Incidence of Osteoarthritis Between ACL Reconstruction With Different Graft Types and Between ACL Reconstruction and Repair: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Background: Variation in stiffness, fixation methods, and donor-site morbidity after anterior cruciate ligament reconstruction (ACLR) with different graft types and with anterior cruciate ligament suture repair (ACLSR) can lead to differences in dynamic knee laxity and consequent differences in posttraumatic osteoarthritis (PTOA) development. Purpose: To compare the incidence of PTOA between different graft types used for primary ACLR and between primary ACLR and ACLSR. It was hypothesized that the incidence of PTOA would vary between ACLR with different autografts and allografts and between ACLR and ACLSR. Study Design: Systematic review; Level of evidence, 1. Methods: A search of the literature was performed to identify all randomized controlled trials (RCTs) comparing radiographic evidence of PTOA after ACLR between different graft types-hamstring tendon (HT) autograft, bone-patellar tendon-bone (BPTB) autograft, quadriceps tendon autograft, and allograft-and between ACLR and ACLSR. The minimum follow-up was 2 years. Study quality was assessed using the modified Coleman Methodology Score. A meta-analysis was performed to determine whether there was a difference in the incidence of PTOA between the different graft types and between ACLR and ACLSR. Results: Eleven randomized controlled trials were included in the meta-analysis-HT: 440 patients (mean follow-up, 9.7 years); BPTB: 307 patients (mean follow-up, 11.8 years); allograft: 246 patients (mean follow-up, 5 years); ACLSR, 22 patients (5 years). No study reporting the incidence after ACLR with quadriceps tendon was included. The study quality ranged from 70 to 88. The meta-analysis indicated no significant difference in the incidence of PTOA between graft types used for ACLR and between ACLR and ACLSR (risk ratios: HT vs BPTB, 1.05; HT vs allograft, 0.81; BPTB vs allograft, 0.82; HT vs ACLSR, not estimable [P > .05 for all]). The combined number of patients with PTOA in all studies per graft type showed that patients who underwent ACLR with a BPTB autograft had the highest percentage of PTOA (HT, 23.4%; BPTB, 29.6%; allograft, 8.1%; ACLSR, 0%). However, excluding studies with a follow-up <5 years resulted in similar outcomes for patients with an HT autograft and a BPTB autograft. Conclusion: This meta-analysis reported no difference in the incidence of PTOA between graft types used for ACLR and between ACLR and ACLSR. More research is necessary to make a reliable conclusion about which technique is associated with the lowest incidence of PTOA after ACL surgery.

Rate of Revision Surgery and Associated Risk Factors After Primary Arthroscopic ACL Repair With Additional Suture Augmentation.

Background: Recent studies have suggested promising patient-reported outcomes after primary anterior cruciate ligament (ACL) repair with additional suture augmentation (SA). Purpose: To evaluate the risk for revision surgery and identify patient- and injury-related risk factors after ACL repair with SA in a large patient cohort subject to strict patient selection. Study Design: Case-control study; Level of evidence, 3. Methods: Included were 86 patients (61 female; 93% follow-up rate) who underwent arthroscopic ACL repair with SA between January 2017 and March 2019 by a single surgeon and had a minimum follow-up of 24 months. Patients were selected for surgery with regard to time to surgery (preferably on the day of injury), tear pattern (limited to Sherman types 1 and 2), and tissue quality (intact synovial coverage). Postoperatively, the patients who needed revision surgery were identified and compared with patients who did not undergo revision surgery, using the Mann-Whitney U test for nonparametric analysis and the Student t test for parametric analysis. A Kaplan-Meier analysis was performed to investigate the survival rate of the ACL repair. Results: A total of 9 patients (10%; median age, 48 years; interquartile range [IQR], 27-50 years) underwent revision surgery at 12 months postoperatively (IQR, 8-25 months). The median follow-up of patients without revision surgery was 35 months (IQR, 33-44 months). The revision-free survival rate was 97% (95% CI, 93%-100%) after 1 year, 93% (95% CI, 88%-98%) after 2 years, and 90% (95% CI, 83%-97%) after 4 years. Patient-related factors-such as sex (P = .98), age at surgery (P = .459), body mass index (P = .352), and preinjury level of sports (P = .53)-had no significant impact on the survival rate of the ACL repair. Injury-related factors-such as concomitant injuries of the medial (P = .860) and lateral menisci (P = .414) and the medial (P = .801) and lateral collateral ligaments (P = .534) or same-day surgery compared with a delay of surgery of up to 18 days (P = .277)-had no significant impact on the survival rate of the ACL repair. Conclusion: The revision rate of primary ACL repair with SA at a 2-year follow-up was 10%. Patient- and injury-related factors were not associated with the survival rate of the ACL repair.

The Integral Role of Physiotherapy in Combined Complete Anterior Cruciate Ligament and Posterior Cruciate Ligament Arthroscopic Reconstruction: A Case Report.

Combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries are infrequent in clinical practice, often leading to severe knee instability and functional limitations. A 30-year-old male presented with right knee pain and swelling following a two-wheeler accident. Diagnostic investigations confirmed complete ACL and PCL tears. The surgical intervention comprised arthroscopic-assisted ACL reconstruction using semitendinosus and gracilis tendons, accompanied by arthroscopic PCL reconstruction. Postoperatively, structured physiotherapy rehabilitation was initiated. After 12 weeks of rehabilitation, significant improvements in range of motion and muscular strength were observed. Tailored physiotherapy facilitated prompt recovery, enhancing functional mobility and independent ambulation. This case highlights the efficacy of comprehensive surgical intervention followed by structured rehabilitation in achieving favorable outcomes in patients with combined ACL and PCL injuries. Tailored physiotherapy plays a crucial role in optimizing functional recovery and facilitates the enhancement of the patient's functional mobility and independent ambulation.

Traditional suture tape versus multiple high-strength sutures for augmentation of anterior cruciate ligament primary repair: A time-zero biomechanical study.

Background/objective: During the initial stages of rehabilitation after anterior cruciate ligament (ACL) surgery, a pivotal role is played in ensuring effective recuperation and averting complications. An often-employed strategy to tackle ACL laxity during this period involves the incorporation of synthetic materials for reinforcement. The objective of this study is to compare the effectiveness of conventional suture tape and multiple high-strength sutures as augmentation techniques for ACL repair. Methods: Ten preserved cadaveric knees embalmed using the Thiel method were segregated into two groups, each containing five knees. In one group, traditional suture tape was employed for augmentation, while the other group utilized multiple high-strength sutures. Each knee underwent a cyclic load of 1000 sine wave cycles, succeeded by an axial distraction load until failure ensued. The resultant displacement and ultimate load at failure were assessed to contrast the efficacy of the two augmentation techniques. Results: The group utilizing multiple high-strength sutures exhibited a significantly higher load to failure at time-zero (1690.7 N) compared to the suture tape group (987.6 N) (P = .003). Furthermore, the multiple high-strength sutures group demonstrated significantly reduced displacement after 1000 cyclic loads (6.6 mm) in comparison to the suture tape group (16.3 mm) (P < .001). Conclusions: Multiple high-strength sutures show better biomechanical properties for the augmentation of ACL repair at time-zero. Both suture tape and multiple high-strength sutures had ultimate load-to-failure values higher than the natural ACL loads. Therefore, these substances might serve as augmentation options to prevent the ACL's gradual elongation, a critical concern particularly in the initial stages of rehabilitation.

Comparison of Clinical Outcomes Between Modern Augmented ACL Repair and Autograft ACL Reconstruction: A Systematic Review and Meta-analysis of Studies With Minimum 2-Year Follow-up.

Background: Anterior cruciate ligament (ACL) reconstruction has been the gold standard for primary ACL rupture since the 1990s. In the past decade, ACL repair has received renewed attention and increased research. Purpose: To compare the clinical outcomes of modern augmented ACL repair versus autograft reconstruction for ACL ruptures. Study Design: Systematic review; Level of evidence, 3. Methods: A search of the PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Library databases was conducted for prospective or retrospective comparative studies published between January 1, 2010, and January 3, 2023, with a minimum 2-year follow-up. Two independent reviewers performed data extraction and methodological quality assessment. Sensitivity analysis was performed to maintain the stability of results. Results: Nine studies were included (minimum follow-up period, 24-60 months). The total sample size was 833 patients (augmented repair group: 358 patients; autograft ACL reconstruction group: 475 patients). There were 4 randomized controlled trials (level 1), 1 prospective comparative study (level 2), 2 retrospective comparative studies (level 3), and 2 case-control studies (level 3). The augmented ACL repair group attained significantly higher Lysholm score (weighted mean difference [WMD] = 1.57; 95% confidence interval [CI], 0.14-3.01; P = .03) and hamstring strength (WMD = 36.69; 95% CI, 29.07-44.31; P < .01) but had higher rates of hardware removal (odds ratio [OR] = 6.30; 95% CI, 2.44-16.23; P = .0001), reoperation (OR = 1.87; 95% CI, 1.33-2.62; P = .0003), and failure (OR = 1.58; 95% CI, 1.03-2.43; P = .0003) compared with the autograft ACL reconstruction group. No significant differences were observed between the repair and reconstruction groups regarding postoperative International Knee Documentation Committee scores, Tegner scores, knee laxity, satisfaction, ACL revisions, complications, and reoperation rather than revision. Conclusion: Augmented ACL repair was associated with higher rates of reoperation, hardware removal, and failure compared with autograft ACL reconstruction in studies with minimum 2-year follow-up data. However, augmented ACL repair had higher Lysholm scores and hamstring strength versus autograft ACL reconstruction.

Revisiting Anterior Cruciate Ligament Repairs in an Athlete With Combined Grade III Medial Collateral Ligament and High-Grade Posterolateral Anterior Cruciate Ligament Tear: A Case Report.

Anterior cruciate ligament tears are primarily treated by reconstruction. The development of novel surgical techniques has led to the reconsideration of this approach. Additionally, Grade III tibial-sided medial collateral ligament tears should be treated surgically due to decreased blood flow and poor healing. We describe the surgical repair of a Grade III tibial-sided tear with partial femoral avulsion of the medial collateral ligament and tear of the posterolateral bundle of the anterior cruciate ligament in a competitive high school athlete. A 17-year-old male presented to the Sports Medicine Clinic after injuring his left knee in a football game. Radiographs suggested normal skeletal anatomical alignment with no acute fractures. Magnetic resonance imaging identified a partial injury of the femoral attachment of the medial collateral ligament and a Grade III medial collateral ligament tear where it attached to the tibia. Arthroscopic evaluation of the knee revealed a posterolateral anterior cruciate ligament tear. Operative management included surgical repair of the Grade III tibial-sided medial collateral ligament tear and the posterolateral anterior cruciate ligament tear. Operative repair of medial collateral ligament and anterior cruciate ligament tears provides an alternative approach to the management of surgical reconstruction.

Pivot shift intraoperative quantitative assessment using a smartphone accelerometer in ACL deficient knees.

PURPOSE: The Pivot Shift (PS) test is a complex clinical sign that assesses the internal rotation and anterior tibial translation, which occurs abnormally in ACL deficient-knees. Because of the high inter-observer variability, different devices have been designed to characterize this complex movement in quantitative variables. The objective of this pilot study is to validate the reproducibility of intraoperative quantitative assessment of the PS with a smartphone accelerometer. METHODS: Twelve ACL-injured knees were included and compared with the contralateral uninjured side. The PS was measured by two independent observers utilizing a smartphone accelerometer and graded according to the IKDC classification. Measurements were taken preoperatively, intraoperatively and postoperatively. Intraoperative readings were taken during each stage of reconstruction or repair of meniscoligamentous lesions including meniscal lesions, ramp lesions, ACL reconstruction and lateral tenodesis. Reproducibility of the measurements were evaluated according to an intraclass correlation coefficient (ICC). RESULTS: The intra-observer reliability was good for the first examiner and excellent for the second examiner, with the ICC 0.89 [0.67, 0.98] p < 0,001 and ICC 0.97 [0.91, 1.0] p < 0,001 respectively. The inter-observer reliability was excellent between the two observers with the ICC 0.99 [0.97, 1.0] p < 0,001. The mean tibial acceleration measured 3.45 m.s2 (SD = 1.71) preoperatively on the injured knees and 1.03 m.s2 (SD = 0.36) on the healthy knees, demonstrating a significant difference following univariate analysis p < 0.001. Postoperatively, no significant difference was observed between healthy and reconstructed knees The magnitudes of tibial acceleration values were correlated with the PS IKDC grade. CONCLUSION: The smartphone accelerometer is a reproducible device to quantitatively assess the internal rotation and anterior tibial translation during ACL reconstruction surgery. The measurements are influenced by the different surgical steps. Other larger cohort studies are needed to evaluate the specific impact of each step of the ACL reconstruction and meniscal repair on this measurement. An external validation using other technologies are needed to validate the reliability of this device to assess the PS test. LEVEL OF EVIDENCE: Level IV, case series, pilot study.

Feasibility study of oxidized naringin as a novel crosslinking agent for crosslinking decellularized porcine Achilles tendon and its potential application for anterior cruciate ligament repair.

Naringin (Nar), a natural flavanone glycoside, has been shown to possess a variety of biological activities, including anti-inflammatory, anti-apoptotic, bone formation, and so forth. In this study, Nar was oxidized by sodium periodate and the oxidized naringin (ONar) was used as a novel biological crosslinking agent. In addition, ONar-fixed porcine decellularized Achilles tendon (DAT) was developed to substitute anterior cruciate ligament (ACL) for researching a novel ACL replacement material. The ONar with a 24 h oxidation time had appropriate aldehyde group content, almost no cytotoxicity, and a good crosslinking effect. The critical characteristics and cytocompatibility of ONar-fixed DAT were also investigated. The results demonstrated that 1% ONar-fixed DAT exhibited good resistance to enzymatic degradation and thermal stability as well as suitable mechanical strength. Moreover, 1% ONar-fixed specimens exhibited excellent L929 fibroblasts-cytocompatibility and MC3T3-E1-cytocompatibility. They also promoted the secretion of hepatocyte growth factor (HGF) and basic fibroblast growth factor (bFGF) from fibroblasts and bone morphogenetic protein-2 (BMP-2) from osteoblasts. And they also showed the good anti-inflammatory properties in vivo experiments. Our data provided an experimental basis for ONar as a new cross-linking reagent in chemical modification of DAT and ONar-fixed DAT for ACL repair.

Collagen wrapping and local platelet-rich fibrin do not improve the survival rates of ACL repair with dynamic intraligamentary stabilization: a retrospective case series after ≥5 years postoperatively.

PURPOSE: Anterior cruciate ligament (ACL) repair has been recommended as a treatment principle for ACL tears. Several authors have advocated a potential role for primary repair techniques in the ACL decision tree. However, long-term results have been controversial. This study aims to determine the survival of the primarily repaired ACL after dynamic intraligamentary stabilization (DIS) with and without augmentation. METHODS: Between 2014 and 2019, 102 patients with isolated proximal ACL ruptures underwent DIS repair within 21 days from injury and were available for follow-up either clinically or telephonically after ≥5 years postoperatively. In 45 cases, DIS repair was augmented with collagen fleece wrapping, platelet-rich fibrin (PRF) or both. Failure was defined as traumatic re-rupture or conversion to ACL reconstruction. The patients being available for physical examination underwent a.-p. stability measurement with a KT-1000 device. Functional outcome was measured with the IKDC, Tegner and Lysholm scores. Kaplan-Meier survival analysis, Log-Rank Test and Binominal logistic regression were performed. RESULTS: After a minimum 5-year follow-up, 71/102 (69.6%) DIS repairs were not re-reptured and clinically and/or subjectively stable. Augmentation did not improve survival rates (p = 0.812). The identified factors influencing failure were a younger age and a pre-injury Tegner activity level of ≥7. 95.7% of those patients with an intact ACL repair had normal or near normal knee function based on the IKDC scoring system. CONCLUSIONS: The 5-year overall survival rate of DIS was 69.6%. Collagen fleece wrapping and local PRF application did not improve survival. Patients not suffering failure of repair demonstrated high satisfaction. Nevertheless, the results are inferior to those of established ACL reconstruction procedures. LEVEL OF EVIDENCE: Case series, Level IV.

fNIRS brain measures of ongoing nociception during surgical incisions under anesthesia.

Significance: Functional near-infrared spectroscopy (fNIRS) has evaluated pain in awake and anesthetized states. Aim: We evaluated fNIRS signals under general anesthesia in patients undergoing knee surgery for anterior cruciate ligament repair. Approach: Patients were split into groups: those with regional nerve block (NB) and those without (non-NB). Continuous fNIRS measures came from three regions: the primary somatosensory cortex (S1), known to be involved in evaluation of nociception, the lateral prefrontal cortex (BA9), and the polar frontal cortex (BA10), both involved in higher cortical functions (such as cognition and emotion). Results: Our results show three significant differences in fNIRS signals to incision procedures between groups: (1) NB compared with non-NB was associated with a greater net positive hemodynamic response to pain procedures in S1; (2) dynamic correlation between the prefrontal cortex (PreFC) and S1 within 1 min of painful procedures are anticorrelated in NB while positively correlated in non-NB; and (3) hemodynamic measures of activation were similar at two separate time points during surgery (i.e., first and last incisions) in PreFC and S1 but showed significant differences in their overlap. Comparing pain levels immediately after surgery and during discharge from postoperative care revealed no significant differences in the pain levels between NB and non-NB. Conclusion: Our data suggest multiple pain events that occur during surgery using devised algorithms could potentially give a measure of "pain load." This may allow for evaluation of central sensitization (i.e., a heightened state of the nervous system where noxious and non-noxious stimuli is perceived as painful) to postoperative pain levels and the resulting analgesic consumption. This evaluation could potentially predict postsurgical chronic neuropathic pain.

Rehabilitation Principles to Consider for Anterior Cruciate Ligament Repair.

CONTEXT: Injury to the anterior cruciate ligament (ACL) is among the most common orthopaedic injuries, and reconstruction of a ruptured ACL is a common orthopaedic procedure. In general, surgical intervention is necessary to restore stability to the injured knee, and to prevent meniscal damage. Along with surgery, intense postoperative physical therapy is needed to restore function to the injured extremity. ACL reconstruction (ACLR) has been the standard of care in recent decades, and advances in surgical technology have reintroduced the prospect of augmented primary repair of the native ACL via a variety of methods. EVIDENCE ACQUISITION: A search of PubMed database of articles and reviews available in English was performed through 2020. The search terms ACLR, anterior cruciate ligament repair, bridge enhanced acl repair, suture anchor repair, dynamic intraligamentary stabilization, internal bracing, suture ligament augmentation, and internal brace ligament augmentation were used. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 5. RESULTS: No exact consensus exists on effective rehabilitation protocols after ACL repair techniques, as the variation in published protocols seem even greater than the variation in those for ACLR. For some techniques such as internal bracing and dynamic interligamentary stabilization, it is likely permissible for the patients to progress to full weightbearing and discontinue bracing sooner. However, caution should be applied with regard to earlier return to sport than after ACLR as to minimize risk for retear. CONCLUSION: More research is needed to address how physical therapies must adapt to these innovative repair techniques. Until that is accomplished, we recommend that physical therapists understand the differences among the various ACL surgery techniques discussed here and work with the surgeons to develop a rehabilitation protocol for their mutual patients. STRENGTH OF RECOMMENDATION TAXONOMY (SORT): C.

Primary stability of single-stage revision reconstruction of the anterior cruciate ligament in case of failure of dynamic intraligamentary stabilization depends on implant position during ACL repair.

INTRODUCTION: The object of this study was to evaluate the primary stability of tibial interference screw (IFS) fixation in single-stage revision surgery of the anterior cruciate ligament (ACL) in the case of recurrent instability after ACL repair with dynamic intraligamentary stabilization (DIS), dependent on the implant position during DIS. MATERIALS AND METHODS: Tibial aperture fixation in ACL reconstruction (ACL-R) was performed in a porcine knee model using an IFS. Native ACL-R was performed in the control group (n = 15). In the intervention groups DIS and subsequent implant removal were performed prior to single-stage revision ACL-R. A distance of 20 mm in group R-DIS1 (n = 15) and 5 mm in group R-DIS2 (n = 15) was left between the joint line and the implant during DIS. Specimens were mounted in a material-testing machine and load-to-failure was applied in a worst-case-scenario. RESULTS: Load to failure was 454 ± 111 N in the R-DIS1 group, 154 ± 71 N in the R-DIS2 group and 405 ± 105 N in the primary ACL-R group. Load-to-failure, stiffness and elongation of the group R-DIS2 were significantly inferior in comparison to R-DIS1 and ACL-R respectively (p < 0.001). No significant difference was found between load-to-failure, stiffness and elongation of R-DIS1 and the control group. CONCLUSION: Primary stability of tibial aperture fixation in single-stage revision ACL-R in case of recurrent instability after DIS depends on monobloc position during ACL repair. Primary stability is comparable to aperture fixation in primary ACL-R, if a bone stock of 20 mm is left between the monobloc and the tibial joint line during the initial procedure.

Prognostic factors for tibiofemoral and patellofemoral osteoarthritis 32-37 years after anterior cruciate ligament injury managed with early surgical repair or rehabilitation alone.

OBJECTIVE: Explore prognostic factors for tibiofemoral (TFJ) and patellofemoral (PFJ) radiographic osteoarthritis (ROA) and 'symptoms plus ROA' (SOA), 32-37 years following anterior cruciate ligament (ACL) injury. DESIGN: Exploratory analysis, longitudinal cohort. METHODS: In 1980-1985, 251 patients aged 15-40 years with acute ACL rupture were allocated to early augmented or non-augmented repair (5 ± 4 days post-injury) plus rehabilitation, or rehabilitation alone. 127 of 190 participants who completed follow-up questionnaires were eligible. We classified ROA as TFJ/PFJ K&L Grade ≥2, and SOA as ROA plus pain and/or symptoms. Multivariable age-adjusted logistic regression investigated potential prognostic factors (assessed at 4 ± 1 year follow-up: ACL treatment, isokinetic quadriceps/hamstrings strength, single-leg-hop for distance, knee flexion/extension deficit, knee laxity, Tegner Activity Scale, Lysholm Scale; sex, baseline meniscus status). RESULTS: 127 patients were aged 58 ± 6 years; BMI 27 ± 4 kg/m2; 28% female; 59% had TFJ-ROA, 48% had TFJ-SOA (including n = 9 knee-arthroplasties), 36% had PFJ-ROA; 27% had PFJ-SOA. Baseline meniscus surgery was a prognostic factor for TFJ-ROA (multivariable age-adjusted odds ratio (95% CI): 3.0 (1.2, 7.8)). A single-leg-hop limb symmetry index (LSI) < 90% was a prognostic factor for PFJ-ROA (5.1 (1.4, 18.7)) and PFJ-SOA (4.9 (1.2, 19.7)). Hamstrings strength LSI <90% was a prognostic factor for PFJ-SOA (5.0 (1.3, 19.3)). ACL treatment with rehabilitation-alone was associated with an 80% reduction in the odds of PFJ-SOA (0.2 (0.1-0.7)), compared with early ACL-repair. CONCLUSIONS: These findings are hypothesis generating, research is needed to determine whether ACL-injured individuals with these characteristics benefit from interventions to prevent or delay the onset of osteoarthritis.

The Utility of Continuous Passive Motion After Anterior Cruciate Ligament Reconstruction: A Systematic Review of Comparative Studies.

BACKGROUND: The application of continuous passive motion (CPM) after anterior cruciate ligament reconstruction (ACLR) was popularized in the 1990s, but advancements in the understanding of ACLR rehabilitation have made the application of CPM controversial. Many sports medicine fellowship-trained surgeons report using CPM machines postoperatively. PURPOSE: To determine the efficacy of CPM use for recovery after ACLR with respect to knee range of motion (ROM), knee swelling, postoperative pain, and postoperative complications. STUDY DESIGN: Systematic review; Level of evidence, 3. METHODS: The PubMed (MEDLINE), EMBASE, Cochrane, Cumulative Index of Nursing, and Allied Health Literature databases were searched from inception to January 1, 2020, for studies with evidence levels 1 to 3 on the use of CPM for ACLR rehabilitation. Included studies were those that comparatively evaluated postoperative outcomes after ACLR between at least 2 groups of patients, with 1 having received CPM rehabilitation and the other not having received CPM. RESULTS: A total of 12 studies from 1989 to 2019 met the inclusion criteria. These studies included 808 patients who underwent ACLR. There was no evidence of CPM improving knee stability, final postoperative ROM, or subjective pain scores. Additionally, CPM did not lead to decreased muscle atrophy or improved International Knee Documentation Committee scores. Regarding pain medication intake during postoperative hospitalization, 2 studies found that the CPM group used less pain medication, 1 study found the CPM group used more pain medication, and 1 study found that there was no difference between the 2 groups. Complications varied widely, with 2 of 12 studies reporting complications that required a return to the operating room. CONCLUSION: A clinical benefit of postoperative CPM use after ACLR was not identified in this review. While our systematic review identified a number of studies that suggest CPM use may be associated with lower usage of pain medication in hospitalized patients, this cannot be confirmed without further investigation with standardized CPM protocols and larger sample sizes. Routine CPM use after ACLR was not supported by this systematic review.

Repair versus reconstruction for proximal anterior cruciate ligament tears: a study protocol for a prospective multicenter randomized controlled trial.

BACKGROUND: For active patients with a tear of the anterior cruciate ligament (ACL) who would like to return to active level of sports, the current surgical gold standard is reconstruction of the ACL. Recently, there has been renewed interest in repairing the ACL in selected patients with a proximally torn ligament. Repair of the ligament has (potential) advantages over reconstruction of the ligament such as decreased surgical morbidity, faster return of range of motion, and potentially decreased awareness of the knee. Studies comparing both treatments in a prospective randomized method are currently lacking. METHODS: This study is a multicenter prospective block randomized controlled trial. A total of 74 patients with acute proximal isolated ACL tears will be assigned in a 1:1 allocation ratio to either (I) ACL repair using cortical button fixation and additional suture augmentation or (II) ACL reconstruction using an all-inside autologous hamstring graft technique. The primary objective is to assess if ACL repair is non-inferior to ACL reconstruction regarding the subjective International Knee Documentation Committee (IKDC) score at two-years postoperatively. The secondary objectives are to assess if ACL repair is non-inferior with regards to (I) other patient-reported outcomes measures (i.e. Knee Injury and Osteoarthritis Outcome Score, Lysholm score, Forgotten Joint Score, patient satisfaction and pain), (II) objective outcome measures (i.e. failure of repair or graft defined as rerupture or symptomatic instability, reoperation, contralateral injury, and stability using the objective IKDC score and Rollimeter/KT-2000), (III) return to sports assessed by Tegner activity score and the ACL-Return to Sports Index at two-year follow-up, and (IV) long-term osteoarthritis at 10-year follow-up. DISCUSSION: Over the last decade there has been a resurgence of interest in repair of proximally torn ACLs. Several cohort studies have shown encouraging short-term and mid-term results using these techniques, but prospective randomized studies are lacking. Therefore, this randomized controlled trial has been designed to assess whether ACL repair is at least equivalent to the current gold standard of ACL reconstruction in both subjective and objective outcome scores. TRIAL REGISTRATION: Registered at Netherlands Trial Register ( NL9072 ) on 25th of November 2020.

Accuracy of magnetic resonance imaging in predicting anterior cruciate ligament tear location and tear degree.

PURPOSE: The purpose of this study is to evaluate the reliability of magnetic resonance imaging (MRI) in predicting the location of ACL tears in preoperative planning for anterior cruciate ligament (ACL) repair. METHODS: Thirty-four patients who underwent ACL repair were retrospectively analyzed to compare intraoperative arthroscopic findings with preoperative MRIs. RESULTS: For identifying type I tears, the sensitivity of MRI was 9.0% and the accuracy of MRI was 8.8%. There was moderate interrater agreement between MRI findings for tear location and tear degree. CONCLUSION: MRI alone may not necessarily be accurate in identifying which ACL tears are amenable to repair. STUDY DESIGN: Retrospective case series; Level of Evidence: IV.

Effect of tranexamic acid in arthroscopic anterior cruciate ligament repair: A systematic review and meta-analysis of randomised clinical trials.

PURPOSE: Perioperative blood loss remains a major challenge to surgeons in anterior cruciate ligament reconstruction (ACLR) surgery, despite of the introduction of minimally invasive approach. Tranexamic acid (TXA) is believed to reduce blood loss, which may minimise the complication of postoperative haemarthrosis with insufficient evidence on its effectiveness in ACLR. The primary aim of this study was to examine the effect of TXA on postoperative blood loss and other secondary outcomes in patients undergoing arthroscopic ACLR surgery. METHOD: PUBMED, EMBASE, MEDLINE and CENTRAL database were systematically searched from its inception until November 2020. All randomised clinical trials (RCTs) comparing TXA (intravenous or intra-articular) versus placebo in the arthroscopic ACLR surgery were included. Case series, case report and editorials were excluded. RESULTS: Five RCTs comprising of a total of 580 patients (291 in TXA group, 289 in control group) were included for qualitative and quantitative meta-analysis. In comparison to placebo, TXA group was significantly associated with lower postoperative blood loss (mean difference (MD): -81.93 ml; 95% CI -141.80 to -22.05) and lower incidence of needing knee aspiration (odd ratio (OR): 0.19; 95% CI 0.08 to 0.44). Patients who randomised to TXA were also reported to have better range of movement (MD: 2.86; 95% CI 0.54 to 5.18), lower VAS Pain Score (MD: -1.39; 95% CI -2.54 to -0.25) and higher Lysholm Score (MD: 7.38; 95% CI 2.75 to 12.01). CONCLUSION: In this meta-analysis, TXA reduced postoperative blood loss with lesser incidence of needing knee aspiration along with better range of knee movement and Lysholm score in patients undergoing arthroscopic ACLR surgery.

Injury-related fear in athletes returning to sports after anterior cruciate ligament reconstruction - A quantitative content analysis of an open-ended questionnaire.

BACKGROUND/OBJECTIVE: Injury-related fear during sport activities are major psychological factors inhibiting a person's return to sports (RTS) following anterior cruciate ligament reconstruction (ACLR). Currently, there are no studies that quantitatively analyse the open-ended questionnaire for knee injury-related fear in post-ACLR athletes.The purpose of this study was to identify knee injury-related fear in athletes who return to ball-centric sports via the use of an open-ended questionnaire. We aimed to determine the main concepts of injury-related fear according to sex, type of sport, and participation level. METHODS: In this study, a quantitative analysis of an open-ended questionnaire was used to examine the type of fear athletes experience after returning to ball-centric sports. The RTS and fear questionnaire collected open-ended questionnaire to knee injury-related fear during sport activities; this questionnaire was completed at the outpatient visit post-RTS. Quantitative content analysis was performed to extract frequently occurring words from the responses to the questionnaire to create a co-occurrence network. The resulting co-occurrence network and extracted words were used to create concepts regarding knee injury-related fear. The relationship between each concept and subject demographics (sex, returned sports events, and participation level) were analysed using the chi-squared test. RESULTS: Fifty-four athletes (30 females and 24 males) aged 16-45 [median age: 21.2; interquartile range (IQR): 11.0] years with an average RTS of 8.0 (IQR: 3.3) months from ACLR participated in the study. A total of 79 responses were included in the analysis. The knee injury-related fear can be summarized as follows: (1) Quick response to the opponent; (2) Ball-related play; (3) Jump-landing; (4) Contact; (5) Loss of balance; and (6) Athletic movement. Chi-squared tests showed that athletes participating in sport events with potential contact with an opponent (soccer, futsal, basketball, handball, lacrosse, and ultimate (frisbee)) were more likely to experience fear in quick response to the opponent (P < 0.01, adjusted residual = 2.943, ϕ = 0.301). CONCLUSION: The knee injury-related fear can be summarized into six concepts. Post-ACLR athletes participating in ball-centric sports need to assess fear in situations such as quick responses to the opponent's movements and ball-related play, in addition to simple movements such as jumping, cutting, and contact.

Bridge-Enhanced Anterior Cruciate Ligament Repair Leads to Greater Limb Asymmetry and Less Cartilage Damage Than Untreated ACL Transection or ACL Reconstruction in the Porcine Model.

BACKGROUND: The extent of posttraumatic osteoarthritis (PTOA) in the porcine anterior cruciate ligament (ACL) transection model is dependent on the surgical treatment selected. In a previous study, animals treated with bridge-enhanced ACL repair using a tissue-engineered implant developed less PTOA than those treated with ACL reconstruction (ACLR). Alterations in gait, including asymmetric weightbearing and shorter stance times, have been noted in clinical studies of subjects with osteoarthritis. HYPOTHESIS: Animals receiving a surgical treatment that results in less PTOA (ie, bridge-enhanced ACL repair) would exhibit fewer longitudinal postoperative gait asymmetries over a 1-year period when compared with treatments that result in greater PTOA (ie, ACLR and ACL transection). STUDY DESIGN: Controlled laboratory study. METHODS: Thirty-six Yucatan minipigs underwent ACL transection and were randomized to receive (1) no further treatment, (2) ACLR, or (3) bridge-enhanced ACL repair. Gait analyses were performed preoperatively, and at 4, 12, 26, and 52 weeks postoperatively. Macroscopic cartilage assessments were performed at 52 weeks. RESULTS: Knees treated with bridge-enhanced ACL repair had less macroscopic damage in the medial tibial plateau than those treated with ACLR or ACL transection (adjusted P = .03 for both comparisons). The knees treated with bridge-enhanced ACL repair had greater asymmetry in hindlimb maximum force and impulse loading at 52 weeks than the knees treated with ACL transection (adjusted P < .05 for both comparisons). Although not significant, there was a trend that knees treated with bridge-enhanced ACL repair had greater asymmetry in hindlimb maximum force and impulse loading (adjusted P < .10 for both comparisons) compared with ACLR. CONCLUSION: Contrary to our hypothesis, the surgical treatment resulting in less macroscopic cartilage damage (ie, bridge-enhanced ACL repair) exhibited greater asymmetry in load-related gait parameters than the other surgical groups. This finding suggests that increased offloading of the surgical knee may be associated with a slower rate of PTOA development. CLINICAL RELEVANCE: Less cartilage damage at 52 weeks was found in the surgical group that continued to protect the limb from full body weight during gait. This finding suggests that protection of the knee from maximum stresses may be important in minimizing the development of PTOA in the ACL-injured knee within 1 year.

Suture tape augmentation ACL repair, stable knee, and favorable PROMs, but a re-rupture rate of 11% within 2 years.

PURPOSE: The aim of this study is to investigate clinical and magnetic resonance imaging (MRI) outcomes after anterior cruciate ligament (ACL) repair using the suture tape augmentation (STA) technique. METHODS: This prospective interventional case series included 35 patients who underwent STA ACL repair and were all followed up for 2 years. The ACL rupture was between 4 and 12 weeks old and per-operatively confirmed repairable. The International Knee Documentation Committee (IKDC), and Lysholm and Tegner scores were collected together with return to work (RTW), return to sport (RTS), re-rupture, and re-intervention rate. Lachman testing was performed and ACL healing was evaluated on MRI using a grading scale based on the ACL's morphology and signal intensity with grade 1 representing good ACL healing and grade 3 representing poor ACL healing. RESULTS: The number of patients who returned to their pre-rupture level for IKDC, Lysholm, and Tegner scores at 2 years of follow-up are 17/26 (65.4%), 13/25 (52.0%), and 18/27 (66.7%) patients, respectively. Median RTW and RTS periods were 5.5 weeks (range 0-32 weeks) and 6 months (range 2-22 months), respectively. The Lachman side-to-side difference decreased significantly (P < 0.001) to less than 3 mm after surgery and remained stable. Four patients [11.4%, 95% CI (3.2, 26.7)] suffered from a re-rupture and three other patients [8.6%, 95% CI (1.8, 23.1)] needed a re-intervention for another reason than re-rupture. MRI follow-up of 31 patients showed overall grade 1 ACL healing in 14 (45.2%) patients, grade 2 ACL healing in 11 (35.5%) patients, and grade 3 ACL healing in 6 (19.4%) patients. A higher risk of re-rupture was associated with grade 3 ACL healing at 6 months post-operatively and a pre-operative Tegner score of ≥ 7. CONCLUSION: This study shows that treatment of the acute, repairable ACL with the STA technique leads to a stable knee and favorable patient-reported outcome measures (PROMs). However, the re-rupture rate of 11.4% within the 2-year follow-up is a concern. LEVEL OF EVIDENCE: IV.