL with the "Kennedy Ligament Augmentation Device ®" (Kennedy LAD®). METHODS The patient collective consisted of 41 patients with an average age of 59.51 years (±10.18 standard deviation). Included were all patients treated operatively with a Kennedy LAD® augmented reattachment of the ACL at the Department of Trauma Surgery between 1983 and 1985. The state of the knee joint was evaluated with the following measures: Knee injury and Osteoarthritis Outcome Score, Lysholm Score, Short Form (36) Health Survey, International Knee Documentation Committee Score (IKDC, objective + subjective form) and Tegner Activity Scale. RESULTS Seven patients (17%) sustained a re-rupture of the Kennedy LAD® augmented ACL after a mean time of 16.28 years. Five of them underwent revision surgery. Another four patients (9.76%) showed an ACL insufficiency in clinical examination. The average IKDC Score was 74.14 ± 16.62, the average Lysholm Score was 86.83 ± 14.10, the average Tegner Activity Scale was 4.34 ± 1.11, and the average Knee injury and Osteoarthritis Outcome Score was 86.25 ± 11.64 at final follow-up. The mean Kellgren Lawrence Score of the operated knee was 2 ± 0.71. CONCLUSION An overall good outcome 30 years after primary ACL augmented repair with the Kennedy LAD® with an implant survival rate of 73% could be reached. These results therefore support the trend of ACL augmentation in selected cases. LEVEL OF EVIDENCE Retrospective study, Level IV.
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Affiliation(s)
- M Winnisch
- Department of Orthopedics and Trauma Surgery, Division of Trauma Surgery, Medical University of Vienna, Austria
| | - T M Tiefenboeck
- Department of Orthopedics and Trauma Surgery, Division of Trauma Surgery, Medical University of Vienna, Austria.
| | - M Steiger
- Department of Orthopedics and Trauma Surgery, Division of Trauma Surgery, Medical University of Vienna, Austria
| | - M Komjati
- Department of Orthopaedics, Sacred Heart Hospital of Jesus, Vienna, Austria
| | - M Hofbauer
- Department of Orthopedics and Trauma Surgery, Division of Trauma Surgery, Medical University of Vienna, Austria
| | - R Kdolsky
- Department of Orthopedics and Trauma Surgery, Division of Trauma Surgery, Medical University of Vienna, Austria
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12
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Liu C, Wang Y, Li Z, Li J, Zhang H, Fu Y, Zhang K. Tibiofemoral joint contact area and stress after single-bundle anterior cruciate ligament reconstruction with transtibial versus anteromedial portal drilling techniques. J Orthop Surg Res 2018; 13:247. [PMID: 30286774 PMCID: PMC6172839 DOI: 10.1186/s13018-018-0956-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 09/25/2018] [Indexed: 02/07/2023] Open
Abstract
Background During single-bundle ACLR, femoral tunnel location plays an important role in restoring the intact knee mechanisms, whereas malplacement of the tunnel was cited as the most common cause of knee instability. The objective of this study is to evaluate, objectively, the tibiofemoral contact area and stress after single-bundle (SB) anterior cruciate ligament reconstruction (ACLR) with femoral tunnel positions drilled by transtibial (TT) or anteromedial (AM) portal techniques. Methods Seven fresh human cadaveric knees underwent ACLR by the use of TT or AM portal techniques in a randomized order. These specimens were reused for ACL-R (TT and AM). The tibiofemoral contact area and stresses were gauged by an electronic stress-sensitive film inserted into the joint space. The knee was under the femoral axial compressive load of 1000 N using a biomechanics testing machine at 0°, 10°, 20°, and 30° of flexion. Three conditions were compared: (1) intact ACL, (2) ACLR by the use of the TT method, and (3) ACLR by the use of the AM portal method. Results Compared with AM portal ACL-reconstructed knees, a significantly decreased tibiofemoral contact area on the medial compartment was detected in the TT ACL-reconstructed knees at 20°of knee flexion (P = .047). Compared with the intact group, the TT ACLR group showed a higher mean stress at 20° and 30° of flexion on the medial compartments (P = .001, P = .003, respectively), while the AM portal ACLR group showed no significant differences at 30° of flexion (P = .073). The TT ACLR group also showed a higher mean maximum stress at 20° of flexion on the medial compartments (P = .047), while the AM portal ACLR group showed no significant differences at this angle(P = .319). Discussion The alternation of the tibiofemoral joint contact area and stress in reconstructed knees may be caused by the mismatch of the tibiofemoral joint during knee movement procedures compared with intact knees. Conclusions SB ACLR by the use of the AM portal method and TT method both alter the tibiofemoral contact area and stress when compared with the intact knee. When compared with the TT technique, ACLR by the AM portal technique more closely restores the intact tibiofemoral contact area and stress at low flexion angles.
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Affiliation(s)
- Chunhui Liu
- Department of Orthopedics, General Hospital of PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Yingpeng Wang
- School of Biomedical Engineering, Capital Medical University, Beijing, 100069, China
| | - Zhongli Li
- Department of Orthopedics, General Hospital of PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China.
| | - Ji Li
- Department of Orthopedics, General Hospital of PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Hao Zhang
- Department of Orthopedics, General Hospital of PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Yangmu Fu
- Department of Orthopedics, General Hospital of PLA, No. 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Kuan Zhang
- School of Biomedical Engineering, Capital Medical University, Beijing, 100069, China
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13
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Ponzo A, Monaco E, Basiglini L, Iorio R, Caperna L, Drogo P, Conteduca F, Ferretti A. Long-Term Results of Anterior Cruciate Ligament Reconstruction Using Hamstring Grafts and the Outside-In Technique: A Comparison Between 5- and 15-Year Follow-up. Orthop J Sports Med 2018; 6:2325967118792263. [PMID: 31457062 PMCID: PMC6700944 DOI: 10.1177/2325967118792263] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Increased femoral tunnel widening and weakness of the hamstring muscles postoperatively have been described as potential adverse events after anterior cruciate ligament (ACL) reconstruction (ACLR) with a hamstring graft. Meniscectomy and cartilage lesions are important factors for the development of degenerative osteoarthritis. Purpose: To compare 15-year follow-up data with 5-year follow-up data from the same cohort of patients after ACLR with a hamstring autograft using an outside-in technique. Study Design: Case series; Level of evidence, 4. Methods: A total of 72 patients who underwent anatomic ACLR with a quadruple hamstring graft and an outside-in technique were selected for this prospective study. Patients were reviewed at a minimum follow-up of 15 years. Results were compared with the same series of patients previously reviewed at 5 years after surgery. Lysholm, International Knee Documentation Committee (IKDC), and Tegner scores as well as KT-1000 arthrometer measurements were obtained at final follow-up. Comparative weightbearing radiographs were obtained and analyzed according to the Fairbank, Kellgren-Lawrence, and IKDC classifications and used for the tunnel evaluation. Results: No significant difference was detected on the subjective evaluation. Objectively, patients categorized as A or B according to the IKDC score were not significantly different at 5 and 15 years (P < .01). A KT-1000 arthrometer side-to-side manual maximum difference >5 mm, a pivot shift >2+, any giving-way episode, and ACL revision surgery were considered as failures, and these were noted in 6 patients at 5 years and 6 patients at 15 years. The radiological evaluation at 15 years showed a higher rate of osteoarthritis in 2 of 3 radiological scales used in the study compared with results at 5-year follow-up (P < .01). At 15-year follow-up, there was a statistically significant reduction in the mean tibial tunnel diameter (P < .01). Conclusion: Endoscopic single-bundle ACLR using hamstring grafts and an outside-in technique demonstrated good results at 15-year follow-up in terms of subjective, objective, and radiographic evaluations. As compared with 5-year follow-up, clinical results remained stable both subjectively and objectively. However, a progression of osteoarthritis changes was observed, especially in patients in whom meniscectomy had been performed.
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Affiliation(s)
- Antonio Ponzo
- Kirk Kilgour Sports Traumatology Center, Sant'Andrea Hospital, La Sapienza University of Rome, Rome, Italy
| | - Edoardo Monaco
- Kirk Kilgour Sports Traumatology Center, Sant'Andrea Hospital, La Sapienza University of Rome, Rome, Italy
| | - Luca Basiglini
- Kirk Kilgour Sports Traumatology Center, Sant'Andrea Hospital, La Sapienza University of Rome, Rome, Italy
| | - Raffaele Iorio
- Kirk Kilgour Sports Traumatology Center, Sant'Andrea Hospital, La Sapienza University of Rome, Rome, Italy
| | - Ludovico Caperna
- Kirk Kilgour Sports Traumatology Center, Sant'Andrea Hospital, La Sapienza University of Rome, Rome, Italy
| | - Piergiorgio Drogo
- Kirk Kilgour Sports Traumatology Center, Sant'Andrea Hospital, La Sapienza University of Rome, Rome, Italy
| | - Fabio Conteduca
- Kirk Kilgour Sports Traumatology Center, Sant'Andrea Hospital, La Sapienza University of Rome, Rome, Italy
| | - Andrea Ferretti
- Kirk Kilgour Sports Traumatology Center, Sant'Andrea Hospital, La Sapienza University of Rome, Rome, Italy
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14
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Mathis DT, Hirschmann A, Falkowski AL, Kiekara T, Amsler F, Rasch H, Hirschmann MT. Increased bone tracer uptake in symptomatic patients with ACL graft insufficiency: a correlation of MRI and SPECT/CT findings. Knee Surg Sports Traumatol Arthrosc 2018; 26:563-573. [PMID: 28551834 DOI: 10.1007/s00167-017-4588-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 05/23/2017] [Indexed: 12/16/2022]
Abstract
PURPOSE Magnetic resonance imaging (MRI) and single-photon emission computerised tomography/computerised tomography (SPECT/CT) are used as diagnostic tools in symptomatic patients after reconstruction of the anterior cruciate ligament (ACL). The benefit of SPECT/CT in comparison with MRI is under debate. The purpose of this study was to investigate whether and how bone tracer uptake (BTU) intensity and distribution in SPECT/CT correlate with MRI findings in symptomatic patients after ACL reconstruction. METHODS Twenty-nine patients (male:female = 22:7, mean age ± SD 26 ± 10 years) with symptoms of pain and instability after ACL reconstruction were retrospectively investigated using prospectively acquired SPECT/CT and MRI. On MRI graft tear, graft signal intensity, bone marrow oedema, tunnel cyst formation, roof impingement, roof osteophytes, local arthrofibrosis, joint effusion and synovial thickness were analysed by two readers blinded to the BTU results. BTU was anatomically localised and volumetrically quantified. Spearman's rho test was used for correlation of BTU in SPECT/CT and MRI findings (p < 0.05). RESULTS SPECT/CT showed increased femoral and tibial BTU in patients with MRI-confirmed graft tear, signal hyperintensity of the intraarticular graft section, joint effusion, synovial thickening, roof osteophytes and bone marrow oedema. Cyst formation in the femoral tunnel results in significantly reduced BTU in femur and tibia. No correlation of increased BTU was found for graft impingement and graft arthrofibrosis. CONCLUSIONS Bone tracer uptake in SPECT/CT and defined MRI findings in symptomatic patients after ACL reconstruction were correlated. Both imaging modalities have a definite role in post-operative diagnostic and have established their value in those patients. This study provides a better understanding of the clinical value of SPECT/CT versus MRI in the clinical decision-making process. SPECT/CT provides a window into the in vivo loading of the joint as well as bone remodelling and graft incorporation process. In addition, ACL graft insufficiency can be detected by increased BTU. LEVEL OF EVIDENCE Retrospective cohort study, Level III.
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Affiliation(s)
- Dominic T Mathis
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101, Bruderholz, Switzerland
| | - Anna Hirschmann
- Department of Radiology and Nuclear Medicine, University of Basel Hospital, 4031, Basel, Switzerland
| | - Anna L Falkowski
- Department of Radiology and Nuclear Medicine, University of Basel Hospital, 4031, Basel, Switzerland
| | - Tommi Kiekara
- Medical Imaging Centre, Tampere University Hospital, 33521, Tampere, Finland
| | | | - Helmut Rasch
- Institute of Radiology and Nuclear Medicine, Kantonsspital Baselland, 4101, Bruderholz, Switzerland
| | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101, Bruderholz, Switzerland. .,University of Basel, Basel, Switzerland.
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15
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Riccardo C, Fabio C, Pietro R. Knee Osteoarthritis after Reconstruction of Isolated Anterior Cruciate Ligament Injuries: A Systematic Literature Review. JOINTS 2017; 5:39-43. [PMID: 29114629 PMCID: PMC5672858 DOI: 10.1055/s-0037-1601409] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Purpose
The aim of this review was to analyze the current literature on osteoarthritic evolution of knees without any combined meniscal or ligament lesions undergoing anterior cruciate ligament (ACL) reconstruction.
Methods
A PubMed/MEDLINE research was performed using the following keywords: “Anterior Cruciate Ligament Reconstruction” [Mesh] AND “Osteoarthritis, Knee” [Mesh]. Only English language literature and articles published after 2005 were included. Studies including concomitant meniscal tears, posterior cruciate or collateral ligament injuries, previous surgery in the affected knees, infections, osteochondral defects, loose bodies, synovial plica syndrome, and posteromedial or posterolateral corner injuries were not considered in this review.
Results
Twelve studies were selected. These papers included 892 patients (mean age at the time of surgery was 22.3 years), with an average follow-up of 11 years. Imaging at follow-up was obtained with standard radiographs in nine studies, magnetic resonance imaging (MRI) in one study, and both X-rays and MRI in two studies. Eight studies reported osteoarthritic evolution, with different prevalence.
Conclusion
Only few high-quality studies focused on these specific patients have been published. When reconstructed, isolated ACL-deficient knees have a low risk of osteoarthritic evolution, but mild signs of joint degeneration are reported by the current literature.
Level of Evidence
Level IV, systematic review of level I to level IV studies.
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Affiliation(s)
- Compagnoni Riccardo
- ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini - CTO, Milan, Italy
| | - Catani Fabio
- Department of Orthopaedic Surgery, Azienda Ospedaliero-Universitaria Policlinico di Modena, University of Modena and Reggio-Emilia, Modena, Italy
| | - Randelli Pietro
- ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini - CTO, Milan, Italy.,Dipartimento di Scienze Biomediche per la Salute, University of Milan, Milan, Italy
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16
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Goodwillie AD, Shah SS, McHugh MP, Nicholas SJ. The Effect of Postoperative KT-1000 Arthrometer Score on Long-Term Outcome After Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2017; 45:1522-1528. [PMID: 28277739 DOI: 10.1177/0363546517690525] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Many long-term studies have looked at outcomes after anterior cruciate ligament reconstruction (ACLR), but none have correlated long-term outcomes with postoperative laxity greater than 5 mm. It has been stated previously that more than 5 mm of postoperative graft laxity constituted a procedural failure. PURPOSE To directly compare tight grafts (<3 mm) and loose grafts (>5 mm) to determine the effect of graft laxity, as measured by KT-1000 arthrometer, after ACLR on long-term clinical outcomes. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS The study included 171 consecutive patients who had undergone transtibial bone-patellar tendon-bone ACLR between 1992 and 1998. At 6, 12, and 24 months postoperatively (the immediate postoperative period), patients were evaluated. Group A included patients with a maximal side-to-side (STS) difference in the immediate postoperative period of less than 3 mm (tight grafts), and group B included patients with a maximal STS difference of greater than 5 mm (loose grafts). Any patient with a history of ipsilateral or contralateral ACLR or ACL injury, meniscectomy, or cartilage restoration was excluded. Patients were prospectively followed to long-term follow-up, when a telephone interview was conducted regarding knee function and to document Lysholm, Tegner, Knee injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) subjective outcome scores. RESULTS Eighty-seven patients met inclusion criteria: 66 tight grafts (group A) and 21 loose grafts (group B). The mean ± SD time to follow-up was 16.3 ± 1.5 years in group A (n = 46) and 16.8 ± 1.3 years in group B (n = 15). Tegner ( P = .77), Lysholm ( P = .85), KOOS ( P = .96), and IKDC ( P = .42) were found to have no statistically significant difference between groups at long-term follow-up. Both Tegner and Lysholm scores significantly improved in tight and loose grafts in the immediate postoperative period as well as at long-term follow-up compared with preoperatively. There were 2 ACL revisions in group A and none in group B. Eleven of 46 patients (24%) in group A required subsequent procedures versus 1 of 15 patients (6.7%) in group B ( P = .146). CONCLUSION Postoperative laxity of greater than 5 mm STS difference as measured by KT-1000 arthrometer does not appear to place patients at a worse clinical outcome at long-term follow-up, nor does it lead to significantly more subsequent procedures. In addition, transtibial ACLR can provide excellent clinical results at long-term follow-up.
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Affiliation(s)
- Andrew D Goodwillie
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, New York, USA
| | - Sarav S Shah
- Department of Orthopaedic Surgery, Northwell Health Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Malachy P McHugh
- Nicholas Institute of Sports Medicine and Athletic Trauma, Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, New York, USA
| | - Stephen J Nicholas
- Nicholas Institute of Sports Medicine and Athletic Trauma, Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, New York, USA
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17
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Parkinson B, Robb C, Thomas M, Thompson P, Spalding T. Factors That Predict Failure in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2017; 45:1529-1536. [PMID: 28296429 DOI: 10.1177/0363546517691961] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anatomic graft placement in anterior cruciate ligament (ACL) reconstruction has become the preferred technique for many surgeons. The predictive factors for graft failure in anatomic single-bundle ACL reconstruction are relatively unknown. PURPOSE To determine the risk factors for graft failure and the relative importance of those factors in anatomic single-bundle ACL reconstruction. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS All primary anatomic ACL reconstructions undertaken at a single institution over a 2-year period were evaluated for subjective and objective measures of graft failure. Risk factors evaluated included time since ACL rupture, age, sex, body mass index, intact or deficient medial and lateral meniscus, meniscal repair, hamstring graft size, and femoral and tibial tunnel position as assessed by 3D computed tomography (CT) scan. The significant factors predicting failure and the relative importance of those factors were determined. RESULTS At a median follow-up of 26 months, 123 patients were available for analysis. Ninety-seven patients underwent postoperative 3D CT for tunnel positions, including all 20 cases with graft failure. The significant predictors of graft failure were medial meniscal deficiency (hazard ratio [HR] 15.1; 95% CI, 4.7-48.5; P < .001), lateral meniscal deficiency (HR 9.9; 95% CI, 3-33; P < .001), shallow nonanatomic femoral tunnel positioning (HR 4.3; 95% CI, 1.6-11.6; P = .004), and younger patient age (HR 0.9; 95% CI, 0.9-1; P = .008). CONCLUSION Meniscal deficiency is the most significant factor to predict graft failure in single-bundle anatomic ACL reconstruction. Shallow nonanatomic femoral tunnel positioning and younger patient age are additional risk factors for failure, but their relative importance is less.
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Affiliation(s)
- Ben Parkinson
- Department of Orthopaedics, Cairns Hospital, Cairns, Queensland, Australia
| | - Curtis Robb
- Warrington and Halton NHS Trust, Warrington, UK
| | - Michael Thomas
- University Hospitals Coventry and Warwickshire (UHCW), Coventry, UK
| | - Peter Thompson
- University Hospitals Coventry and Warwickshire (UHCW), Coventry, UK
| | - Tim Spalding
- University Hospitals Coventry and Warwickshire (UHCW), Coventry, UK
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18
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Filbay SR, Roos EM, Frobell RB, Roemer F, Ranstam J, Lohmander LS. Delaying ACL reconstruction and treating with exercise therapy alone may alter prognostic factors for 5-year outcome: an exploratory analysis of the KANON trial. Br J Sports Med 2017; 51:1622-1629. [PMID: 28515057 PMCID: PMC5754848 DOI: 10.1136/bjsports-2016-097124] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2017] [Indexed: 12/29/2022]
Abstract
Aim Identify injury-related, patient-reported and treatment-related prognostic factors for 5-year outcomes in acutely ACL-ruptured individuals managed with early reconstruction plus exercise therapy, exercise therapy plus delayed reconstruction or exercise therapy alone. Methods Exploratory analysis of the Knee Anterior Cruciate Ligament, Nonsurgical versus Surgical Treatment (KANON) trial (ISRCTN84752559). Relationships between prognostic factors (baseline cartilage, meniscus and osteochondral damage, baseline extension deficit, baseline patient-reported outcomes, number of rehabilitation visits, graft/contralateral ACL rupture, non-ACL surgery and ACL treatment strategy) and 5-year Knee Injury and Osteoarthritis Outcome Score (KOOS) pain, symptoms, sport/recreation and quality of life (QOL) scores were explored using multivariable linear regression. Estimates were adjusted for sex, age, body mass index, preinjury activity level, education and smoking. Results For all participants (n=118), graft/contralateral ACL rupture, non-ACL surgery and worse baseline 36-item Short-Form Mental Component Scores were associated with worse outcomes. Treatment with exercise therapy alone was a prognostic factor for less knee symptoms compared with early reconstruction plus exercise therapy (regression coefficient 10.1, 95% CI 2.3 to 17.9). Baseline meniscus lesion was associated with worse sport/recreation function (−14.4, 95% CI −27.6 to –1.3) and osteochondral lesions were associated with worse QOL (−12.3, 95% CI −24.3 to –0.4) following early reconstruction plus exercise therapy. In the same group, undergoing additional non-ACL surgery and worse baseline KOOS scores were prognostic for worse outcome on all KOOS subscales. Following delayed reconstruction, baseline meniscus damage was a prognostic factor for less pain (14.3, 95% CI 0.7 to 27.9). Following exercise therapy alone, undergoing non-ACL surgery was prognostic for worse pain. Conclusions Treatment-dependent differences in prognostic factors for 5-year outcomes may support individualised treatment after acute ACL rupture in young active individuals. Trial registration number Current Controlled Trials ISRCTN84752559.
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Affiliation(s)
- Stephanie R Filbay
- Arthritis Research UK Centre for Sport, Exercise and Osteoarthritis, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ewa M Roos
- Research Unit for Musculoskeletal Function and Physiotherapy, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Richard B Frobell
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Faculty of Medicine, Lund, Sweden
| | - Frank Roemer
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Faculty of Medicine, Lund, Sweden.,Department of Radiology, University of Erlangen-Nuremberg, Erlangen, Germany.,Quantitative Imaging Center (QIC), Department of Radiology, Boston University School of Medicine, Boston, Massachusetts, USA
| | | | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Faculty of Medicine, Lund, Sweden
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19
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Lee SM, Yoon KH, Lee SH, Hur D. The Relationship Between ACL Femoral Tunnel Position and Postoperative MRI Signal Intensity. J Bone Joint Surg Am 2017; 99:379-387. [PMID: 28244908 DOI: 10.2106/jbjs.16.00241] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to find the ideal femoral tunnel position in single-bundle anterior cruciate ligament (ACL) reconstruction using three-dimensional computed tomography (3D-CT) by comparing clinical scores, stability of the knee joint, and graft signal intensity on follow-up magnetic resonance imaging (MRI). We hypothesized that positioning the femoral tunnel near the anteromedial bundle or center would lead to better results in terms of clinical outcomes and graft signal intensity on follow-up MRI than would positioning the tunnel near the posterolateral bundle. METHODS Two hundred patients underwent arthroscopic single-bundle ACL reconstruction with a soft-tissue graft; all patients had the same surgeon, surgical technique (anteromedial transportal technique), and rehabilitation protocol. Each patient underwent 3D-CT within 1 week after the operation and MRI at 1 year after the operation. Outcomes were evaluated in terms of clinical scores and the stability of the knee joint. We classified patients into three groups based on the femoral tunnel position: the anteromedial position group, the posterolateral position group, and the center position group. We evaluated graft signal intensity on follow-up MRI. RESULTS This study included 77 patients: 25 patients in the anteromedial position group, 15 patients in the posterolateral position group, and 33 patients in the center position group. Four patients had an eccentric tunnel position and were excluded. The 3 groups did not differ significantly (p > 0.05) in preoperative demographic characteristics. There were no significant differences (p > 0.05) between groups in clinical outcomes. However, patients in the anteromedial position group and in the center position group had better graft signal intensity on follow-up MRI than those in the posterolateral position group. CONCLUSIONS Positioning the femoral tunnel near the anteromedial bundle and center led to better graft signal intensity on follow-up MRI in anatomic single-bundle ACL reconstruction than did positioning the femoral tunnel near the posterolateral bundle. There were no differences in clinical scores or stability of the knee joint among the three groups. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Se Min Lee
- 1Department of Orthopaedic Surgery, Graduate School (S.M.L.), College of Medicine (K.H.Y. and D.H.), Kyung Hee University, Seoul, South Korea 2Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
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20
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Mayr HO, Brandt CM, Weig T, Koehne M, Bernstein A, Suedkamp NP, Hube R, Stoehr A. Long-term Results of Arthroscopic Arthrolysis for Arthrofibrosis After Anterior Cruciate Ligament Reconstruction. Arthroscopy 2017; 33:408-414. [PMID: 27789072 DOI: 10.1016/j.arthro.2016.07.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 07/14/2016] [Accepted: 07/22/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE The current study was conducted to evaluate the long-term clinical and radiological outcomes after arthroscopic arthrolysis for arthrofibrosis after anterior cruciate ligament reconstruction (ACLR). METHODS All patients treated with arthrolysis between 1990 and 1998 were included. Indication was arthrofibrosis in at least one knee compartment or a cyclops syndrome limiting range of motion (ROM) by > 5° of extension deficit and 15° of flexion deficit. International Knee Documentation Committee (IKDC) 2000 subjective and objective, Lysholm score, and x-ray evaluation were documented. Statistical analysis and power calculation were performed (P < .05). RESULTS One hundred forty-one patients (follow-up, 71%) were examined at a mean of 18.7 ± 2.6 years after arthroscopic arthrolysis. Mean IKDC 2000 score was 79.49 ± 14.32. IKDC objective was normal in 0%, nearly normal in 6%, abnormal in 56%, and severely abnormal in 38%. One hundred percent of patients showed more than grade II osteoarthritis. ROM improvement after arthrolysis did not change significantly compared with midterm results (t = 4.5 years). Patients with persisting motion deficits (P = .02) and after medial meniscus resection (P < .001) at time of ACLR showed significantly greater progression of osteoarthritis in comparison with patients without these additional disorders. In case of arthrolysis later than 1 year after ACLR, a more severe osteoarthritis grade (4% vs 20% grade III; P = .038) and a lower jump distance (IKDC: 61% A, 25% B vs 39% A, 41% B; P = .028) were obvious compared with patients who underwent arthrolysis within the first year after ACLR. CONCLUSIONS Long-term motion improvement can be achieved by arthrolysis. Persistent loss of motion resulted in a higher degree of osteoarthritis in the study population. Early intervention seems advisable as patients with arthrolysis later than 1 year after index surgery reached worse IKDC objective grading. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Hermann O Mayr
- Department of Orthopedic and Trauma Surgery, Albert Ludwig University of Freiburg, Germany.
| | | | - Thomas Weig
- Department of Anaesthesiology, Munich University Hospital, Germany
| | | | - Anke Bernstein
- Department of Orthopedic and Trauma Surgery, Albert Ludwig University of Freiburg, Germany
| | - Norbert P Suedkamp
- Department of Orthopedic and Trauma Surgery, Albert Ludwig University of Freiburg, Germany
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Ettinger M, Etter F, Calliess T, Bohnsack M, Becher C. Long term results of bone-patella-tendon-bone ACL reconstruction. J Orthop 2016; 14:91-94. [PMID: 27829732 DOI: 10.1016/j.jor.2016.10.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 10/12/2016] [Accepted: 10/16/2016] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND To assess outcomes of bone-patella-tendon-bone ACL-reconstruction at 18 years follow-up. MATERIAL AND METHODS Outcome measures included the IKDC clinical examination form and clinical scores. Radiographs were analyzed to determine the grade of osteoarthritis. RESULTS 69% of the examined patients (n = 54) had a normal/nearly normal knee, 14% were abnormal and 17% severely abnormal with significant improvement (P ≤ 0.001). The mean Lysholm score was 87.7 ± 12.4 and the Tegner activity level was 5 ± 2. Osteoarthritic changes were present in 52%. CONCLUSION BPTB ACL-reconstruction provides a satisfactory outcome with a high incidence of radiographic osteoarthritic changes.
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Affiliation(s)
- Max Ettinger
- Department of Orthopaedic Surgery, Hannover Medical School, Hannover, Germany
| | - Friedel Etter
- Department Orthopaedic and Trauma Surgery, DIAKO, Bremen, Germany
| | - Tilman Calliess
- Department of Orthopaedic Surgery, Hannover Medical School, Hannover, Germany
| | - Michael Bohnsack
- Department Orthopaedic and Trauma Surgery, DIAKO, Bremen, Germany
| | - Christoph Becher
- International Center of Hip-, Knee- and Foot Surgery, ATOS Clinic, Heidelberg, Germany
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22
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Cantin O, Lustig S, Rongieras F, Saragaglia D, Lefèvre N, Graveleau N, Hulet C. Outcome of cartilage at 12years of follow-up after anterior cruciate ligament reconstruction. Orthop Traumatol Surg Res 2016; 102:857-861. [PMID: 27544885 DOI: 10.1016/j.otsr.2016.06.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/05/2016] [Accepted: 06/09/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In cases of chronic anterior laxity, reconstruction of the anterior cruciate ligament (ACL) can slow the development of osteoarthritis. This study was conducted to determine the overall prevalence of osteoarthritis and to identify the risk factors after ACL reconstruction. HYPOTHESIS Meniscus tears, time from injury to surgery, body mass index (BMI), residual laxity, and cartilage lesions influence the progression towards osteoarthritis. MATERIALS AND METHODS This multicenter, retrospective study on the outcome of cruciate ligaments at 12 years of follow-up was conducted within the 2014 SOFCOT Symposium. The cohort included 675 arthroscopic reconstructions of the ACL from January 2002 to December 2003. The clinical evaluation included the objective and subjective IKDC score. Osteoarthritis was analyzed on 589 knee X-rays according to the IKDC classification. The predictive factors of osteoarthritis development studied were age, gender, BMI, time from injury to surgery, activity level, medial or lateral meniscectomy, type of graft, medial or lateral chondropathy, tunnel positioning, and residual laxity. Univariate and multivariate analyses with logistic regression were performed. RESULTS The mean follow-up was 11.9±0.8 years. The subjective IKDC score was 83.7±13. At 12 years, the rate of moderate to severe osteoarthritis l (IKDCC or D) was 19% (16% medial tibiofemoral osteoarthritis, 4% lateral tibiofemoral osteoarthritis, and 2% patellofemoral osteoarthritis). The prognostic factors were age at surgery greater than 34 years (P<0.05), cartilage lesions at surgery (P<0.05), medial or lateral meniscectomy (P<0.05), and residual laxity (P<0.05). CONCLUSIONS This large-scale study identified risk factors for osteoarthritis that should improve the information provided to patients on long-term progression after ACL reconstruction. LEVEL OF EVIDENCE Retrospective cohort study, level IV.
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Affiliation(s)
- O Cantin
- Service de chirurgie orthopédique, centre Albert-Trillat, hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69004 Lyon, France
| | - S Lustig
- Service de chirurgie orthopédique, centre Albert-Trillat, hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69004 Lyon, France.
| | - F Rongieras
- Service de chirurgie orthopédique, hôpital d'instruction des armées Desgenettes, 108, boulevard Pinel, 69003 Lyon, France
| | - D Saragaglia
- Clinique universitaire de chirurgie orthopédique et de traumatologie du sport, hôpital Sud, CHU de Grenoble, avenue de Kimberley, 38130 Échirolles, France
| | - N Lefèvre
- Institut de l'appareil locomoteur Nollet, 75017 Paris, France; Clinique du sport Paris V, 75005 Paris, France
| | - N Graveleau
- Centre de consultation orthopédique et sportive, clinique du sport de Bordeaux-Mérignac, 2, rue Negrevergne, 33700 Mérignac, France
| | - C Hulet
- Département d'orthopédie-traumatologie, Unité Inserm COMETE, UMR U1075, CHU de Caen, avenue Côte-de-Nacre, 14000 Caen, France
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- SoFCOT, 56, rue Boissonade, 75014 Paris, France
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Barber-Westin SD, Noyes FR. Aerobic Physical Fitness and Recreational Sports Participation After Total Knee Arthroplasty. Sports Health 2016; 8:553-560. [PMID: 27644234 PMCID: PMC5089358 DOI: 10.1177/1941738116670090] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Context: Total knee arthroplasty (TKA) is routinely performed in younger patients who desire to be active in fitness and recreational sports. The activities patients can participate in without symptoms and the level of aerobic fitness routinely maintained are important to investigate. Objective: To determine physical activity (PA) and recreational sports resumed after primary TKA, symptoms or limitations with these activities, and the effect of postoperative rehabilitation on achieving fitness and sports goals. Data Sources: A systematic review of the literature from 2005 through 2015 was conducted using the PubMed database. Study Selection: Original investigations that were conducted at least 1 year after primary TKA and reported the percentage of patients who returned to recreational activities or routinely participated in aerobic PA recommended by the American Heart Association (AHA) were included in this study. Study Design: Systematic review. Level of Evidence: Level 4. Data Extraction: Data were extracted as available from 19 eligible studies. Assessment of study quality was rated using the MINORS (Methodological Index for Non-Randomized Studies) instrument. Results: There were 5179 knees (mean age, 67.5 years) followed for a mean 4.8 years postoperatively. Marked variability was present between studies regarding the percentage of patients who resumed recreational activities (34%-100%), most of which were low impact. Only 2 studies used accelerometers to measure PA; these reported a low range (0%-16.5%) of patients who met AHA guidelines. Few studies determined whether symptoms or limitations were experienced during PA. None described rehabilitation exercises or factors that would influence patients’ ability to return to recreational or fitness activities. Conclusion: Little evidence is available regarding the effect of TKA on return to recreational and (objectively measured) aerobic fitness. The extent of symptoms or limitations during PA and the long-term effects of such problems remain unclear. Valid predictions cannot be made on factors that may affect return to recreational sports or other aerobic PA after TKA.
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Affiliation(s)
- Sue D Barber-Westin
- Cincinnati SportsMedicine & Orthopaedic Center-Mercy Health and the Noyes Knee Institute, Cincinnati, Ohio
| | - Frank R Noyes
- Cincinnati SportsMedicine & Orthopaedic Center-Mercy Health and the Noyes Knee Institute, Cincinnati, Ohio
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Dai C, Wang F, Wang X, Wang R, Wang S, Tang S. Arthroscopic single-bundle anterior cruciate ligament reconstruction with six-strand hamstring tendon allograft versus bone-patellar tendon-bone allograft. Knee Surg Sports Traumatol Arthrosc 2016; 24:2915-2922. [PMID: 25763849 DOI: 10.1007/s00167-015-3569-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 03/03/2015] [Indexed: 01/14/2023]
Abstract
PURPOSE The aim of this study was to compare the clinical outcomes of arthroscopic single-bundle anterior cruciate ligament (ACL) reconstruction with six-strand hamstring tendon (HT) allograft versus bone-patellar tendon-bone (BPTB) allograft. METHODS The prospective randomized controlled trial was included 129 patients. Sixty-nine patients received reconstruction with six-strand HT allografts (HT group), whereas 60 patients with BPTB allografts (BPTB group). Outcome assessment included re-rupture findings, International Knee Documentation Committee (IKDC) scores, Lysholm scores, KT-1000 arthrometer, Lachman test, pivot-shift test, range of motion (ROM) and single-leg hop test. RESULTS At a mean follow-up of 52 months, 113 patients (HT group, 61 patients; BPTB group, 52 patients) completed a minimum 4-year follow-up. Four patients in HT group and six in BPTB group experienced ACL re-rupture (6.2 vs. 10.3 %) and received revision surgery. Significant between-group differences were observed in KT-1000 outcomes and pivot-shift test 1 (1.2 ± 1.5 vs. 1.8 ± 1.3, p = 0.025; positive rate 6.5 vs. 18.9 %, p = 0.036), 2 (1.1 ± 1.4 vs. 1.6 ± 1.2, p = 0.044; 8.1 vs. 20.7 %, p = 0.039), 4 (1.1 ± 1.5 vs. 1.7 ± 1.4, p = 0.031; 9.7 vs. 25 %, p = 0.012) years postoperatively. The outcomes between the two groups were comparable in terms of IKDC scores, Lysholm scores, Lachman test, ROM and single-leg hop test. CONCLUSIONS Six-strand HT allograft achieved superior anteroposterior and rotational stability after single-bundle ACL reconstruction. It is a reasonable graft substitute for ACL reconstruction. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Chengliang Dai
- Department of Joint Surgery, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Fei Wang
- Department of Joint Surgery, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.
| | - Xiaomeng Wang
- Department of Joint Surgery, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Ruipeng Wang
- Department of Joint Surgery, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Shengjie Wang
- Department of Joint Surgery, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Shiyu Tang
- Department of Joint Surgery, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
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The difference in clinical outcome of single-bundle anterior cruciate ligament reconstructions with and without remnant preservation: A meta-analysis. Knee 2016; 23:566-74. [PMID: 27198759 DOI: 10.1016/j.knee.2015.07.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Revised: 06/07/2015] [Accepted: 07/24/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aim of this study was to compare the clinical performance and complications between an ACL reconstruction with a remnant-preserving single-bundle technique and a standard single-bundle technique. METHODS A search was performed of RCTs comparing the clinical outcomes and complications of ACL reconstruction with remnant-preserving and standard single-bundle techniques during October 2014. Relevant data were extracted and CONSORT was used to assess the methodological quality. Stata/SE 12.0 was used to perform a meta-analysis of the clinical outcomes. RESULTS Six RCTs were included, with a total of 378 patients: 190 in the remnant-preservation technique group and 188 patients in standard-technique group. Assessing anterior stability, no difference was found between the groups for the KT arthrometer, negative rate of Lachman, and the pivot shift test. Assessing functional outcome, there was no significant difference in IKCD scores and grades or Lysholm score. In terms of complications, the percentage of tibial tunnel enlargement in the group of the remnant-preservation technique was significantly lower, despite no significant difference in the incidence of cyclops lesions. CONCLUSIONS The outcome of single-bundle ACL reconstruction with the remnant-preservation technique is similar to that with the standard technique in terms of anterior stability and functional recovery of the knee. Remnant preservation in ACL reconstruction decreases the percentage of tibial tunnel enlargement. Level of evidence is II.
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Meniscal and Articular Cartilage Predictors of Clinical Outcome After Revision Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2016; 44:1671-9. [PMID: 27161867 PMCID: PMC5467863 DOI: 10.1177/0363546516644218] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstructions. PURPOSE/HYPOTHESIS The purpose of this study was to determine if the prevalence, location, and/or degree of meniscal and chondral damage noted at the time of revision ACL reconstruction predicts activity level, sports function, and osteoarthritis symptoms at 2-year follow-up. The hypothesis was that meniscal loss and high-grade chondral damage noted at the time of revision ACL reconstruction will result in lower activity levels, decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Between 2006 and 2011, a total of 1205 patients who underwent revision ACL reconstruction by 83 surgeons at 52 hospitals were accumulated for study of the relationship of meniscal and articular cartilage damage to outcome. Baseline demographic and intraoperative data, including the International Knee Documentation Committee (IKDC) subjective knee evaluation, Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx activity score, were collected initially and at 2-year follow-up to test the hypothesis. Regression analysis was used to control for age, sex, body mass index, smoking status, activity level, baseline outcome scores, revision number, time since last ACL reconstruction, incidence of having a previous ACL reconstruction on the contralateral knee, previous and current meniscal and articular cartilage injury, graft choice, and surgeon years of experience to assess the meniscal and articular cartilage risk factors for clinical outcomes 2 years after revision ACL reconstruction. RESULTS At 2-year follow-up, 82% (989/1205) of the patients returned their questionnaires. It was found that previous meniscal injury and current articular cartilage damage were associated with the poorest outcomes, with prior lateral meniscectomy and current grade 3 to 4 trochlear articular cartilage changes having the worst outcome scores. Activity levels at 2 years were not affected by meniscal or articular cartilage pathologic changes. CONCLUSION Prior lateral meniscectomy and current grade 3 to 4 changes of the trochlea were associated with worse outcomes in terms of decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery, but they had no effect on activity levels. REGISTRATION NCT00625885.
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Negahi Shirazi A, Chrzanowski W, Khademhosseini A, Dehghani F. Anterior Cruciate Ligament: Structure, Injuries and Regenerative Treatments. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 881:161-86. [PMID: 26545750 DOI: 10.1007/978-3-319-22345-2_10] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Anterior cruciate ligament (ACL) is one of the most vulnerable ligaments of the knee. ACL impairment results in episodic instability, chondral and meniscal injury and early osteoarthritis. The poor self-healing capacity of ACL makes surgical treatment inevitable. Current ACL reconstructions include a substitution of torn ACL via biological grafts such as autograft, allograft. This review provides an insight of ACL structure, orientation and properties followed by comparing the performance of various constructs that have been used for ACL replacement. New approaches, undertaken to induce ACL regeneration and fabricate biomimetic scaffolds, are also discussed.
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Affiliation(s)
- Ali Negahi Shirazi
- School of Chemical and Biomolecular Engineering, University of Sydney, Sydney, NSW, 2006, Australia
| | | | - Ali Khademhosseini
- Center for Biomedical Engineering, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Cambridge, MA, USA.,Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Fariba Dehghani
- School of Chemical and Biomolecular Engineering, University of Sydney, Sydney, NSW, 2006, Australia. .,Department of Bioengineering, University of Sydney, Sydney, NSW, Australia.
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Robb C, Kempshall P, Getgood A, Standell H, Sprowson A, Thompson P, Spalding T. Meniscal integrity predicts laxity of anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2015; 23:3683-90. [PMID: 25217313 DOI: 10.1007/s00167-014-3277-x] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 08/26/2014] [Indexed: 01/14/2023]
Abstract
PURPOSE The aim of this study was to evaluate the incidence of failure of anterior cruciate ligament (ACL) reconstruction and to assess the prognostic factors for such an outcome. METHODS A prospective inception cohort of patients undergoing ACL reconstruction was analysed for failure (patient reported symptoms of rotational instability, a clinically positive pivot shift, MRI or arthroscopy showing ACL graft rupture). Risk factors evaluated included medial and lateral meniscal deficiency, medial and lateral meniscal repair, age, gender, BMI, graft size and time to surgery. Survival analysis was performed using the Kaplan-Meier method. Prognostic factors were assessed using the Cox proportional hazard model to investigate whether covariate risk factors influenced graft survival. RESULTS One hundred and twenty-three patients were available for final analysis at a follow-up of 2 years. Eighteen patients satisfied the criteria of failure (15.4 %). Risk factors for failure were medial meniscal deficiency (hazard ratio 4.5; 95 % CI 1.8-11.5; p = 0.002), or lateral meniscal deficiency (hazard ratio 3.5; 95 % CI 1.3-9.3; p = 0.01). At 2-year follow-up, ACL survival was 94.5 % (95 % CI 89-100) for patients with intact menisci and 69 % (95 % CI 56-86) for those with deficiency of the medial or lateral meniscus (log-rank test p = 0.017). Patients were 4.9 times more likely to fail if they had a deficient medial or lateral meniscus. Those patients who underwent meniscal repair did not demonstrate any increased risk of failure. CONCLUSION Medial and lateral meniscal tears are important prognostic factors that influence the survival of ACL reconstruction. Surgeons should endeavour to repair all meniscal tears associated with ACL reconstruction. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Curtis Robb
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, West Midlands, CV2 2DX, UK.
| | - Peter Kempshall
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, West Midlands, CV2 2DX, UK
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, 3M Centre, University of Western Ontario, London, Ontario, Canada
| | - Hayley Standell
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, West Midlands, CV2 2DX, UK
| | - Andrew Sprowson
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, West Midlands, CV2 2DX, UK
| | - Peter Thompson
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, West Midlands, CV2 2DX, UK
| | - Tim Spalding
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, West Midlands, CV2 2DX, UK
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Complex function of the knee joint: the current understanding of the knee. Knee Surg Sports Traumatol Arthrosc 2015; 23:2780-8. [PMID: 25962963 DOI: 10.1007/s00167-015-3619-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 04/27/2015] [Indexed: 01/14/2023]
Abstract
Since the early years of orthopaedics, it is a well-known fact that anatomy follows function. During the evolution of mankind, the knee has been optimally adapted to the forces and loads acting at and through the knee joint. However, anatomy of the knee joint is variable and the only constant is its complex function. In contrast to the time of open surgery, nowadays the majority of reconstructive knee surgery is done arthroscopically. Keyhole surgery is less invasive, but on the backside, the knee surgeon lacks daily visualisation of the complex open anatomy. As open anatomical knowledge is less present in our daily practice, it is even more important to highlight this complex anatomy and function of the knee. It is the purpose of this review to perform a systematic review of knee anatomy, highlight the complex function of the knee joint and present an overview about recent and current knowledge about knee function. Level of evidence Systematic review, Level IV.
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30
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van Meer BL, Meuffels DE, van Eijsden WA, Verhaar JAN, Bierma-Zeinstra SMA, Reijman M. Which determinants predict tibiofemoral and patellofemoral osteoarthritis after anterior cruciate ligament injury? A systematic review. Br J Sports Med 2015; 49:975-83. [DOI: 10.1136/bjsports-2013-093258] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2015] [Indexed: 01/12/2023]
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Adler T, Friederich NF, Amsler F, Müller W, Hirschmann MT. Clinical and radiological long-term outcome after posterior cruciate ligament reconstruction and nonanatomical popliteus bypass. INTERNATIONAL ORTHOPAEDICS 2014; 39:131-6. [PMID: 25228007 DOI: 10.1007/s00264-014-2515-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 08/21/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study was to analyse the long-term outcome of patients treated for combined posterior cruciate ligament (PCL) and posterolateral corner injuries by combined PCL reconstruction and popliteus bypass according to Mueller or refixation of the popliteus tendon. METHODS Sixteen patients treated by combined PCL reconstruction and popliteus bypass according to Mueller (n = 7) or refixation of the popliteus tendon (n = 9) were included. A mean follow-up of 24 ± three years was performed using the International Knee Documentation Committee (IKDC) 2000, Lysholm, Tegner and the Knee Injury and Osteoarthritis Outcome (KOOS) scores. Bilateral stress radiographs were performed. The degree of osteoarthritis was assessed using Kellgren Lawrence score. Pearson correlations of predictive factors for worse outcome were performed (p < 0.05). RESULTS Categorically, total IKDC 2000 was B (nearly normal) in five (31%), C (abnormal) in seven (44%) and D (severely abnormal) in four (25%) patients. Lysholm score was 68 ± 22; KOOS symptom score was 40 ± 13, KOOS pain 26 ± 24, KOOS activity 18 ± 18, KOOS sport 51 ± 32 and KOOS LQ 44 ± 26. Median Tegner score decreased from pre-injury 7 (range 4-10) to 4 (range 2-10) at follow-up. Kellgren Lawrence score showed minimal osteoarthritis in seven (44%), moderate osteoarthritis in seven (44%) and severe osteoarthritis in one (12%) patient. CONCLUSIONS The challenging group of patients treated by PCL reconstruction and popliteus bypass according to Mueller et al. or popliteus refixation showed only moderate clinical and radiological long-term outcome without statistical difference, even if patient age at surgery and the long-term follow-up is acknowledged. Anatomical posterolateral corner reconstruction techniques should be preferred.
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Affiliation(s)
- Tom Adler
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland-Bruderholz, CH-4101, Bruderholz, Switzerland
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Mather RC, Hettrich CM, Dunn WR, Cole BJ, Koenig L, Bach BR, Amendola A, Andrish JT, Huston LJ, Kaeding CK, Marx RG, McCarty EC, Parker RD, Reinke EK, Wright RW, Spindler KP. Cost-Effectiveness Analysis of Early Reconstruction Versus Rehabilitation and Delayed Reconstruction for Anterior Cruciate Ligament Tears. Am J Sports Med 2014; 42:1583-91. [PMID: 24801663 PMCID: PMC4222991 DOI: 10.1177/0363546514530866] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND An initial anterior cruciate ligament (ACL) tear can be treated with surgical reconstruction or focused rehabilitation. The KANON (Knee Anterior cruciate ligament, NON-surgical versus surgical treatment) randomized controlled trial compared rehabilitation plus early ACL reconstruction (ACLR) to rehabilitation plus optional delayed ACLR and found no difference at 2 years by an intention-to-treat analysis of total Knee injury and Osteoarthritis Outcome Score (KOOS) results. PURPOSE To compare the cost-effectiveness of early versus delayed ACLR. STUDY DESIGN Economic and decision analysis; Level of evidence, 2. METHODS A Markov decision model was constructed for a cost-utility analysis of early reconstruction (ER) versus rehabilitation plus optional delayed reconstruction (DR). Outcome probabilities and effectiveness were derived from 2 sources: the KANON study and the Multicenter Orthopaedic Outcomes Network (MOON) database. Collectively, these 2 sources provided data from 928 ACL-injured patients. Utilities were measured by the Short Form-6 dimensions (SF-6D). Costs were estimated from a societal perspective in 2012 US dollars. Costs and utilities were discounted in accordance with the United States Panel on Cost-Effectiveness in Health and Medicine. Effectiveness was expressed in quality-adjusted life-years (QALYs) gained. Principal outcome measures were average incremental costs, incremental effectiveness (as measured by QALYs), and net health benefits. Willingness to pay was set at $50,000, which is the currently accepted standard in the United States. RESULTS In the base case, the ER group resulted in an incremental gain of 0.28 QALYs over the DR group, with a corresponding lower overall cost to society of $1572. Effectiveness gains were driven by the low utility of an unstable knee and the lower utility for the DR group. The cost of rehabilitation and the rate of additional surgery drove the increased cost of the DR group. The most sensitive variable was the rate of knee instability after initial rehabilitation. When the rate of instability falls to 51.5%, DR is less costly, and when the rate of instability falls below 18.0%, DR becomes the preferred cost-effective strategy. CONCLUSION An economic analysis of the timing of ACLR using data exclusively from the KANON trial, MOON cohort, and national average reimbursement revealed that early ACLR was more effective (improved QALYs) at a lower cost than rehabilitation plus optional delayed ACLR. Therefore, early ACLR should be the preferred treatment strategy from a societal health system perspective.
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Affiliation(s)
- Richard C. Mather
- Department of Orthopaedics, Duke University School of Medicine, Durham, NC
| | - Carolyn M. Hettrich
- Department of Orthopaedic Surgery, University of Iowa School of Medicine, Iowa City, IA
| | - Warren R. Dunn
- Department of Orthopaedics, University of Wisconsin Medical Center, Madison, WI
| | - Brian J. Cole
- Division of Sports Medicine, Rush University Medical Center, Chicago, IL
| | | | - Bernard R. Bach
- Division of Sports Medicine, Rush University Medical Center, Chicago, IL
| | - Annunziato Amendola
- Department of Orthopaedic Surgery, University of Iowa School of Medicine, Iowa City, IA
| | - Jack T. Andrish
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Laura J. Huston
- Vanderbilt Orthopaedic Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Christopher K. Kaeding
- Department of Orthopaedic Surgery, The Ohio State University School of Medicine, Columbus, OH
| | - Robert G. Marx
- Sports Medicine Division, Hospital for Special Surgery, New York, NY
| | - Eric C. McCarty
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Denver, CO
| | - Richard D. Parker
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Emily K. Reinke
- Vanderbilt Orthopaedic Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Rick W. Wright
- Department of Orthopaedic Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO
| | - Kurt P. Spindler
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
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Filbay SR, Ackerman IN, Russell TG, Macri EM, Crossley KM. Health-related quality of life after anterior cruciate ligament reconstruction: a systematic review. Am J Sports Med 2014; 42:1247-55. [PMID: 24318609 DOI: 10.1177/0363546513512774] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament reconstructions (ACLRs) are frequently performed on young, active patients and can result in persistent knee symptoms and activity limitations that may affect health-related quality of life (HRQoL). To date, there has been no systematic review of HRQoL outcomes after ACLR. PURPOSE The objectives of this study were to report HRQoL ≥5 years after ACLR, compare HRQoL outcomes with available population norms, and describe factors that may affect HRQoL in this population. STUDY DESIGN Systematic review. METHODS All studies reporting HRQoL ≥5 years after ACLR with hamstring or patellar tendon autografts were eligible for review. Common HRQoL outcomes were pooled using a random-effects meta-analysis and compared with published population norms. The Spearman rank correlation coefficient (ρ) was used to identify variables associated with HRQoL outcomes. Where insufficient data were available, outcomes were reported descriptively. RESULTS Fourteen studies were eligible for review, and HRQoL was reported for 2493 patients at a mean of 9 years (range, 5-16 years) after ACLR. Pooling of knee-related quality of life outcomes (Knee injury and Osteoarthritis Outcome Score [KOOS]-QOL) found impairments after ACLR when compared with population norms. In comparison, studies using the Short Form-36 (SF-36) reported similar or better HRQoL compared with normative data. The KOOS-QOL subscores correlated strongly with KOOS-sport/recreation (ρ = .70, P = .04) and KOOS-pain (ρ = .85, P = .003) subscores. Severe radiographic osteoarthritis, meniscal injuries sustained after surgery, and revision ACLR were associated with poorer HRQoL outcomes at a minimum 5-year follow-up. The negative influence of concomitant meniscal surgery on HRQoL became apparent more than 10 years after ACLR. CONCLUSION This review found that patients assessed using a knee-specific measure (KOOS-QOL) were more likely to report poorer HRQoL values, compared with population norms, than those assessed using a generic HRQoL measure (SF-36). Revision surgeries, meniscal injuries, and severe radiographic osteoarthritis were associated with poorer HRQoL outcomes after ACLR. However, these relationships should be interpreted with caution, as they were only investigated in a small number of studies. CLINICAL RELEVANCE These results can be used by clinicians to educate patients about potential long-term outcomes after ACLR and to develop strategies for optimizing postoperative HRQoL.
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Affiliation(s)
- Stephanie R Filbay
- Kay M. Crossley, BPhysio(Hons Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD 4072, Australia. )
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Cox CL, Huston LJ, Dunn WR, Reinke EK, Nwosu SK, Parker RD, Wright RW, Kaeding CC, Marx RG, Amendola A, McCarty EC, Wolf BR, Harrell FE, Spindler KP. Are articular cartilage lesions and meniscus tears predictive of IKDC, KOOS, and Marx activity level outcomes after anterior cruciate ligament reconstruction? A 6-year multicenter cohort study. Am J Sports Med 2014; 42:1058-67. [PMID: 24647881 PMCID: PMC4195485 DOI: 10.1177/0363546514525910] [Citation(s) in RCA: 180] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Identifying risk factors for inferior outcomes after anterior cruciate ligament reconstruction (ACLR) is important for prognosis and future treatment. HYPOTHESIS Articular cartilage lesions and meniscus tears/treatment would predict International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS) (all 5 subscales), and Marx activity level at 6 years after ACLR. STUDY DESIGN Cohort study (prognosis); Level of evidence, 1. METHODS Between 2002 and 2004, a total of 1512 ACLR patients were prospectively enrolled and followed longitudinally, with the IKDC, KOOS, and Marx activity score completed at entry, 2 years, and 6 years. A logistic regression model was built incorporating variables from patient demographics, surgical technique, articular cartilage injuries, and meniscus tears/treatment to determine the predictors (risk factors) of IKDC and KOOS scores and Marx activity level at 6 years. RESULTS A minimum follow-up on 86% (1307/1512) of the cohort was completed at 6 years. The cohort was 56% male and had a median age of 23 years at the time of enrollment, with 76% reporting a noncontact injury mechanism. Incidence of concomitant injury at the time of surgery consisted of the following: articular cartilage (medial femoral condyle [MFC], 25%; lateral femoral condyle [LFC] 20%; medial tibial plateau [MTP], 6%; lateral tibial plateau [LTP], 12%; patella, 20%; trochlear, 9%) and meniscus (medial, 38%; lateral, 46%). Both articular cartilage lesions and meniscus tears were significant predictors of 6-year outcomes on the IKDC and KOOS. Grade 3 or 4 articular cartilage lesions (excluding patella) significantly reduced IKDC and KOOS scores at 6 years. The IKDC demonstrated worse outcomes with the presence of a grade 3 or 4 chondral lesion on the MFC, MTP, and LFC. Likewise, the KOOS score was negatively affected by cartilage injury. The sole significant predictor of reduced Marx activity level was the presence of a grade 4 lesion on the MFC. Lateral meniscus repairs did not correlate with inferior results, but medial meniscus repairs predicted worse IKDC and KOOS scores. Lateral meniscus tears left alone significantly improved prognosis. Small partial meniscectomies (<33%) on the medial meniscus fared worse; conversely, larger excisions (>50%) on either the medial or lateral menisci improved prognosis. Analogous to previous studies, other significant predictors of lower outcome scores were lower baseline scores, higher body mass index, lower education level, smoking, and anterior cruciate ligament revisions. CONCLUSION Both articular cartilage injury and meniscus tears/treatment at the time of ACLR were significant predictors of IKDC and KOOS scores 6 years after ACLR. Similarly, having a grade 4 MFC lesion significantly reduced a patient's Marx activity level score at 6 years.
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Affiliation(s)
- Charles L. Cox
- Vanderbilt Orthopaedic Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Laura J. Huston
- Vanderbilt Orthopaedic Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Warren R. Dunn
- Vanderbilt Orthopaedic Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Emily K. Reinke
- Vanderbilt Orthopaedic Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Samuel K. Nwosu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Richard D. Parker
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Rick W. Wright
- Department of Orthopaedic Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO
| | - Christopher C. Kaeding
- Department of Orthopaedic Surgery, The Ohio State University School of Medicine, Columbus, OH
| | - Robert G. Marx
- Sports Medicine Division, Hospital for Special Surgery, New York, NY
| | - Annunziata Amendola
- Department of Orthopaedic Surgery, University of Iowa School of Medicine, Iowa City, IA
| | - Eric C. McCarty
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Denver, CO
| | - Brian R. Wolf
- Department of Orthopaedic Surgery, University of Iowa School of Medicine, Iowa City, IA
| | - Frank E. Harrell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Kurt P. Spindler
- Vanderbilt Orthopaedic Institute, Vanderbilt University Medical Center, Nashville, TN
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Barenius B, Ponzer S, Shalabi A, Bujak R, Norlén L, Eriksson K. Increased risk of osteoarthritis after anterior cruciate ligament reconstruction: a 14-year follow-up study of a randomized controlled trial. Am J Sports Med 2014; 42:1049-57. [PMID: 24644301 DOI: 10.1177/0363546514526139] [Citation(s) in RCA: 322] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The reported prevalence of radiological osteoarthritis (OA) after anterior cruciate ligament (ACL) reconstruction varies from 10% to 90%. Purpose/ HYPOTHESIS To report the prevalence of OA after ACL reconstruction and to compare the OA prevalence between quadrupled semitendinosus tendon (ST) and bone-patellar tendon-bone (BPTB) grafts. The hypothesis was that there would be no difference in OA prevalence between the graft types. The secondary aim was to study whether patient characteristics and additional injuries were associated with long-term outcomes. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS Radiological examination results, Tegner activity levels, and Knee injury and Osteoarthritis Outcome Score (KOOS) values were determined in 135 (82%) of 164 patients at a mean of 14 years after ACL reconstruction randomized to an ST or a BPTB graft. Osteoarthritis was defined according to a consensus by at least 2 of 3 radiologists of Kellgren-Lawrence grade ≥2. Using regression analysis, graft type, sex, age, overweight, time between injury and reconstruction, additional meniscus injury, and a number of other variables were assessed as risk factors for OA 14 years after ACL reconstruction. RESULTS Osteoarthritis of the medial compartment was most frequent, with 57% of OA cases in the ACL-reconstructed knee and 18% of OA cases in the contralateral knee (P < .001). There was no difference between the graft types: 49% of OA of the medial compartment for BPTB grafts and 65% for ST grafts (P = .073). The KOOS results were lower for patients with OA in all subscales, indicating that OA was symptomatic. No difference in the KOOS between the graft types was found. Meniscus resection was a strong risk factor for OA of the medial compartment (odds ratio, 3.6; 95% CI, 1.4-9.3) in the multivariable logistic regression analysis. CONCLUSION A 3-fold increased prevalence of OA was found after an ACL injury treated with reconstruction compared with the contralateral healthy knee. No differences in the prevalence of OA between the BPTB and quadrupled ST reconstructions were found. An initial meniscus resection was a strong risk factor for OA; the time between injury and reconstruction was not.
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Affiliation(s)
- Björn Barenius
- Björn Barenius, Orthopaedics Section, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, SE-118 83 Stockholm, Sweden.
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Leiter JRS, Gourlay R, McRae S, de Korompay N, MacDonald PB. Long-term follow-up of ACL reconstruction with hamstring autograft. Knee Surg Sports Traumatol Arthrosc 2014; 22:1061-9. [PMID: 23595537 DOI: 10.1007/s00167-013-2466-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 02/25/2013] [Indexed: 12/11/2022]
Abstract
PURPOSE To investigate the differences in the incidence and severity of knee osteoarthritis (OA), joint space narrowing, knee laxity, and knee flexion and extension strength between an anterior cruciate ligament (ACL)-reconstructed knee and the contralateral non-reconstructed limb. METHODS Retrospective case series of patients from a single surgeon that had an ACL reconstruction with a semitendinosus/gracilis autograft more than 12 years ago. Outcome measures included radiographic analysis, International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), KT-1000, Tegner Activity Level Scale, Lysholm Knee Score, ACL quality of life score (ACL-QOL) and knee flexor/extensor strength. RESULTS Seventy-four patients consented and sixty-eight (43 male, 25 female) were included for analysis. Average age (SD) at the time of surgery was 31.2 (±9.1) years. At follow-up of 14.6 (1.9) years, 9% had re-ruptured their ACL, whereas 5% ruptured the contralateral ACL. Reconstructed knees had a greater incidence and severity of OA (P < 0.01). Medial meniscus surgery was a strong predictor of OA. Seventy-five per cent scored a normal or nearly normal knee on the IKDC. The mean Lysholm score was 75.8% and Tegner Activity Level Scale scores decreased (P < 0.001) from the time of surgery. Knee extension strength was greater in the contralateral knee at speeds of 60°/s (P = 0.014) and 150°/s (P = 0.012). CONCLUSIONS Reconstructed knees have a greater incidence and severity of OA than non-reconstructed knees, which suggests degenerative changes are secondary to ACL rupture. Medial meniscus surgery is a strong predictor of OA. Despite this, 75% of patients reported good outcomes.
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Affiliation(s)
- Jeff R S Leiter
- Pan Am Clinic Foundation, 75 Poseidon Bay, Winnipeg, MB, R3M 3E4, Canada,
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Tengman E, Brax Olofsson L, Nilsson KG, Tegner Y, Lundgren L, Häger CK. Anterior cruciate ligament injury after more than 20 years: I. Physical activity level and knee function. Scand J Med Sci Sports 2014; 24:e491-500. [PMID: 24673102 DOI: 10.1111/sms.12212] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2014] [Indexed: 01/05/2023]
Abstract
Little is known about physical activity level and knee function including jump capacity and fear of movement/reinjury more than 20 years after injury of the anterior cruciate ligament (ACL). Seventy persons with unilateral ACL injury participated (23 ± 2 years post-injury): 33 treated with physiotherapy in combination with surgical reconstruction (ACLR ), and 37 treated with physiotherapy alone (ACLPT ). These were compared with 33 age- and gender-matched controls. Assessment included knee-specific and general physical activity level [Tegner activity scale, International Physical Activity Questionnaire (IPAQ)], knee function [Lysholm score, Knee injury and Osteoarthritis Outcome Score (KOOS)], jump capacity (one-leg hop, vertical jump, side hops), and fear of movement/reinjury [Tampa Scale for Kinesiophobia (TSK)]. Outcomes were related to degree of osteoarthritis (OA). ACL-injured had lower Lysholm, KOOS, and Tegner scores than controls (P < 0.001), while IPAQ score was similar. ACL-injured demonstrated inferior jump capacity in injured compared with noninjured leg (6-25%, P < 0.001-P = 0.010 in the different jumps), while noninjured leg had equal jump capacity as controls. ACL groups scored 33 ± 7 and 32 ± 7 of 68 on TSK. Lower scores on Lysholm and KOOS symptom were seen for persons with moderate-to-high OA than for no-or-low OA, while there were no differences for physical activity and jump capacity. Regardless of treatment, there are still negative knee-related effects of ACL injury more than 20 years later.
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Affiliation(s)
- E Tengman
- Department of Community Medicine and Rehabilitation, Section for Physiotherapy, Umeå University, Umeå, Sweden
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Sasaki N, Farraro KF, Kim KE, Woo SLY. Biomechanical evaluation of the quadriceps tendon autograft for anterior cruciate ligament reconstruction: a cadaveric study. Am J Sports Med 2014; 42:723-30. [PMID: 24401682 PMCID: PMC4144981 DOI: 10.1177/0363546513516603] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recently, many surgeons have chosen the quadriceps tendon (QT) as an autograft for anterior cruciate ligament (ACL) reconstruction. However, there have not been biomechanical studies that quantitatively evaluated knee function after reconstruction using a QT autograft. PURPOSE To measure the 6 degrees of freedom knee kinematics and in situ graft forces after reconstruction with a QT autograft compared with a quadrupled semitendinosus and gracilis (QSTG) tendon autograft. STUDY DESIGN Controlled laboratory study. METHODS Ten human cadaveric knees (age, 54-64 years) were tested in 3 conditions: (1) intact, (2) ACL deficient, and (3) after ACL reconstruction using a QT or QSTG autograft. With use of a robotic/universal force-moment sensor testing system, knee kinematics and in situ forces in the ACL and autografts were obtained at 5 knee flexion angles under externally applied loads: (1) 134-N anterior tibial load, (2) 134-N anterior tibial load with 200-N axial compression, and (3) 10-N·m valgus and 5-N·m internal tibial torque. RESULTS Under the anterior tibial load, both autografts restored anterior tibial translation to within 2.5 mm of the intact knee and in situ forces to within 20 N of the intact ACL at 15°, 30°, and 60°. Adding compression did not change these findings. With the combined rotatory load, the anterior tibial translation and graft in situ forces were again not significantly different from the intact ACL. There were no significant differences between the grafts under any experimental condition. CONCLUSION Reconstruction of the ACL with a QT autograft restored knee function to similar levels as that reconstructed with a QSTG autograft under loads simulating clinical examinations. CLINICAL RELEVANCE The positive biomechanical results of this cadaveric study lend support to the use of a QT autograft for ACL reconstruction, as it could restore knee function immediately after surgery under applied loads that mimic clinical examinations.
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Affiliation(s)
- Norihiro Sasaki
- Musculoskeletal Research Center, Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kathryn F. Farraro
- Musculoskeletal Research Center, Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kwang E. Kim
- Musculoskeletal Research Center, Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Savio L-Y. Woo
- Musculoskeletal Research Center, Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA,Address correspondence to Savio L-Y. Woo, PhD, DSc (Hon), DEng (Hon), Musculoskeletal Research Center, Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, 405 Center for Bioengineering, 300 Technology Drive, Pittsburgh, PA 15219 (
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Abrams GD, Harris JD, Gupta AK, McCormick FM, Bush-Joseph CA, Verma NN, Cole BJ, Bach BR. Functional Performance Testing After Anterior Cruciate Ligament Reconstruction: A Systematic Review. Orthop J Sports Med 2014; 2:2325967113518305. [PMID: 26535266 PMCID: PMC4555525 DOI: 10.1177/2325967113518305] [Citation(s) in RCA: 173] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: When to allow an athlete to return to unrestricted sporting activity after anterior cruciate ligament (ACL) reconstruction remains controversial. Purpose: To report the results of functional performance testing reported in the literature for individuals at differing time points following ACL reconstruction and to examine differences between graft types. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of Medline, Scopus, and Cochrane Central Register of Controlled Trials was performed using PRISMA guidelines. Inclusion criteria were English-language studies that examined any functional rehabilitation test from 6 months to 2 years following ACL reconstruction. All patient-, limb-, and knee-specific demographics were extracted from included investigations. All functional rehabilitation tests were analyzed and compared when applicable. Results: The search term returned a total of 890 potential studies, with 88 meeting inclusion and exclusion criteria. A total of 4927 patients were included, of which 66% were male. The mean patient age was 26.5 ± 3.4 years. The predominant graft choices for reconstruction were bone–patellar tendon–bone (BPTB) autograft (59.8%) and hamstring autograft (37.9%). The most commonly reported functional tests were the hop tests. The results of these functional tests, as reported in the Limb Symmetry Index (LSI), improved with increasing time, with nearly all results greater than 90% at 1 year following primary ACL reconstruction. At 6 months postoperatively, a number of isokinetic strength measurements failed to reach 80% LSI, most commonly isokinetic knee extension testing in both BPTB and hamstring autograft groups. The knee flexion strength deficit was significantly less in the BPTB autograft group as compared with those having hamstring autograft at 1 year postoperatively, while no significant differences were found in isokinetic extension strength between the 2 groups. Conclusion: Hop testing was the most commonly reported functional test following ACL reconstruction. Increases in performance on functional tests were predictably seen as time increased following surgery. Those with hamstring autografts may experience increased strength deficits with knee flexion versus those having BPTB autograft. These data provide information that may assist providers in determining timing of return to unrestricted sporting activity.
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Affiliation(s)
- Geoffrey D Abrams
- Department of Orthopedic Surgery, Stanford University, Stanford, California, USA. ; Veterans Administration Hospital-Palo Alto, Palo Alto, California, USA
| | - Joshua D Harris
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | - Anil K Gupta
- Florida Orthopedic Institute, Tampa, Florida, USA
| | - Frank M McCormick
- Orthopedic Institute, Holy Cross Hospital, Fort Lauderdale, Florida, USA
| | | | - Nikhil N Verma
- Department of Orthopedic Surgery, Rush University, Chicago, Illinois, USA
| | - Brian J Cole
- Department of Orthopedic Surgery, Rush University, Chicago, Illinois, USA
| | - Bernard R Bach
- Department of Orthopedic Surgery, Rush University, Chicago, Illinois, USA
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Shaerf DA, Pastides PS, Sarraf KM, Willis-Owen CA. Anterior cruciate ligament reconstruction best practice: A review of graft choice. World J Orthop 2014; 5:23-29. [PMID: 24649411 PMCID: PMC3952691 DOI: 10.5312/wjo.v5.i1.23] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 09/05/2013] [Accepted: 10/20/2013] [Indexed: 02/06/2023] Open
Abstract
There is much literature about differing grafts used in anterior cruciate ligament (ACL) reconstruction. Much of this is of poor quality and of a low evidence base. We review and summarise the literature looking at the four main classes of grafts used in ACL reconstruction; bone-patella tendon-bone, hamstrings, allograft and synthetic grafts. Each graft has the evidence for its use reviewed and then compared, where possible, to the others. We conclude that although there is no clear “best” graft, there are clear differences between the differing graft choices. Surgeon’s need to be aware of the evidence behind these differences, in order to have appropriate discussions with their patients, so as to come to an informed choice of graft type to best suit each individual patient and their requirements.
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Sawadkar P, Alexander S, Tolk M, Wong J, McGrouther D, Bozec L, Mudera V. Development of a surgically optimized graft insertion suture technique to accommodate a tissue-engineered tendon in vivo. Biores Open Access 2013; 2:327-35. [PMID: 24083088 PMCID: PMC3776617 DOI: 10.1089/biores.2013.0028] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The traumatic rupture of tendons is a common clinical problem. Tendon repair is surgically challenging because the tendon often retracts, resulting in a gap between the torn end and its bony insertion. Tendon grafts are currently used to fill this deficit but are associated with potential complications relating to donor site morbidity and graft necrosis. We have developed a highly reproducible, rapid process technique to manufacture compressed cell-seeded type I collagen constructs to replace tendon grafts. However, the material properties of the engineered constructs are currently unsuitable to withstand complete load bearing in vivo. A modified suture technique has been developed to withstand physiological loading and off load the artificial construct while integration occurs. Lapine tendons were used ex vivo to test the strength of different suture techniques with different sizes of Prolene sutures and tissue-engineered collagen constructs in situ. The data were compared to standard modified Kessler suture using a standard tendon graft. Mechanical testing was carried out and a finite element analysis stress distribution model constructed using COMSOL 3.5 software. The break point for modified suture technique with a tissue-engineered scaffold was significantly higher (50.62 N) compared to a standard modified Kessler suture (12.49 N, p<0.05). Distributing suture tension further proximally and distally from the tendon ends increased the mechanical strength of the repairs. We now have ex vivo proof of concept that this suture technique is suitable for testing in vivo, and this will be the next stage of our research.
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Affiliation(s)
- Prasad Sawadkar
- Tissue Repair and Engineering Center, Division of Surgery and Interventional Science, UCL-Stanmore Campus, University College London , London, United Kingdom . ; Division of Biomaterials and Tissue Engineering, UCL Eastman Dental Institute and London Center for Nanotechnology, University College London , London, United Kingdom
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Double-bundle versus single-bundle anterior cruciate ligament reconstructions: a prospective, randomized study with 2-year follow-up. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2013; 24:559-65. [PMID: 23595769 DOI: 10.1007/s00590-013-1221-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Accepted: 04/07/2013] [Indexed: 01/15/2023]
Abstract
This prospective, randomized study was conducted to compare the short-term results of arthroscopic double-bundle with single-bundle anterior cruciate ligament (ACL) reconstruction. One hundred and eight patients with a symptomatic ACL rupture were randomized to either double-bundle (Group DB) or single-bundle (Group SB) ACL reconstruction. Follow-up was conducted at 6, 12, 18 and 24 months postoperatively. At the 24-month follow-up, 94 of the 108 patients (87%) were available for evaluation. The rotational stability, as evaluated by pivot shift test, was significantly superior in the Group DB to that in the Group SB. No significant difference with regard to ACL revisions, total flexion work, mean peak flexion torque and extension work between the groups was detected. There was no significant difference between the groups in terms of the Tegner activity score, the knee injury and osteoarthritis outcome score, the Lysholm functional score, anterior knee pain or mobility, subjective knee function. In addition, no significant difference in laxity on the Lachman test or the KT-1000 maximum manual force test was investigated. All the results were significantly more satisfactory at each follow-up period than preoperatively, in both groups. Both SB- and DB-ACL reconstruction resulted in satisfactory subjective outcome and objective stability. Both these techniques can therefore be considered as suitable alternatives for ACL reconstruction. Moreover, as it seems to be according to the pivot shift test, the risk for the development of degenerative changes of the knee joint in a long run could be smaller in the Group DB.
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Arthroskopische VKB-Ersatzplastik mit BPTB-Transplantat in Press-fit-Technik. ARTHROSKOPIE 2013. [DOI: 10.1007/s00142-012-0716-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Hirschmann MT, Mathis D, Rasch H, Amsler F, Friederich NF, Arnold MP. SPECT/CT tracer uptake is influenced by tunnel orientation and position of the femoral and tibial ACL graft insertion site. INTERNATIONAL ORTHOPAEDICS 2012; 37:301-9. [PMID: 23142862 DOI: 10.1007/s00264-012-1704-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 10/21/2012] [Indexed: 01/22/2023]
Abstract
PURPOSE SPECT/CT is a hybrid imaging modality, which combines a 3D scintigraphy (SPECT) and a conventional computerised tomography (CT). SPECT/CT allows accurate anatomical localisation of metabolic tracer activity. It allows the correlation of surgical factors such as tunnel position and orientation with mechanical alignment, clinical outcome and biological factors. The purpose of this study was to investigate whether the SPECT/CT tracer uptake (intensity and distribution) correlates with the stability and laxity of the knee joint and the position and orientation of the tibial and femoral tunnels in patients after anterior cruciate ligament (ACL) reconstruction. METHODS A consecutive series of knees (n=66), with symptoms of pain and/or instability after ACL reconstruction were prospectively evaluated using clinical examination and 99mTc-HDP-SPECT/CT. Clinical laxity testing was performed using the Rolimeter (Ormed, Freiburg, Germany) including Lachman testing (0-2 mm, 3-5 mm, 6-10 mm, >10 mm), anterior drawer test (0-2 mm, 3-5 mm, 6-10 mm, >10 mm), pivot shift test (positive versus negative) and patient-based subjective instability (yes versus no). For analysis of SPECT/CT tracer uptake a previously validated SPECT/CT localisation scheme consisting of 17 tibial, nine femoral and four patellar regions on standardised axial, coronal, and sagittal slices was used. The tracer activity on SPECT/CT was localised and recorded using a 3D volumetric and quantitative analysis software. Mean, standard deviation, minimum and maximum of grading for each area of the localisation scheme were recorded. The position and orientation of the tibial and femoral tunnel was assessed using a previously published method on 3D-CT. RESULTS Correlation of instability, pivot shift as well as clinical laxity testing with 99mTc-HDP-SPECT/CT tracer uptake intensity and distribution showed no significant correlation. 99mTc-HDP-SPECT/CT tracer uptake correlated significantly with the position and orientation of the ACL graft. A more horizontal femoral graft position showed significantly increased tracer uptake within the superior and posterior femoral regions. A more posteriorly-placed femoral insertion site showed significantly more tracer uptake within the femoral and tibial tunnel regions. A more vertical or a less medial tibial tunnel orientation showed significant increased uptake within the tibial and femoral tunnel regions. A more anterior tibial tunnel position showed significantly more tracer uptake in the femoral and tibial tunnel regions as well as the entire tibiofemoral joint. CONCLUSIONS SPECT/CT tracer uptake intensity and distribution showed a significant correlation with the femoral and tibial tunnel position and orientation in patients with symptomatic knees after ACL reconstruction. No correlation was found with stability or clinical laxity. SPECT/CT tracer uptake distribution has the potential to give us important information on joint homeostasis and remodelling after ACL reconstruction. It might help to predict ACL graft failure and improve our surgical ACL reconstruction technique in finding the optimal tunnel and graft position and orientation.
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Affiliation(s)
- Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Bruderholz, 4101, Bruderholz, Switzerland.
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