Anterior cruciate ligament-return to sport after injury scale: validation of the Norwegian language version.

PURPOSE: Evidence is emerging on the importance of psychological readiness to return to sport after anterior cruciate ligament (ACL) reconstruction. The ACL-Return to Sport after Injury scale (ACL-RSI) is developed to assess this. The aim of the current study was to translate ACL-RSI into Norwegian and examine the measurement properties of the Norwegian version (ACL-RSI-No). METHODS: ACL-RSI was translated according to international guidelines. A cohort of 197 ACL-reconstructed patients completed ACL-RSI-No and related questionnaires nine months post-surgery. One hundred and forty-six patients completed hop tests and 142 patients completed strength tests. Face and structural validity (confirmative factor analysis and explorative analyses), internal consistency [Cronbach's alpha (α)], test-retest reliability [Intraclass Correlation Coefficients (ICC)], measurement error [Standard error of measurement (SEM) and smallest detectable change at individual (SDCind) and group level (SDCgroup)] and construct validity (hypotheses testing; independent t tests, Pearson's r) were examined. RESULTS: ACL-RSI-No had good face validity. Factor analyses suggested that the use of a sum score is reasonable. Internal consistency and test-retest reliability were good (α 0.95, ICC 0.94 (95% CI 0.84-0.97) and measurement error low (SEM 5.7). SDCind was 15.8 points and SDCgroup was 2.0. Six of seven hypotheses were confirmed. CONCLUSIONS: ACL-RSI-No displayed good measurement properties. Factor analyses suggested one underlying explanatory factor for "psychological readiness"-supporting the use of a single sum score. ACL-RSI-No can be used in the evaluation of psychological readiness to return to sport after ACL injury. LEVEL OF EVIDENCE: III.

Increased revision rate with posterior tibial tunnel placement after using the 70-degree tibial guide in ACL reconstruction.

PURPOSE: To map knee morphology radiographically in a population with a torn ACL and to investigate whether anatomic factors could be related to outcomes after ACL reconstruction at mid- to long-term follow-up. Further, we wanted to assess tibial tunnel placement after using the 70-degree "anti-impingement" tibial tunnel guide and investigate any relation between tunnel placement and revision surgery. METHODS: Patients undergoing ACL reconstruction involving the 70-degree tibial guide from 2003 to 2008 were included. Two independent investigators analysed pre- and post-operative radiographs. Demographic data and information on revision surgery were collected from an internal database. Anatomic factors and post-operative tibial tunnel placements were investigated as predictors of revision. RESULTS: Three-hundred and seventy-seven patients were included in the study. A large anatomic variation with significant differences between men and women was seen. None of the anatomic factors could be related to a significant increase in revision rate. Patients with a posterior tibial tunnel placement, defined as 50 % or more posterior on the Amis and Jakob line, did, however, have a higher risk of revision surgery compared to patients with an anterior tunnel placement (P = 0.03). CONCLUSION: Use of the 70-degree tibial guide did result in a high incidence (47 %) of posterior tibial tunnel placements associated with an increased rate of revision surgery. The current study was, however, not able to identify any anatomic variation that could be related to a higher risk of revision surgery. Avoiding graft impingement from the femoral roof in anterior tibial tunnel placements is important, but the insight that overly posterior tunnel placement can lead to inferior outcome should also be kept in mind when performing ACL surgery. LEVEL OF EVIDENCE: IV.

The effect of intraoperative fluoroscopy on the accuracy of femoral tunnel placement in single-bundle anatomic ACL reconstruction.

PURPOSE: The purpose of the current study was to investigate the potential effect of intraoperative fluoroscopy on the accuracy of femoral tunnel placement in anatomic ACL reconstruction, using an ideal anatomic point as reference and evaluating postoperative tunnel placement based on 3D CT. METHODS: An experienced ACL surgeon, using the anatomic approach for femoral tunnel placement, relying on intraarticular landmarks and remnants of the torn ACL-and novel to the fluoroscopic assist-was introduced to its use. A prospective series of patients was included where group 1 (without fluoroscopy) and group 2 (with fluoroscopy) both had postoperative CT scans so that femoral tunnel position could be evaluated and compared to an ideal tunnel centre based on anatomic studies by using the Bernard and Hertel grid. RESULTS: Group 2, where fluoroscopy was used, had a mean femoral tunnel that was closer to the ideal anatomic centre than group 1. In the Bernard and Hertel grid, the distance in the high-low axis (y-axis) was found significantly closer (P = 0.001), whilst the deep-shallow axis (x-axis) and a total absolute distance were not significantly closer to the ideal described anatomic centre. CONCLUSIONS: Intraoperative fluoroscopy was found effective as an aid for placing the femoral tunnel in a more accurate position, as compared to a desired anatomic centre. Although the concept of the "one-size-fits-all" approach for tunnel placement is debatable, the avoidance of grossly misplaced tunnels is the benefit of using fluoroscopy during ACL reconstruction. The authors hold that fluoroscopy is readily available, safe and easy to use and therefore a good aid in the anatomic approach for graft tunnel placement, for example, in a learning situation, in revision cases and when performing low volumes of such surgery. LEVEL OF EVIDENCE: III.

The effect of feedback from post-operative 3D CT on placement of femoral tunnels in single-bundle anatomic ACL reconstruction.

PURPOSE: To evaluate the effect of feedback from post-operative 3D CT in the learning process of placing the femoral graft tunnel anatomically using the anteromedial (AM)-portal technique in single-bundle anterior cruciate ligament (ACL) reconstruction. METHODS: An experienced knee surgeon converting from transtibial to AM-portal technique was offered post-operative feedback on tunnel placement. Three groups of patients were included: transtibial drilling, (AM1) anteromedial drilling without feedback and (AM2) anteromedial drilling with post-operative CT feedback. Intra-articular landmarks were used as the only guidance for tunnel placement. Tunnel position was compared to an ideal anatomical ACL position using the Bernard and Hertel grid and visual feedback was given on tunnel placements. The effect of feedback was measured as the distance from the anatomical centre, and spread of tunnel placements on post-operative CT performed feedback was initiated. RESULTS: When comparing the femoral tunnel placement to an ideal anatomical centre, there was an improvement in the mean tunnel position after (A) changing from a transtibial to an anatomical technique and a further improvement after (B) initializing the radiological feedback. There was a great variation of femoral tunnel localizations when initially only using intra-articular landmarks as guidance for tunnel placement--this variation, however, converged towards the anatomical centre throughout the feedback period and the AM2 group had a femoral tunnel closer (P = 0.001) to the anatomical centre than the AM1 group. CONCLUSIONS: Post-operative 3D CT is effective in the learning process of placing femoral tunnels anatomically by giving post-operative feedback on tunnel placement. Bony landmarks and ACL remnants were found unreliable as the only guidance for femoral tunnel placement in the AM-portal technique-therefore, the use of an aid is recommended to reduce unwanted tunnel variations in a learning phase. LEVEL OF EVIDENCE: Cohort Study, Level III.

Symptoms and function in patients with articular cartilage lesions in 1,000 knee arthroscopies.

PURPOSE: Focal chondral lesions of the knee are commonly occurring. A lot is known about their frequency, size and localisation in arthroscopic series, but less about the symptoms they elicit and little about how the arthroscopic findings and symptoms correlate. The purposes of the present study included to investigate the relationship between articular cartilage lesion factors and patient factors, and to compare the symptoms and function of cartilage lesion patients to those of patients with a deficient ACL. METHODS: A prospective registration was conducted of preoperative data including Lysholm knee score and perioperative findings in 1,000 consecutive patients undergoing an arthroscopic procedure of the knee-including microfracture of articular cartilage defects and ACL reconstructions. RESULTS: Chondral or osteochondral lesions were found in 57 % of the arthroscopies. The mean Lysholm score in this subgroup was 55. The mean Lysholm score was significantly lower in women (50, SD 19) compared to men (59, SD 18, p < 0.001). Among the chondral lesion factors, only kissing (vs. non-kissing) lesions and multiple (vs. single) lesions influenced symptoms and function to a more than negligible degree. Microfracture in one or two articular cartilage defects was performed in 187 patients. The microfracture group had a significant lower mean Lysholm score (54, SD 18) than a group of patients (N = 71) undergoing ACL reconstruction group (67, SD 17, p < 0.001). CONCLUSION: The study confirms that articular cartilage lesions are both common and cumbersome. Women seem to have more problems than men, whereas chondral lesion factors-such as localisation and size-seem to influence symptoms and function to a small degree. These aspects should be addressed when designing outcome studies, and should also be of interest to the orthopaedic surgeon-in the day-by-day clinical work. When treating these patients, our prime focus need to be on knee function rather than the cartilage defect as the relationship between the latter and the former is unclear. LEVEL OF EVIDENCE: Case-control study, Level III.

Results at 10-14 years after microfracture treatment of articular cartilage defects in the knee.

PURPOSE: To evaluate the long-term clinical outcome after microfracture treatment of focal chondral defects of the knee and to investigate possible early determinants of the outcome. METHODS: A prospective cohort of 110 patients, treated with microfracture, was evaluated at a median of 12 years (range 10-14) by Lysholm score, VAS of knee function and VAS of knee pain. Pre- and perioperative information was collected, and additional surgery to the same knee during the follow-up period was recorded. Analysis of variance and paired t test were used for comparison of the long-term data to results from the baseline examination and a former 5-year (midterm) follow-up evaluation. RESULTS: Forty-three patients needed additional surgery to the knee including seven knee replacements. Fifty had a poor long-term outcome-defined as a knee replacement surgery or Lysholm score below 64. A poor result was more common in subgroups with mild degenerative changes in the cartilage surrounding the treated defect, concurrent partial meniscectomy, poor baseline Lysholm score or long-standing knee symptoms. The Lysholm score, function VAS and pain VAS all significantly improved from the baseline values to the mean scores of 65 (SD 24), 65 (SD 24) and 31 (SD 24), respectively, at the long-term evaluation. The long-term scores did not differ significantly from the midterm scores. CONCLUSIONS: The outcome scores improved significantly from baseline to the long-term evaluation and were not different from the midterm outcome. Still, a normal knee function was generally not achieved, and many patients had further surgery. The results call for more research and, at present, caution in recommending microfracture in articular cartilage defects, especially in subgroups with worse prognosis. LEVEL OF EVIDENCE: Case series, Level IV.

The impact of sensory deficits after harvesting hamstrings autograft for ACL reconstruction.

PURPOSE: The aim of this study was threefold: to investigate the incidence of sensory deficits after harvesting hamstrings autografts, to localise and measure the area of altered sensibility and to investigate the impact of any sensory deficit on the patients daily life. METHODS: A consecutive series of sixty-one patients were examined for sensory deficits related to harvest of hamstrings tendons 10 years after having had an anterior cruciate ligament reconstruction. A neurological examination of the leg was performed to investigate for potential altered sensibility and to quantify the extent of the lesion. The patients answered the anterior knee symptoms (AKS) questionnaire and additional questions regarding impact on activities of daily life by any sensory deficit. RESULTS: Eighty-five per cent of the examined patients had sensory deficits--experienced as numbness (78 %) and paraesthesia (16 %)--distal to the site of tendon harvesting. The mean affected area was 70 (SD 62) cm(2). No patients experienced sensory deficit symptoms to such a degree that it affected their activities of daily life, but the group with sensory deficit had significantly more AKS than patients without sensory deficit, as evaluated by the AKS score (P = 0.02). The most commonly reported complaints were related to strenuous activities and kneeling knee position. CONCLUSIONS: This long-term evaluation shows that sensory deficit after hamstring tendons harvesting affects a majority of patients and is probably permanent. Most patients reported this as being only mildly bothersome, but they have significantly more AKS as assessed by the AKS questionnaire. In clinical practice, patients should be counselled prior to tendon harvesting on the incidence and characteristic of the sensory deficit along with other possible peri- and postoperative complications. LEVEL OF EVIDENCE: Case series, Level IV.

Effect of a too posterior placement of the tibial tunnel on the outcome 10-12 years after anterior cruciate ligament reconstruction using the 70-degree tibial guide.

PURPOSE: To examine the relationship between the radiographically assessed placement of the tibial tunnel and the long-term clinical and subjective outcome in anterior cruciate ligament-reconstructed patients. METHODS: Patients were examined clinically, with subjective score systems and with standardised radiographs 10-12 years postoperatively. Only patients reconstructed with the aid of the 70-degree tibial drill guide were included. A posterior placement of the tibial tunnel was defined as >50% along the Amis and Jakob line (AJL). A high tunnel inclination was defined as >75° in the coronal plane. The possible linear relationships between clinical findings, subjective scores and tibial tunnel placement were investigated. RESULTS: Eighty-six percentage of the 96 patients were available for examination. Mean tibial tunnel inclination was 71.1° (SD 4.2). No difference was found in subjective scores and knee stability between high (14%) and low (86%) inclination groups. Mean placement of the tibial tunnel along the AJL was 46% (SD 5). Patients with a posterior tibial tunnel placement (24%) had a higher incidence of rotational instability (P = 0.02). Patients with rotational instability (grade 2 pivot shift) had significant lower Lysholm score than those with grade 0 and 1 rotational instability (P = 0.001). CONCLUSIONS: The use of a tibial drill guide that relates to the femoral roof leads to a posterior tibial tunnel placement (>50% of the tibial AP-diameter) in 24% of the patients. These patients have a significant higher proportion of rotational instability and worse subjective outcome. LEVEL OF EVIDENCE: Case series, Level IV.

ACL Reconstruction Using Quadrupled Semitendinosus Versus Double-Stranded Semitendinosus and Gracilis Autograft: 2-Year Results From a Prospective Randomized Controlled Study.

BACKGROUND: A disadvantage of using hamstring tendon autograft consisting of the semitendinosus and gracilis tendons for anterior cruciate ligament reconstruction is pain from tendon harvesting and persistent hamstring weakness. In the tendon-sparing all-inside technique, a quadrupled semitendinosus graft and adjustable-loop cortical fixation are suggested to give less postoperative flexion deficits while displaying overall similar clinical results to the traditional hamstring technique. However, there are a limited number of high-quality studies comparing these techniques with inconsistent results. PURPOSE: To investigate differences between the all-inside (quadrupled semitendinosus) and traditional hamstring (double-stranded semitendinosus and gracilis) technique regarding (1) self-reported function, (2) hamstring strength, and (3) knee laxity. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 98 patients were randomized to either the all-inside or the traditional hamstring technique. Perioperatively, duration of surgery and graft size were obtained. The International Knee Documentation Committee 2000 Subjective Knee Form score, Knee injury and Osteoarthritis Outcome Score, Tegner Activity Scale score, knee laxity (KT-1000 arthrometer side-to-side difference and pivot shift), range of motion, isokinetic knee strength, and hop test score were collected preoperatively and 2 years postoperatively. Return-to-sport readiness was evaluated 9 months postoperatively. RESULTS: A total of 89 patients completed 2-year follow-up, 45 patients with the all-inside technique and 44 patients with the traditional hamstring technique. There were no significant differences between groups in any of the outcome measures 2 years after surgery, but there was a tendency in the all-inside group toward having increased anterior translation (mean, 3.6 mm vs 2.7 mm), a higher number of revision surgeries (5 patients vs 2 patients), and more patients having +1 and +2 pivot-shift values (29 vs 18 patients) when compared with the traditional group. CONCLUSION: The all-inside technique yields equivalent results to the traditional hamstring technique 2 years after surgery and should be considered a reliable technique to use for ACL reconstruction. Sparing the gracilis tendon does not lead to less persistent hamstring weakness. Long-term follow-up is needed to further determine whether the tendency of increased anterior translation seen at 2 years postoperatively will lead to a higher risk of graft failure.

How to read post-operative radiographs and CT scans after single-bundle anterior cruciate ligament reconstruction.

Reconstruction of the anterior cruciate ligament (ACL) is a well-established surgical procedure. However, post-operative imaging in the early phase is not routinely performed. The rationale for performing such imaging is to provide a baseline examination for future controls, to provide immediate feedback to surgeons regarding tunnel placement, and to assess placement of fixation devices. The purpose of this paper is to enable the reader to accurately read post-operative radiographs and CT scans after single-bundle ACL reconstruction.

Long-term results after reconstruction of the ACL with hamstrings autograft and transtibial femoral drilling.

PURPOSE: To evaluate the long-term clinical, patient-reported and radiological outcome of patients reconstructed for anterior cruciate ligament (ACL) insufficiency. We wanted to examine the relationship between clinical findings and patient-reported scores. METHODS: The 96 first successive patients that underwent ACL reconstruction using transtibial technique, hamstrings autograft and tunnel placement ad modum Howell were evaluated 10 years post-operatively. Subjective outcomes were Lysholm score, IKDC 2000 subjective score and Tegner activity scale. The clinical examination included evaluation of rotational and sagittal laxity. Evaluation of osteoarthritis was done radiologically. RESULTS: Eighty-three patients (86%) were available for follow-up at mean 10.2 years post-operatively. Three patients had revision ACL surgery prior to the 10-year evaluation. The mean Lysholm score, subjective IKDC 2000 score and Tegner activity scale were 89 (SD 13), 83 (SD 15) and 5 (range, 3-9), respectively. Six patients (8%) had moderate or severe osteoarthritis. Eighty-six per cent of patients had normal or near-normal anterior-posterior ACL laxity. Twenty per cent of patients had positive pivot shift and 42 % had a pivot glide. The former group had a significant lower Lysholm score compared to the rest of the patients. CONCLUSIONS: Although the mean Lysholm score was classified as good (89) at the 10-year follow-up, a positive pivot shift was found in 20% of these patients. Compared to patients with normal rotational laxity or pivot glide, this patient group reported significant lower subjective satisfaction at the long-term follow-up. LEVEL OF EVIDENCE: Case series, level IV.

Long-term follow-up of patellar tendon grafts or hamstring tendon grafts in endoscopic ACL reconstructions.

PURPOSE: Several studies compare the short- and long-term results of anterior cruciate ligament (ACL) reconstruction using bone-patellar tendon-bone (BPTB) graft or double-looped semitendinosus and gracilis (DLSG) graft. However, no studies evaluate the long-term results of BPTB grafts fixed with metal interference screws and DLSG grafts fixed with the Bone Mulch Screw and the Washer Loc. This prospective randomized multicentre study has the null hypothesis that there is no difference in long-term outcome between the two procedures. METHODS: A total of 114 patients with a symptomatic ACL rupture were randomized to reconstruction with either a BPTB graft (N = 58) or a DLSG graft (N = 56). Follow-up was conducted after one, two and seven years. At the seven-year follow-up, 102 of the 114 patients (89%) were available for evaluation; however, 16 of these by telephone-interview only. RESULTS: Ten patients in the BPTB group and 19 patients in the DLSG group underwent additional knee surgery (P = 0.048), two and three, respectively, of these were ACL revisions (n.s.). The total flexion work was lower in the DLSG group (P = 0.001). The mean peak flexion torque and extension work, however, showed no difference between the groups. No significant differences were found between the groups regarding the Tegner activity score, the Lysholm functional score, the Knee injury and osteoarthritis outcome score (KOOS), subjective knee function, anterior knee pain or mobility. There was no significant difference in laxity between the groups on the Lachman test or the KT-1,000 maximum manual force test. CONCLUSIONS: Both grafts and fixation methods resulted in satisfactory subjective outcome and objective stability. Both these methods can therefore be considered as suitable alternatives for ACL reconstructions. LEVEL OF EVIDENCE: II.

The Effect of Posterior Tibial Slope on the Risk of Revision Surgery After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: A significant proportion of patients undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) later experience graft failure. Some studies suggest an association between a steep posterior tibial slope (PTS) and graft failure. PURPOSE: To examine the PTS in a large cohort of patients about to undergo ACLR and to determine whether a steep PTS is associated with later revision surgery. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A retrospective review of a cohort undergoing isolated ACLR between 2002 and 2012 (with 8-19 years of follow-up) was conducted. Preoperative sagittal radiographs of knees in full extension were used for measurements of the PTS. There were 2 independent examiners who performed repeated measurements to assess the reliability of the method. Statistical analyses were performed to compare the PTS in the groups with and without later revision surgery. RESULTS: A total of 728 patients, with a mean age of 28 years at the time of surgery, were included. Overall, 10% (n = 76) underwent revision surgery during the observation period. The group of injured knees had a significantly steeper PTS compared with the group of uninjured knees (9.5° vs 8.7°, respectively; P < .05). The mean PTS in the no revision group was 9.5° compared with 9.3° in the revision group (not significant). Dichotomized testing of revision rates related to PTS cutoff values of ≥10°, ≥12°, ≥14°, ≥16°, and ≥18° showed no association of PTS steepness (not significant) to graft failure. Patients with revision were younger than the ones without (mean age, 24 ± 8 vs 29 ± 10 years, respectively) and had a shorter time from injury to ACLR (mean, 14 ± 27 vs 24 ± 44 months, respectively) as well as a smaller graft size (8.2 vs 8.4 mm, respectively; P = .040). CONCLUSION: The current study did not find any association between a steep PTS measured on lateral knee radiographs and revision ACL surgery. However, a steeper PTS was seen in the group of injured knees compared with the group of uninjured (contralateral) knees. Independent of the PTS, younger patients, those with a shorter time from injury to surgery, and those with a smaller graft size were found to undergo revision surgery more often.

Predictors of Osteoarthritis Development at a Median 25 Years After Anterior Cruciate Ligament Reconstruction Using a Patellar Tendon Autograft.

BACKGROUND: Few studies have investigated the outcome ≥20 years after an anterior cruciate ligament reconstruction (ACLR) with a bone-patellar tendon-bone autograft, and there is a wide range in the reported rates of radiographic osteoarthritis (OA). PURPOSE: To report on radiographic OA development and to assess risk factors of knee OA at a median 25 years after ACLR with a bone-patellar tendon-bone autograft. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Unilateral ACLRs performed at a single center from 1987 to 1994 were included (N = 235). The study population was followed prospectively with clinical testing and questionnaires. Results from the 3-month, 12-month, and median 25-year follow-up are presented. In addition, a radiographic evaluation was performed at the final follow-up. Radiographic OA was defined as Kellgren-Lawrence grade ≥2 or having undergone ipsilateral knee replacement surgery. Possible predictors of OA development included patient age, sex, time from injury to surgery, use of a Kennedy ligament augmentation device, any concomitant meniscal surgery, and return to preinjury sports after surgery. RESULTS: At long-term follow-up, 60% (141/235) of patients had radiographic OA in the involved knee and 18% (40/227) in the contralateral knee (P < .001). Increased age at surgery, male sex, increased time between injury and surgery, a Kennedy ligament augmentation device, and medial and lateral meniscal surgery were significant predictors of OA development in univariate analyses. Return to preinjury level of sports after surgery was associated with less development of OA. In the multivariate model, medial meniscal surgery and lateral meniscal surgery were independently associated with OA development. The adjusted odds ratio was 1.88 (95% CI, 1.03-3.43; P = .041) for medial meniscal surgery and 1.96 (95% CI, 1.05-3.67; P = .035) for lateral meniscal surgery. Patients who had developed radiographic signs of OA had significantly lower Knee injury and Osteoarthritis Outcome Score and Lysholm scores at long-term follow-up. CONCLUSION: At 25 years after ACLR, 60% of patients had developed OA in the involved knee, and these patients reported significantly lower subjective outcomes. Medial meniscal surgery and lateral meniscal surgery were independent predictors of OA development at long-term follow-up.

Effect of Early Residual Laxity After Anterior Cruciate Ligament Reconstruction on Long-term Laxity, Graft Failure, Return to Sports, and Subjective Outcome at 25 Years.

BACKGROUND: In spite of supposedly successful surgery, slight residual knee laxity may be found at follow-up evaluations after anterior cruciate ligament reconstruction (ACLR), and its clinical effect is undetermined. PURPOSE: To investigate whether a 3- to 5-mm increase in anterior translation 6 months after ACLR affects the risk of graft failure, rate of return to sports, and long-term outcome. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: From a cohort of 234 soccer, team handball, and basketball players undergoing ACLR using bone-patellar tendon-bone graft, 151 athletes were included who attended 6-month follow-up that included KT-1000 arthrometer measures. A tight graft was defined as <3-mm side-to-side difference between knees (n = 129), a slightly loose graft as 3 to 5 mm (n = 20), and a loose graft as >5 mm (n = 2). Graft failure was defined as ACL revision surgery, >5-mm side-to-side difference, or anterolateral rotational instability 2+ or 3+ at 2-year follow-up. Finally, a 25-year evaluation was performed, including a clinical examination and questionnaires. RESULTS: The rate of return to pivoting sports was 74% among athletes with tight grafts and 70% among those with slightly loose grafts. Also, return to preinjury level of sports was similar between those with slightly loose and tight grafts (40% vs 48%, respectively), but median duration of the sports career was longer among patients with tight grafts: 6 years (range, 1-25 years) vs 2 years (range, 1-15 years) (P = .01). Five slightly loose grafts (28%) and 6 tight grafts (5%) were classified as failures after 2 years (P = .002). Thirty percent (n = 6) of patients with slightly loose grafts and 6% (n = 8) with tight grafts had undergone revision (P = .004) by follow-up (25 years, range, 22-30 years). Anterior translation was still increased among the slightly loose grafts as compared with tight grafts at long-term follow-up (P < .05). In patients with tight grafts, 94% had a Lysholm score ≥84 after 24 months and 58% after 25 years, as opposed to 78% (P = .02) and 33% (P = .048), respectively, among patients with slightly loose grafts. CONCLUSION: A slightly loose graft at 6 months after ACLR increased the risk of later ACL revision surgery and/or graft failure, reduced the length of the athlete's sports career, caused permanent increased anterior laxity, and led to an inferior Lysholm score.

Association Between Psychological Readiness and Knee Laxity and Their Predictive Value for Return to Sport in Patients With Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Deciding when patients are ready to return to sport (RTS) after an anterior cruciate ligament (ACL) reconstruction (ACLR) is challenging. The understanding of which factors affect readiness and how they may be related is limited. Therefore, despite widespread use of RTS testing, there is a lack of knowledge about which tests are informative on the ability to resume sports. PURPOSE: To examine whether there is an association between knee laxity and psychological readiness to RTS after ACLR and to evaluate the predictive value of these measures on sports resumption. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients aged ≥16 years engaged in physical activity/sports before injury were recruited at routine clinical assessment 9-12 months after ACLR. Exclusion criteria were concomitant ligament surgery at ACLR and/or previous ACL injury in the contralateral knee. At baseline, a project-specific activity questionnaire and the ACL-Return to Sport After Injury (ACL-RSI) scale were completed. Knee laxity was assessed by use of the Lachman test, KT-1000 arthrometer, and pivot-shift test. Two years after surgery, knee reinjuries and RTS status (the project-specific questionnaire) were registered. Associations between psychological readiness and knee laxity were evaluated with the Spearman rho test, and predictive ability of the ACL-RSI and knee laxity tests were examined using regression analyses. RESULTS: Of 171 patients screened for eligibility, 132 were included in the study. There were small but significant associations between the ACL-RSI score and the Lachman test (rho = -0.18; P = .046) and KT-1000 arthrometer measurement (rho = -0.18; P = .040) but no association between the ACL-RSI and the pivot-shift test at the time of recruitment. Of the total patients, 36% returned to preinjury sport level by 2 years after surgery. Higher age, better psychological readiness, and less anterior tibial displacement (KT-1000 arthrometer measurement) were significant predictors of 2-year RTS (explained variance, 33%). CONCLUSION: Small but significant associations were found between measurements of psychological readiness and anterior tibial displacement, indicating that patients with less knee laxity after ACLR feel more ready to RTS. ACL-RSI and KT-1000 arthrometer measurements were independent predictors of 2-year RTS and should be considered in RTS assessments after ACLR.

The Role of Psychological Readiness in Return to Sport Assessment After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Knowledge about the predictive value of return to sport (RTS) test batteries applied after anterior cruciate ligament reconstruction (ACLR) is limited. Adding assessment of psychological readiness has been recommended, but knowledge of how this affects the predictive ability of test batteries is lacking. PURPOSE: To examine the predictive ability of a RTS test battery on return to preinjury level of sport and reinjury when evaluation of psychological readiness was incorporated. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 129 patients were recruited 9 months after ACLR. Inclusion criteria were age ≥16 years and engagement in sports before injury. Patients with concomitant ligamentous surgery or ACL revision surgery were excluded. Baseline testing included single-leg hop tests, isokinetic strength tests, the International Knee Documentation Committee (IKDC) Subjective Knee Form 2000, a custom-made RTS questionnaire, and the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale. The RTS criteria were IKDC 2000 score ≥85% and ≥85% leg symmetry index on hop and strength test. At a 2-year follow-up evaluation, further knee surgery and reinjuries were registered and the RTS questionnaire was completed again. Regression analyses and receiver operating characteristic analyses were performed to study the predictive ability of the test battery. RESULTS: Out of the 103 patients who completed the 2-year follow-up, 42% returned to their preinjury level of sport. ACL-RSI 9 months after surgery (odds ratio [OR], 1.03) and age (OR, 1.05) predicted RTS. An ACL-RSI score <47 indicated that a patient was at risk of not returning to sport (area under the curve 0.69; 95% CI, 0.58-0.79), with 85% sensitivity and 45% specificity. The functional tests did not predict RTS. Six patients sustained ACL reinjuries and 7 underwent surgery for other knee complaints/injuries after RTS testing. None of the 29 patients who passed all RTS criteria, and were therefore cleared for RTS, sustained a second knee injury. CONCLUSION: ACL-RSI and age were predictors of 2-year RTS, while functional tests were not informative. Another main finding was that none of the patients who passed the 85% RTS criteria sustained another knee injury.

Autologous patellar tendon and quadrupled hamstring grafts in anterior cruciate ligament reconstruction: a prospective randomized multicenter review of different fixation methods.

ACL reconstruction with bone patellar tendon bone (BPTB) grafts has been shown to produce dependable results. Recently, reconstructions with double-looped semitendinosus gracilis (DLSG) grafts have become common. The prevailing opinion is that ACL reconstruction with patellar tendon graft produces a more stable knee with more anterior knee pain than DLSG grafts, while the functional results and knee scores are similar. The present study evaluates BPTB grafts fixed with metallic interference screws and DLSG grafts fixed with Bone Mulch Screw on the femur and WasherLoc fixation on the tibia. All else being the same, there is no difference in the outcome between the two grafts and fixation methods. This is a prospective randomized multicenter study. A total of 115 patients with isolated ACL ruptures were randomized to either reconstruction with BPTB grafts fixed with metal interference screws (58 patients) or DLSG grafts (57 patients) fixed with Bone Mulch Screws and WasherLoc Screws. Follow-up was at one and two years; the latter by an independent observer. At two years, one ACL revision had been performed in each group. Eight patients in the DLSG group and one in the BPTB group underwent meniscus surgery in the follow-up period (P = 0.014). Mean Lysholm score at the two year follow-up was 91 (SD +/- 10.3) in the DLSG group and also 91 (SD +/- 10.2) in the BPTB group. Mean KT-1000 at two years was 1.5 mm in the BPTB group and 1.8 mm in the DLSG group (n.s.). At two years, four patients in the BPTB group and three in the DLSG group had a Lachman test grade 2 or 3 (n.s.). More patients in the BPTB group had pain at the lower pole of the patella (P = 0.04). Peak flexion torque and total flexion work were lower in the DLSG group at one year (P = 0.003 and P = 0.000) and total flexion work also at two years (P = 0.05). BPTB ACL reconstruction fixed with interference screws and DLSG fixed with Bone Mulch Screws on the femur and WasherLoc Screws on the tibia produce satisfactory and nearly identical outcomes. Among our patients in the DLSG group, flexion strength was lower, and more patients underwent meniscus surgery in the follow-up period. The BPTB group has more anterior knee pain.

Microfracture treatment of single or multiple articular cartilage defects of the knee: a 5-year median follow-up of 110 patients.

We compared the results of microfracture in single versus multiple symptomatic articular cartilage defects in the knee in 110 patients with a median age of 38 years (range 15-60). Cases of reoperation of the cartilage defect were classified as failures. Clinical outcome in non-failures was evaluated by the Lysholm score and grading of knee pain and function of the knee by the use of patient-administered visual analog scales (VAS; 0-100). Data were prospectively collected before the operation and at the 2- to 9-year follow-up. The single lesion or the largest of multiple lesions were located on the medial femoral condyle (n = 62), trochlea (n = 18), lateral tibia (n = 11), patella (n = 10) or lateral femoral condyle (n = 9). We treated one (n = 76), two (n = 27) or three (n = 7) lesions with a median total area of 4 cm(2) (range 1-15). A total of 24 failures (22%) were registered-18% in the single-defect subgroup and 29% in the multiple-defects subgroup. In the remaining group of patients (n = 86), the mean Lysholm score, mean pain-score (0 = no pain; 100 = worst possible pain) and mean function-score (0 = useless; 100 = full function) improved from 51, 52 and 41, respectively, to 71 (P < 0.001), 30 (P < 0.001) and 69 (P < 0.001) at the follow-up. The pain-score was significant lower (P = 0.042), and the function-score significantly higher (P = 0.001) in the group of patients with a single lesion compared to the group with 2 or 3 lesions. The Lysholm score did not differ significantly between the two subgroups (P = 0.06).

Failed Meniscal Repairs After Anterior Cruciate Ligament Reconstruction Increases Risk of Revision Surgery.

BACKGROUND: Failed anterior cruciate ligament (ACL) reconstruction (ACLR) can lead to reduced quality of life because of recurrent episodes of instability, restrictions in level of activity, and development of osteoarthritis. A profound knowledge of the causes of a failed surgery can ultimately help improve graft survival rates. PURPOSE: To investigate the patient-related risks of inferior outcomes leading to revision surgery after ACLR. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: From a prospective cohort of primary ACLRs performed at a single center, patients who required later revision surgery were matched with a control group of uneventful primary ACLRs. Patient characteristics, data from the preoperative examinations, KT-1000 arthrometer laxity testing, Tegner activity scale, International Knee Documentation Committee subjective score, Knee injury and Osteoarthritis Outcome Score, and perioperative data from the initial surgery were included. RESULTS: A total of 100 revision cases and 100 matched controls, with a median follow-up time of 11 years, were included in the study. Those who had undergone revision surgery were younger at the time of reconstruction and had a shorter time from injury to surgery than their matched controls (P = .006). The control group-of uneventful ACLRs-had a higher incidence of meniscal repair at reconstruction (P = .024). Also, the revision group more frequently experienced later failure of the previous meniscal repair (P = .004). Surgeon experience was not found to affect the risk of revision ACL surgery. Those who had undergone ACL revision surgery had more frequently received a hamstring tendon graft size of <8 mm (P = .018) compared with the controls. CONCLUSION: The current study demonstrated that failed meniscal repair and a hamstring tendon graft size of <8 mm were associated with primary ACLR failure. Also, younger age at the time of surgery and shorter time from injury to surgery were found to affect the risk of undergoing revision ACL surgery.