Younger age and hamstring tendon graft are associated with higher IKDC 2000 and KOOS scores during the first year after ACL reconstruction.

PURPOSE: Although reference values in healthy subjects have been published for both the International Knee Documentation Committee 2000 subjective knee form (IKDC 2000) and the Knee injury and Osteoarthritis Outcome Score (KOOS), data obtained during the first year after anterior cruciate ligament reconstruction (ACL-R) are sparse. The aim was to establish patient reference values for both questionnaires at different time points and depending on nine individual patient characteristics during the first year after ACL-R. METHODS: Prospectively recorded data from a hospital-based registry were retrospectively extracted from the database. IKDC 2000 and KOOS questionnaires were self-administered pre-operatively and 6 weeks, 3 months, and 6 and 12 months following primary ACL-R. Score values were compared according to nine individual patient criteria: gender, age, body mass index, level of activity, involvement in competition, previous contralateral knee injury and/or surgery, graft type, meniscal repair and/or cartilage lesions. The feature which had a significant and consistent impact on the outcomes was considered as main reference. RESULTS: Two-hundred and nighty-eight patients met the inclusion criteria. Overall, the score values increased over time after ACL-R. At 12 months, they were significantly greater than at any other time point (p < 0.05). The main individual feature influencing the IKDC 2000 score was age. Patients below 30 years of age had up to 9 points higher IKDC 2000 score values at all time points (p < 0.05). The main individual characteristic influencing the KOOS score was graft type. Patients with hamstring tendon grafts (STGR) had up to 15 points higher KOOS score values than patients with bone-patellar tendon-bone (BPTB) grafts during the first months after ACL-R (p < 0.05). At 12 months, no differences in KOOS score values could be identified anymore. CONCLUSIONS: Younger age (< 30 years) and STGR grafts were related to higher IKDC 2000 and KOOS score values within the first year after primary ACL-R. The patient reference values adjusted to age and graft provided in this study may help to identify patients with lower outcomes within the first year after ACL-R. LEVEL OF EVIDENCE: Level III.

Outcomes of Revision Anterior Cruciate Ligament Surgery in Adolescents.

BACKGROUND: Although primary anterior cruciate ligament (ACL) reconstructions have been well studied in children and adolescents, the literature lacks information about revision ACL reconstructions in this population. PURPOSE: This study aims to analyze the outcomes of revision ACL surgeries in the pediatric population. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective study was performed on all revision ACL reconstructions performed at a single institution between 2009 and 2017. Patient demographic, injury, and operative data from both the initial surgery and the revision were documented. Outcome measures included the Lysholm score, Single Assessment Numeric Evaluation (SANE) score, Tegner activity score, visual analog scale for pain, Hospital for Special Surgery Pediatric Functional Activity Brief Scale score, patient satisfaction, ability to return to the same level of sport, and any additional injury and/or surgery. Outcomes of the revision surgeries were compared with our institution's outcome database of primary ACL reconstructions. RESULTS: During the study period, 60 revision ACL reconstructions were performed in 57 patients. Of these patients, 84% (n = 48) were available for a minimum 2-year follow-up and a mean follow-up of 4.4 years. A greater number of meniscal tears and cartilage injuries were documented in the revision cohort. Compared with the primary cohort, the revision cohort had lower SANE scores, Lysholm scores, and satisfaction. Furthermore, the revision cohort had a higher rate of graft failure than the primary cohort (21% vs 9%, respectively; P = .015), and only 27% of revision patients returned to the same level of sport. In a comparison of revision procedures performed with autograft versus allograft tissue, the autograft patients had higher Lysholm scores than the allograft patients (91 vs 83, respectively; P = .045) and trended toward a lower failure rate (11% vs 27%, respectively; P = .199). CONCLUSION: Adolescent patients undergoing revision ACL reconstruction had more meniscal and cartilage abnormalities, poorer functional outcomes, and higher graft failure rates than patients undergoing primary ACL reconstructions. Additionally, revision procedures performed with allograft tissue resulted in lower Lysholm scores and a trend toward higher failure rates. When an ACL graft fails in a young patient, strong consideration should be given to using autograft tissue for the revision.

Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft with Remnant Preservation: Comparison of Outcomes According to the Amount of Remnant Tissue.

There has been controversy about whether remnant tissue of anterior cruciate ligament (ACL) has to be preserved in ACL reconstruction. The purpose of the study was to compare clinical outcomes between groups of patients who underwent ACL reconstruction with bone-patellar tendon-bone (BPTB) autograft divided according to amount of ACL remnant and investigate effect of remnant preservation on outcomes of ACL reconstruction. A total of 185 patients who underwent ACL reconstruction with BPTB autograft were retrospectively reviewed. Patients were divided into four groups according to proportion of length of remnant tissue of injured ACL covering part of reconstructed ACL to total length of reconstructed ACL: group A included 83 patients with no remnant, group B consisted of 38 patients with remnant of < 1/3, group C consisted of 35 patients with remnant of 1/3 to2/3, and group D consisted of 29 patients with remnant of > 2/3. Primary outcome was International Knee Documentation Committee (IKDC) subjective score. Secondary outcomes were stability, range of motion, patient-reported outcomes determined by Lysholm knee scoring scale and Tegner activity scale, IKDC objective grade, and single hop for distance. Return to activity and near-return to activity were investigated. A minimum follow-up duration was 24 months. There was no statistically significant difference between four groups regarding postoperative anterior translation (p = 0.731), Lysholm knee score (p = 0.599), IKDC objective grade (p > 0.999), hop test (p = 0.878), and near-return to activity (p = 0.193). However, patients of group D had significantly better outcomes in IKDC subjective score (group A = 85.0 ± 5.9, group B = 84.9 ± 8.1, group C = 87.4 ± 6.4, group D = 89.2 ± 8.1, p = 0.017), Tegner activity scale (group A = 5.0 ± 1.1, group B = 5.2 ± 1.0, group C = 5.7 ± 1.3, group D = 5.9 ± 1.0, p = 0.001), and return to activity (group A = 25.3%, group B = 31.6%, group C = 45.7%, group D = 55.2%, p = 0.014). ACL reconstruction using BPTB autograft with remnant preservation did not provide better anterior stability compared with conventional ACL reconstruction. However, preservation of remnant of > 2/3 led to more improved activity-related clinical outcomes than no remnant preservation. In cases with substantial remnant tissue of injured ACL remaining, reconstruction of ACL while preserving as much remnant tissue as possible is recommended. This is a Level III, retrospective comparative therapeutic study.

Significant anterior enlargement of femoral tunnel aperture after hamstring ACL reconstruction, compared to bone-patellar tendon-bone graft.

PURPOSE: This study aimed to retrospectively compare the enlargement and migration of the femoral tunnel aperture after anatomic rectangular tunnel anterior cruciate ligament (ACL) reconstruction with a bone-patella tendon-bone (BTB) or hamstring tendon (HT) graft using three-dimensional (3-D) computer models. METHODS: Thirty-two patients who underwent ACL reconstruction and postoperative computed tomography (CT) at 3 weeks and 6 months were included in this study. Of these, 20 patients underwent ACL reconstruction with a BTB graft (BTBR group), and the remaining 12 with an HT graft (HTR group). The area of the femoral tunnel aperture was extracted and measured using a 3-D computer model generated from CT images. Changes in the area and migration direction of the femoral tunnel aperture during this period were compared between the two groups. RESULTS: In the HTR group, the area of the femoral tunnel aperture was significantly increased at 6 months compared to 3 weeks postoperatively (P < 0.05). The average area of the femoral tunnel aperture at 6 months postoperatively was larger by 16.0 ± 12.4% in the BTBR group and 41.9 ± 22.2% in the HTR group, relative to that measured at 3 weeks postoperatively (P < 0.05). The femoral tunnel aperture migrated in the anteroinferior direction in the HTR group, and only in the inferior direction in the BTBR group. CONCLUSIONS: The femoral tunnel aperture in the HTR group was significantly more enlarged and more anteriorly located at 6 months after ACL reconstruction, compared to the BTBR group. LEVEL OF EVIDENCE: IV.

Outcome after Combined Lateral Extra-articular Tenodesis and Anterior Cruciate Ligament Revision in Professional Soccer Players.

We report the functional outcome after combined anterior cruciate ligament (ACL) reconstruction and lateral extra-articular tenodesis (LET) for ACL re-rupture and high-grade pivot shift in professional soccer players. For this retrospective review, the medical records of 24 professional soccer players were analyzed. The mean age at surgery was 23.8 ± 4.2 years and the mean follow-up was 42.2 ± 16.9 months. Pre- and postoperative assessment included the KT-1000 Lachman test, pivot shift test, International Knee Documentation Committee (IKDC) subjective knee evaluation, Tegner activity scale (TAS), and Lysholm score. The rate of return to sports and the level of play at final follow-up were recorded. ACL revision was performed with an autologous bone-patellar tendon-bone autograft or a hamstring graft. LET was performed using an extra-articular MacIntosh procedure as modified by Arnold-Coker. Anterior-posterior laxity was significantly reduced at the final clinical assessment (p < 0.0001): 22 patients (91.7%) had a negative pivot shift and 2 (8.3%) had residual glide (+), with significant improvement (p < 0.0001). The mean subjective IKDC and Lysholm score improved from 69.5 ± 11.1 (range: 56-90) to 88.4 ± 8.9 (range: 62.1-100) and from 58.1 ± 11.7 (range: 33-72) to 97.4 ± 3.2 (range: 88-100), respectively, with significant improvement (p < 0.0001) over preoperative values. The overall failure rate was 8.3%. There were no differences between mean preinjury and final TAS scores (p > 0.05). The rate of return to sports at the same level was 91.7% and the mean time to return to sports was 9.2 ± 2.2 months. Mid-term functional outcome after combined extra-articular reconstruction and ACL revision surgery was satisfactory, with a reduction in residual postoperative rotatory instability and degree of pivot shift.

Bone-patellar tendon-bone autograft could be recommended as a superior graft to hamstring autograft for ACL reconstruction in patients with generalized joint laxity: 2- and 5-year follow-up study.

PURPOSE: The present study aimed to compare 2- and 5-year outcomes of ACL reconstruction between patients with and without generalized joint laxity and to perform comparative evaluation between two types of grafts used for ACL reconstruction in patients with generalized joint laxity. METHODS: Two hundred and thirty-seven patients who underwent ACL reconstruction from 2001 to 2008 were included. Patients were classified into two groups according to the presence or the absence of generalized joint laxity, and further subdivided into two subgroups based on the type of graft used: bone-patellar tendon-bone (BPTB) or hamstring. Generalized joint laxity was assessed with the Beighton and Horan criteria using a point scoring system. Stability reflected by the Lachman test, pivot-shift test, and anterior translation measured with KT-2000, and functional outcomes reflected by Lysholm knee score, and International Knee Documentation Committee (IKDC) subjective score were investigated. IKDC objective grade and radiographic grade were also assessed. Clinical assessments were conducted preoperatively and at 2 and 5 years after operation. RESULTS: Two-year follow-up results showed that patients with generalized joint laxity receiving hamstring grafts had poorer outcomes than those without generalized joint laxity. Five-year follow-up results showed that patients with generalized joint laxity experienced poorer outcomes than patients without generalized joint laxity, irrespective of the type of graft. Comparison of grafts used showed that, in patients with generalized joint laxity, BPTB graft provided significantly better stability and functional outcomes than hamstring graft at both 2- and 5-year follow-ups. Comparisons between serial outcomes measured at 2 and 5 years demonstrated that stability and functional outcomes deteriorated over time in patients with generalized joint laxity. CONCLUSIONS: Less satisfactory stability and functional outcomes were noted in patients with generalized joint laxity, compared to patients without generalized joint laxity. Comparisons of stability and functional outcomes after ACL reconstruction in patients with generalized joint laxity between two different grafts demonstrated that BPTB graft achieves better results than hamstring graft. LEVEL OF EVIDENCE: III, a retrospective cohort study.

Risk Factors for Early ACL Reconstruction Failure in Pediatric and Adolescent Patients: A Review of 561 Cases.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction failure is relatively common in young high-risk athletes. The purpose of this study was to examine a single center's 10-year experience with ACL reconstructions in pediatric and adolescent patients to better define short-term failure rates and risk factors for revision ACL surgery. METHODS: This institutional review board-approved retrospective study included all patients who underwent a primary ACL reconstruction between 2002 and 2013. Chart and radiographic review was performed to assess patient demographic, injury, and surgical data including growth plate status, concomitant ligament/meniscus/cartilage injury, surgical procedures, femoral drilling technique, graft source and type, femoral and tibial fixation devices, and graft size. Graft failures had to be confirmed both with clinical examination and magnetic resonance imaging or the patient had to undergo a revision ACL reconstruction. Potential factors associated with failure were evaluated using either parametric or nonparametric analysis as appropriate. RESULTS: A total of 561 ACL reconstructions were performed that met our inclusion criteria. The average patient age was 15.4 years (range, 5 to 19 y) and 53% of the patients were male. In all, 54 failures were identified for a 9.6% failure rate. Soft tissue grafts were twice as likely to fail compared with patellar tendon grafts (13% vs. 6%; P<0.001). Multivariate analysis revealed that graft choice (soft tissue vs. patellar tendon) was the primary variable predictive of failure (P<0.05), with interactions/mediating effects contributed by maturity (growth plate status) and ACL technique (P<0.05). The average time to failure was 13.6 months and hamstring grafts and anatomic femoral tunnels were both found to fail earlier (P<0.05). During the study period, approximately 8% of patients sustained a contralateral ACL injury. CONCLUSIONS: ACL failure rates in adolescent and pediatric patients vary based on patient age, graft selection, and surgical technique. Bone patellar tendon bone autografts had the lowest failure rate in this high-risk population. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Outcomes After 1-Stage Versus 2-Stage Revision Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Revision anterior cruciate ligament reconstruction (ACLR) is becoming increasingly common as the number of primary ACLR cases continues to rise. Despite this, there are limited data on the outcomes of revision ACLR and even less information specifically addressing the differences in 1-stage revision reconstruction versus those performed in a 2-stage fashion after primary reconstruction. PURPOSE: To compare the outcomes, patient satisfaction, and failure rates of 1-stage versus 2-stage revision ACLR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All patients who underwent revision ACLR between 2010 and 2014 by a single surgeon were collected, and skeletally mature patients over the age of 17 years were included. Patients were excluded if they were skeletally immature; had a previous intra-articular infection in the ipsilateral knee; underwent a prior alignment correction procedure, cartilage repair or transplant procedure, or meniscal allograft transplantation; or had an intra-articular fracture. An ipsilateral or contralateral bone-patellar tendon-bone (BPTB) autograft was the graft of choice. A BPTB allograft was considered for patients aged ≥50 years, for any patient with an insufficient ipsilateral or contralateral patellar tendon, or for those who chose not to have the contralateral patellar tendon graft harvested. Patients completed a subjective questionnaire preoperatively and at a minimum of 2 years postoperatively. Magnetic resonance imaging and computed tomography of all knees were performed preoperatively to assess for associated injuries and to evaluate the ACLR tunnel size and location. Patients with malpositioned tunnels that would critically overlap with an anatomically placed tunnel or those with tunnels ≥14 mm in size underwent bone grafting. RESULTS: A total of 88 patients met the inclusion criteria for this study. There were 39 patients in the 1-stage revision surgery group (19 male, 20 female) and 49 patients in the 2-stage revision surgery group who underwent tunnel bone grafting first (27 male, 22 female). In both groups, the 12-item Short Form Health Survey (SF-12) Physical Component Summary, Western Ontario and McMaster Universities Arthritis Index, Lysholm, and Tegner activity scale scores significantly improved from preoperatively to postoperatively. There was no significant difference in the SF-12 Mental Component Summary score before and after surgery in either group. Furthermore, there was no significant difference in failure rates or other demographic data between the groups. We observed 4 failures in the 1-stage reconstruction group (10.3%) and 3 failures in the 2-stage reconstruction group (6.1%). CONCLUSION: In this study, objective outcomes and subjective patient scores and satisfaction were not significantly different between 1-stage and 2-stage revision ACLRs. Both groups had significantly improved objective outcomes and patient subjective outcomes without notable differences in failure rates. Further longitudinal studies comparing 1-stage and 2-stage revision ACLRs over a longer time frame are recommended.

One-stage revision ACL reconstruction after primary ACL double bundle reconstruction: is bone-patella tendon-bone autograft reliable?

PURPOSE: The purpose of this study is to assess the results of revision anterior cruciate ligament (ACL) reconstruction after the failure of primary ACL double bundle reconstruction (ACL-DBR). METHODS: Twenty-two knees in 22 patients (group R) that underwent ACL revision surgery using bone-patellar tendon-bone (BTB) autograft after the failure of primary ACL-DBR were included in this study. Intraoperative findings and postoperative knee laxity and clinical outcomes in group R were assessed. Forty-four knees in 44 patients that were age- and gender- matched with group R and underwent primary ACL reconstruction using BTB autograft were used as a control group (group P). RESULTS: The incidence of medial meniscus and cartilage injury in group R was significantly higher than those in group P (p < 0.05). At final follow-up, median Lysholm score was 90.5 (64-100) in group R and 94 (59-100) in group P, respectively. Fourteen patients (63.6%) in group R and 31 patients (70.5%) in group P were able to return to previously-played sports, respectively. There were no significant differences in KT-1000 outcomes (2.0 mm in group R and 1.4 mm in group P) or pivot shift test between the two groups. The rate of subsequent ACL injury was similar in both groups. CONCLUSIONS: Revision ACL reconstruction using BTB autograft after failed primary ACL-DBR provided almost compatible postoperative clinical outcomes and knee stability with primary ACL reconstruction using BTB autograft, while the incidence of medial meniscus and cartilage injury at revision surgery was higher. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Increased Risk of Revision After Anterior Cruciate Ligament Reconstruction With Soft Tissue Allografts Compared With Autografts: Graft Processing and Time Make a Difference.

BACKGROUND: The optimal graft for anterior cruciate ligament reconstruction (ACLR) remains controversial. PURPOSE: To compare the risk of aseptic revision between bone-patellar tendon-bone (BPTB) autografts, hamstring autografts, and soft tissue allografts. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Prospectively collected ACLR cases reconstructed with BPTB autografts, hamstring autografts, and soft tissue allografts were identified using the Kaiser Permanente ACLR Registry. Aseptic revision was the endpoint. The type of graft and allograft processing method (nonprocessed, <1.8-Mrad irradiation with and without chemical processing [Allowash or AlloTrue], ≥1.8-Mrad irradiation with and without chemical processing, and chemical processing alone [BioCleanse]) were the exposures evaluated. Analyses were adjusted for age, sex, and race. Kaplan-Meier curves and Cox proportional hazards models were employed. RESULTS: The cohort included 14,015 cases: there were 8924 (63.7%) male patients, there were 6397 (45.6%) white patients, 4557 (32.5%) ACLRs used BPTB autografts, 3751 ACLRs (26.8%) used soft tissue allografts, and 5707 (40.7%) ACLRs used hamstring autografts. The median age was 34.6 years for soft tissue allografts, 24.3 years for hamstring autografts, and 22.0 years for BPTB autografts. The crude nonadjusted revision rates were 85 (1.9%) in BPTB autograft cases, 132 (2.3%) in hamstring autograft cases, and 83 (2.2%) in soft tissue allograft cases. After adjusting for age, sex, and race, compared with hamstring autografts, a higher risk of revision was found with allografts with ≥1.8 Mrad without chemical processing after 2.5 years (hazard ratio [HR], 3.88; 95% CI, 1.48-10.12) and ≥1.8 Mrad with chemical processing after 1 year (HR, 3.43; 95% CI, 1.58-7.47) and with BioCleanse processed grafts at any time point (HR, 3.02; 95% CI, 1.40-6.50). Nonprocessed allografts and those irradiated with <1.8 Mrad with or without chemical processing were not found to have a different risk of revision compared with hamstring autografts. Compared with BPTB autografts, a higher risk of revision was seen with hamstring autografts (HR, 1.51; 95% CI, 1.15-1.99) and BioCleanse processed allografts (HR, 4.67; 95% CI, 2.15-10.16). Allografts irradiated with <1.8 Mrad with chemical processing (Allowash or AlloTrue) (HR, 2.19; 95% CI, 1.42-3.38) and without chemical processing (HR, 2.31; 95% CI, 1.40-3.82) had a higher risk of revision, as did allografts with ≥1.8 Mrad without chemical processing after 2 years (HR, 6.30; 95% CI, 3.18-12.48) and ≥1.8 Mrad with chemical processing (Allowash or AlloTrue) after 1 year (HR, 5.03; 95% CI, 2.30-11.00) compared with BPTB autografts. Nonprocessed allografts did not have a higher risk of revision compared with autografts. With the numbers available, direct comparisons between the specific allograft processing methods were not possible. CONCLUSION: When soft tissue allografts are used for ACLR, processing and time from surgery affect the risk of revision. Tissue processing has a significant effect on the risk of revision surgery, which is most profound with more highly processed grafts and increases with increasing follow-up time. Surgeons and patients need to be aware of the increased risks of revision with the various soft tissue allografts used for ACLR.

Anterolateral Ligament Reconstruction Is Associated With Significantly Reduced ACL Graft Rupture Rates at a Minimum Follow-up of 2 Years: A Prospective Comparative Study of 502 Patients From the SANTI Study Group.

BACKGROUND: Graft failure and low rates of return to sport are major concerns after anterior cruciate ligament (ACL) reconstruction, particularly in a population at risk. PURPOSE: To evaluate the association between reconstruction techniques and subsequent graft rupture and return-to-sport rates in patients aged 16 to 30 years participating in pivoting sports. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A prospective study of patients undergoing primary ACL reconstruction with a bone-patellar tendon-bone (B-PT-B) graft, quadrupled hamstring tendon (4HT) graft, or hamstring tendon graft combined with anterolateral ligament reconstruction (HT+ALL) was conducted by the Scientific ACL NeTwork International (SANTI) Study Group. Survivorship data from Kaplan-Meier analysis were analyzed in multivariate Cox regression models to identify the prognosticators of graft ruptures and return to sport. RESULTS: Five hundred two patients (mean age, 22.4 ± 4.0 years) with a mean follow-up of 38.4 ± 8.5 months (range, 24-54 months) were included. There were 105 B-PT-B, 176 4HT, and 221 HT+ALL grafts. The mean postoperative scores at latest follow-up were the following: Lysholm: 92.4 ± 8.6, Tegner: 7.4 ± 2.1, and subjective International Knee Documentation Committee (IKDC): 86.8 ± 10.5 for B-PT-B grafts; Lysholm: 91.3 ± 9.9, Tegner: 6.6 ± 1.8, and subjective IKDC: 85.4 ± 10.4 for 4HT grafts; and Lysholm: 91.9 ± 10.2, Tegner: 7.0 ± 2.0, and subjective IKDC: 81.8 ± 13.1 for HT+ALL grafts. The mean side-to-side laxity was 0.6 ± 0.9 mm for B-PT-B grafts, 0.6 ± 1.0 mm for 4HT grafts, and 0.5 ± 0.8 mm for HT+ALL grafts. At a mean follow-up of 38.4 months, the graft rupture rates were 10.77% (range, 6.60%-17.32%) for 4HT grafts, 16.77% (range, 9.99%-27.40%) for B-PT-B grafts, and 4.13% (range, 2.17%-7.80%) for HT+ALL grafts. The rate of graft failure with HT+ALL grafts was 2.5 times less than with B-PT-B grafts (hazard ratio [HR], 0.393; 95% CI, 0.153-0.953) and 3.1 times less than with 4HT grafts (HR, 0.327; 95% CI, 0.130-0.758). There was no significant difference in the graft failure rate between 4HT and B-PT-B grafts (HR, 1.204; 95% CI, 0.555-2.663). Other prognosticators of graft failure included age ≤25 years ( P = .012) and a preoperative side-to-side laxity >7 mm ( P = .018). The HT+ALL graft was associated with higher odds of returning to preinjury levels of sport than the 4HT graft (odds ratio [OR], 1.938; 95% CI, 1.174-3.224) but not compared with the B-PT-B graft (OR, 1.460; 95% CI, 0.813-2.613). CONCLUSION: In a high-risk population of young patients participating in pivoting sports, the rate of graft failure with HT+ALL grafts was 2.5 times less than with B-PT-B grafts and 3.1 times less than with 4HT grafts. The HT+ALL graft is also associated with greater odds of returning to preinjury levels of sport when compared with the 4HT graft.

Patient demographics and surgical characteristics in ACL revision: a comparison of French, Norwegian, and North American cohorts.

PURPOSE: The goal of this paper is to compare patient factors, intra-operative findings, and surgical techniques between patients followed in large cohorts in France, Norway, and North America. METHODS: Data collected on 2,286 patients undergoing revision anterior cruciate ligament reconstruction (ACLR) were obtained. These data included 1,216 patients enrolled in the Multicenter ACL Revision Study (MARS) in North America, 793 patients undergoing revision ACLR and recorded in the Norwegian Knee Ligament Registry (NKLR), and 277 patients recorded in the revision ACL database of the Société Française d'Arthroscopie (SFA) in France. Data collected from each database included patient demographics (age, sex, height, and weight), graft choice and reason for failure of the primary ACLR, time from primary to revision ACLR, pre-revision patient-reported outcome scores (Knee Injury and Osteoarthritis Outcome Score, subjective International Knee Documentation Committee), associated intra-articular findings and treatments at revision, and graft choice for revision reconstruction. RESULTS: Patient demographics in the three databases were relatively similar. Graft choice for primary and revision ACLR varied significantly, with more allografts used in the MARS cohort. Hamstring autograft was favoured in the NKRL, while bone-patellar tendon-bone autograft was most common in the SFA cohort. Reasons for failure of the primary ACLR were comparable, with recurrent trauma noted in 46-56 % of patients in each of the three cohorts. Technical error was cited in 44-51 % of patients in the MARS and SFA cohorts, but was not clearly elucidated in the NKLR cohort. Biologic failure of the primary graft was more common in the MARS cohort. Differences in associated intra-articular findings were noted at the time of revision ACLR, with significantly more high-grade cartilage lesions noted in the MARS group. CONCLUSIONS: Significant differences exist between patient populations followed in revision ACL cohorts throughout the world that should be considered when applying findings from such cohorts to different patient populations. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Patient predictors of early revision surgery after anterior cruciate ligament reconstruction: a cohort study of 16,930 patients with 2-year follow-up.

BACKGROUND: Revision surgery is one of the most important endpoints during follow-up after anterior cruciate ligament (ACL) reconstruction. PURPOSE: To investigate if commonly known patient factors can predict revision surgery after ACL reconstruction. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: This prospective cohort study was based on data from the Swedish National Knee Ligament Register during the period of January 1, 2005, through December 31, 2013. Patients who underwent primary ACL reconstruction with hamstring tendon or bone-patellar tendon-bone autografts were included. Follow-up started on the date of primary ACL reconstruction, and follow-up ended with ACL revision surgery, after 24 months of follow-up, or on December 31, 2013, whichever occurred first. The analyzed patient variables were activity at the time of injury, sex, age, height, weight, body mass index, smoking, and the use of smokeless tobacco. The primary study endpoint was revision surgery, defined as replacement of a primary ACL reconstruction. Relative risk (RR) and 95% CIs were calculated and adjusted for confounding factors using multivariate statistics. RESULTS: A total of 16,930 patients were included (males, n=9767 [57.7%]; females, n=7163 [42.3%]). The 2-year revision rate was 1.82% (95% CI, 1.62%-2.02%). There was no significant difference between male and female revision rates (1.74% [95% CI, 1.48%-2.00%] vs 1.93% [95% CI, 1.61%-2.25%], P=.383). In both males and females there was a significantly increased risk of revision surgery associated with soccer playing and adolescence (age 13-19 years) (males: RR=1.58 [95% CI, 1.12-2.23], P=.009 and RR=2.67 [95% CI, 1.91-3.73], P<.001, respectively; females: RR=1.43 [1.01-2.04], P=.045 and RR=2.25 [95% CI, 1.57-3.24], P<.001, respectively). A combination of these predictors were associated with a further increased risk of revision surgery (males: RR=2.87 [95% CI, 1.79-4.60], P<.001; females: RR=2.59 [95% CI, 1.69-3.96], P<.001). CONCLUSION: Soccer players and adolescents had an increased risk of revision surgery after ACL reconstruction, with a respective factor of 1.5 and 2.5. Individuals with a combination of these 2 predictors carried an almost 3-fold higher risk of revision surgery. There were no significant associations for sex, height, weight, body mass index, or tobacco use.

Outcomes and revision rate after bone-patellar tendon-bone allograft versus autograft anterior cruciate ligament reconstruction in patients aged 18 years or younger with closed physes.

PURPOSE: The purpose of this study was to compare revision rates and outcomes after anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BPTB) autografts versus BPTB allografts in patients aged 18 years or younger with closed physes. METHODS: Institutional review board approval was obtained for this study. This study included 90 consecutive patients aged 18 years or younger with closed physes who underwent primary ACL reconstruction by a single surgeon between 1998 and 2009, with either BPTB autograft (n = 70) or BPTB allograft (n = 20). Patients who had concomitant ligament injuries were excluded. Outcome measures included the Lysholm score, Tegner activity scale, and patient satisfaction (0, very unsatisfied; 10, very satisfied). Failures were defined as cases requiring ACL revision surgery. RESULTS: Of the 90 patients, 79 (88%) were contacted (20 of 20 with allografts and 59 of 70 with autografts). Of these 79 patients, 9 (11%) required revision ACL reconstruction. In the autograft group, 3% (2 of 59) required revision ACL reconstruction at a mean of 15.4 months (range, 13.0 to 17.7 months) after the index procedure. In the allograft group, 35% (7 of 20) required revision ACL reconstruction at a mean of 9.1 months (range, 5.3 to 12.0 months) after the index procedure. The allograft group was 15 (95% confidence interval [CI], 2 to 123) times more likely to require revision reconstruction than the autograft group (P = .001). The mean Lysholm score at follow-up was 85 (95% CI, 80.4 to 90.3) for the autograft group and 91 (95% CI, 88.1 to 97.3) for the allograft group (P = .46). The median Tegner activity scale was 7.0 (95% CI, 6.9 to 8.0) for autograft group and 6.5 (95% CI, 4.9 to 8.4) for the allograft group (P = .27). Median patient satisfaction score was 10 of 10 in both cohorts. No failures were seen in either group at 2 years postoperatively. Five of seven allograft failures occurred because of a premature return to sports. CONCLUSIONS: No significant differences in function, activity, or satisfaction were found between allograft and autograft reconstructions in this patient population. The allograft group had a failure rate 15 times greater than that in the autograft group, with all failures occurring within the first year after reconstruction. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Clinical results and risk factors for reinjury 15 years after anterior cruciate ligament reconstruction: a prospective study of hamstring and patellar tendon grafts.

BACKGROUND: There is a lack of prospective studies comparing the long-term outcome of endoscopic anterior cruciate ligament (ACL) reconstruction with either a patellar tendon or hamstring tendon autograft. PURPOSE: This prospective longitudinal study compared the results of isolated endoscopic ACL reconstruction utilizing a 4-strand hamstring tendon (HT) or patellar tendon (PT) autograft over a 15-year period with respect to reinjury, clinical outcomes, and the development of osteoarthritis. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Ninety consecutive patients with isolated ACL rupture were reconstructed with a PT autograft, and 90 patients received an HT autograft, with an identical surgical technique. Patients were assessed at 2, 5, 7, 10, and 15 years. Assessment included the International Knee Documentation Committee (IKDC) knee ligament evaluation including radiographic evaluation, KT-1000 arthrometer testing, and Lysholm knee score. RESULTS: Patients who received the PT graft had significantly worse outcomes compared with those who received the HT graft at 15 years for the variables of radiologically detectable osteoarthritis (grade A: 46% in PT and 69% in HT; P = .04), motion loss (extension deficit <3°: 79% in PT and 94% in HT; P = .03), single-legged hop test (grade A: 65% in PT and 92% in HT; P = .001), participation in strenuous activity (very strenuous or strenuous: 62% of PT and 77% of HT; P = .04), and kneeling pain (moderate or greater pain: 42% of PT and 26% of HT; P = .04). There was no significant difference between the HT and PT groups in overall IKDC grade (grade A: 47% of PT and 57% of HT; P = .35). An ACL graft rupture occurred in 17% of the HT group and 8% of the PT group (P = .07). An ACL graft rupture was associated with nonideal tunnel position (odds ratio [OR], 5.0) and male sex (OR, 3.2). Contralateral ACL rupture occurred in significantly more PT patients (26%) than HT patients (12%) (P = .02) and was associated with age ≤18 years (OR, 4.1) and the PT graft (OR, 2.6). CONCLUSION: Anterior cruciate ligament reconstruction using ipsilateral autograft continues to show excellent results in terms of patient satisfaction, symptoms, function, activity level, and stability. The use of HT autograft does, however, show better outcomes than the PT autograft in all of these outcome measures. Additionally, at 15 years, the HT graft-reconstructed ACLs have shown a lower rate of radiological osteoarthritis.

Analysis of return to competition and repeat rupture for 298 anterior cruciate ligament reconstructions with patellar or hamstring tendon autograft in sportspeople.

OBJECTIVES: To establish the influence of the type of surgical technique, competitive level, type of sport and the time before returning to competition on the reinjury rate after anterior cruciate ligament (ACL) surgery. METHODS: The authors followed-up 540 competitive sportspeople who had undergone ACL surgery via patellar or hamstring tendon autograft (HTA) techniques in 2003 and 2004. The sportspeople (all of whom had competed at a regional or higher level) were asked to fill out a questionnaire during their fourth postoperative year. RESULTS: The 298 respondees (reply rate: 55.1%) had the same characteristics as the initial (operated) population. The reinjury rates after HTA and patellar tendon autograft (PTA) were 12.7 and 6.1%, respectively. There was no statistically significant difference between these two values (P=0.14). Age and gender were not correlated with the frequency of reinjury. The reinjury rate rose slightly with increasing competitive level (regional level: 8.1%; national level: 10.4%; international level: 12.5%) but these differences were not statistically significant. Soccer had the highest reinjury rate (20.8%). Regardless of the surgical technique, sportspeople returning to competition within seven months of surgery had a greater risk of reinjury than those returning after this time point (15.3 versus 5.2%, P=0.014). The risk dropped from 13.9 to 2.6% (P=0.047) for PTA and from 16.6 to 7.6% (P=0.2) for HTA. Of the four reinjuries in sportspeople returning to competition with the first six months postoperative, three occurred within one month of resumption. CONCLUSION: Post-HTA reinjury rates are higher than post-PTA rates but the difference is not statistically significant. For sportspeople at a regional or higher level, the time interval before the return to competition has an influence on the risk of reinjury.

Comparison of revision rates in bone-patella tendon-bone autograft and allograft anterior cruciate ligament reconstruction.

This study compared the revision rates after autograft and allograft bone-patella tendon-bone anterior cruciate ligament (ACL) reconstruction. All bone-patella tendon-bone ACL reconstructions performed by a single surgeon between January 2000 and December 2006 were identified by retrospective chart review. Two hundred twenty-three patients met the inclusion criteria and 173 patients were available for follow-up. One hundred forty-two patients underwent bone-patella tendon-bone autograft reconstruction, and 31 patients underwent bone-patella tendon-bone allograft reconstruction. At a mean follow-up of 49 months (range, 11-91 months), revision rates were 0.7% (1/142) in the bone-patella tendon-bone autograft group versus 9.7% (3/31) in the bone-patella tendon-bone allograft group (P=.02). Subjective International Knee Documentation Committee (IKDC) scores of nonrevised (surviving) grafts in the bone-patella tendon-bone autograft group were 98.3 versus 95.2 in the bone-patella tendon-bone-allograft group (P=.0006). Tegner scores of nonrevised grafts in the bone-patella tendon-bone-autograft group were 6.2 vs 6.5 in the bone-patella tendon-bone-allograft group (P=.03). Fourteen of the 31 (45%) allografts were irradiated and all failures occurred in irradiated grafts. When irradiated grafts were excluded, no difference in revision rates was found. Anterior cruciate ligament reconstruction with the use of bone-patella tendon-bone allografts is associated with a higher revision rate when compared to bone-patella tendon autograft reconstruction. In addition, when comparing surviving grafts, the subjective IKDC scores are higher in the autograft group. When irradiated grafts are excluded, no difference in revision rates was found. Surgeons should be aware of the higher revision rate associated with allograft ACL reconstruction when counseling patients on graft options.