Sports activity and quality of life improve after isolated ACL, isolated PCL, and combined ACL/PCL reconstruction.

PURPOSE: To compare patient-reported outcomes following isolated anterior cruciate ligament reconstruction (ACL-R), isolated posterior cruciate ligament reconstruction (PCL-R), and combined ACL-R and PCL-R (ACL/PCL-R), at a minimum follow-up of 2 years. METHODS: This was a prospective observational registry cohort study based on the Swedish National Knee Ligament Registry. Patients undergoing isolated ACL-R, isolated PCL-R, and combined ACL/PCL-R between 2005 and 2019 were eligible for inclusion. Demographic characteristics as well as injury- and surgery-related data were queried from the SNKLR. To evaluate functional outcomes, the Knee Injury and Osteoarthritis Outcome Score (KOOS) was collected preoperatively and at 1- and 2-year follow-ups and compared between the treatment groups. RESULTS: In total, 45,169 patients underwent isolated ACL-R, 192 patients isolated PCL-R, and 203 patients combined ACL/PCL-R. Preoperatively, and at the 1- and 2-year follow-ups, KOOS subscales were highest for the isolated ACL-R group, followed by the isolated PCL-R, and lowest for the combined ACL/PCL-R groups. Significant improvements were observed across all treatment groups in the majority of KOOS subscales between the preoperative, and 1- and 2-year follow-ups. All treatment groups showed the greatest improvements between the preoperative and 2-year follow-ups in the knee-related quality of life (mean improvement: isolated ACL-R, + 28 points; isolated PCL-R, + 23 points; combined ACL/PCL-R, + 21 points) and the function in sport and recreation (mean improvement: isolated ACL-R, + 26 points; isolated PCL-R, + 20 points; combined ACL/PCL-R, + 19 points) subscales. CONCLUSION: Clinically relevant improvements in knee function can be expected after isolated ACL-R, isolated PCL-R, and combined ACL/PCL-R. Functional improvements were particularly pronounced in the KOOS function in sport and recreation subscale, indicating the importance of knee stability for sports activity. This study facilitates more comprehensive patient education about functional expectations after surgical treatment of isolated and combined ACL and PCL injuries. LEVEL OF EVIDENCE: Level 2.

Different patient and activity-related characteristics result in different injury profiles for patients with anterior cruciate ligament and posterior cruciate ligament injuries.

PURPOSE: To compare patient characteristics including patient sex, age, body mass index (BMI), activities at the time of injury and injury profiles in patients with anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries. METHODS: Data were obtained from the Swedish National Knee Ligament Registry. Two study groups were created: (1) index ACL reconstruction (ACL group) and (2) index PCL reconstruction (PCL group). Between-group differences were investigated using Fisher's exact test and Fisher's non-parametric permutation test for dichotomous variables and continuous variables, respectively. RESULTS: Of 39,010 patients, 38,904 were ACL injuries. A larger proportion of patients with combined injuries to the PCL, meniscus and cartilage were female, aged > 25 years and with a BMI of > 35 kg/m2 compared with patients with combined injuries to the ACL, meniscus and cartilage. An isolated ACL injury was more commonly found in males, while all other injury profiles of ACL, including combined injuries with meniscus, cartilage and collateral ligament injuries, were more frequently observed in females. The PCL injuries were sustained either during pivoting sports, non-pivoting sports or were traffic-related. CONCLUSION: Different patient characteristics (BMI, age and sex), and activities at the time of injury (sport- versus traffic-related activities), resulted in distinct injury profiles for the ACL and PCL groups. These findings provide valuable information of the way specific injury patterns of cruciate ligament injuries occur, and subsequently may help clinicians with the diagnostic process of ACL and PCL injuries. LEVEL OF EVIDENCE: III.

'I was young, I wanted to return to sport, and re-ruptured my ACL' - young active female patients' voices on the experience of sustaining an ACL re-rupture, a qualitative study.

BACKGROUND: Despite anterior cruciate ligament (ACL) re-ruptures being common, research on patient experiences after knee trauma has primarily focused on the time after primary ACL reconstruction. Integrating qualitative research and patient experiences can facilitate researchers and clinicians in understanding the burden of an ACL re-rupture. The aim of the study was to explore the experiences of an ACL re-rupture journey in young active females aiming to return to knee-strenuous sports after primary ACL reconstruction. METHOD: Fifteen young (19[range 16-23] years old) active females who suffered an ACL re-rupture were interviewed with semi-structured interviews. Qualitative content analysis using deductive approach based on Wiese-Bjornstal's 'integrated model of response to sport injury' was used. RESULTS: The results are presented in two timelines 1) from first ACL injury to ACL re-rupture, and 2) from ACL re-rupture to present day, and further stratified according to the domains of the 'integrated model of psychological response to injury'. Results in the first timeline are summarised into seven categories: Finding hope for the journey; Accepting my ACL injury; I succeeded; What matters now? Who am I?; Where will this end? What is going to happen? In the second timeline, eight categories were identified: Fighting spirit; A helping hand; Working hard; I am a new me; I am destroyed; Loneliness; Painful changes; and, I could have made it to the pro´s. CONCLUSION: Young active females who suffered an ACL re-rupture did not express any positive experience following their first ACL injury, however, in contrast, expressed positive experiences and personal growth after going through the ACL re-rupture journey, characterized by a lot of struggling, and ultimately led to the experience of becoming a new, stronger person.

Greater proportion of patients report an acceptable symptom state after ACL reconstruction compared with non-surgical treatment: a 10-year follow-up from the Swedish National Knee Ligament Registry.

OBJECTIVES: To compare the proportion of patients with anterior cruciate ligament (ACL) injury reporting an acceptable symptom state, between non-surgical and surgical treatment during a 10-year follow-up. METHODS: Data were extracted from the Swedish National Knee Ligament Registry. Exceeding the Patient Acceptable Symptom State (PASS) for the Knee injury and Osteoarthritis Outcome Score (KOOS) was the primary outcome. The PASS and KOOS4 (aggregated KOOS without the activities of daily living (ADL) subscale) were compared cross-sectionally at baseline and 1, 2, 5 and 10 years after ACL injury, where patients treated non-surgically were matched with the maximum number of patients with ACL reconstruction for age, sex and activity at injury. RESULTS: The non-surgical group consisted of 982 patients, who were each matched against 9 patients treated with ACL reconstruction (n=8,838). A greater proportion of patients treated with ACL reconstruction exceeded the PASS in KOOS pain, ADL, sports and recreation, and quality of life compared with patients treated non-surgically at all follow-ups. With respect to quality of life, significantly more patients undergoing ACL reconstruction achieved a PASS compared with patients receiving non-surgical treatment at all follow-ups except at baseline, with differences ranging between 11% and 25%; 1 year -25.4 (-29.1; -21.7), 2 years -16.9 (-21.2; -12.5), 5 years -11.0 (-16.9; -5.1) and 10 years -24.8 (-36.0; -13.6). The ACL-reconstructed group also reported statistically greater KOOS4 at all follow-ups. CONCLUSION: A greater proportion of patients treated with ACL reconstruction report acceptable knee function, including higher quality of life than patients treated non-surgically at cross-sectional follow-ups up to 10 years after the treatment of an ACL injury.

Different injury patterns exist among patients undergoing operative treatment of isolated PCL, combined PCL/ACL, and isolated ACL injuries: a study from the Swedish National Knee Ligament Registry.

PURPOSE: To compare demographic characteristics and concomitant injury patterns in patients undergoing primary isolated posterior cruciate ligament reconstruction (PCL-R) and combined posterior cruciate ligament (PCL) and anterior cruciate ligament (ACL) reconstruction (PCL-R/ACL-R) with isolated ACL reconstruction (ACL-R) as a reference using data from the Swedish National Knee Ligament Registry (SNKLR). METHODS: This cohort study based on the SNKLR comprised patients undergoing either PCL-R, ACL-R, or combined PCL-R/ACL-R between January 1, 2005 and December 31, 2019 in Sweden. Demographic and surgery-related data with regards to injury mechanism, concomitant intraarticular lesions and their treatment, neurovascular damage, and concomitant ligamentous injuries were extracted. Exclusion criteria included concomitant fractures of the femur, fibula, patella or tibia, and quadriceps or patellar tendon injury. RESULTS: A total of 45,564 patients were included in this study. Isolated PCL-R, combined PCL-R/ACL-R, and isolated ACL-R were performed in 192 (0.4%), 203 (0.5%) and 45,169 (99.1%) patients, respectively. Sports were identified as the cause of 64% of PCL-Rs, 54% of PCL-R/ACL-Rs, and 89% of ACL-Rs, while a traffic-related mechanism was identified in 20% of PCL-Rs, 27% of PCL-R/ACL-Rs and 2% of ACL-Rs. Meniscus injury prevalence was 45% in ACL-Rs, 31% in PCL-R/ACL-Rs and 16% in isolated PCL-Rs (p < 0.001). Cartilage injuries were more common in PCL-R (37%) and PCL-R/ACL-R patients (40%) compared to ACL-R patients (26%, p < 0.001). Concomitant knee ligament injury was identified in 28-44% of PCL-R/ACL-R patients. Neurovascular injuries were present in 9% of PCL-R/ACL-Rs, 1% of PCL-Rs, and 0.3% of ACL-Rs (p < 0.001). CONCLUSION: Differences in injury mechanisms among patient groups confirm that operatively treated PCL tears are frequently caused by both traffic and sports. Cartilage and ligament injuries were more frequent in patients with PCL-R compared to ACL-R. Consequently, combined PCL and ACL tears should raise suspicion for concomitant knee lesions with clinical relevance during the operative treatment of these complex injuries. LEVEL OF EVIDENCE: III.

Psychological impairments after ACL injury - Do we know what we are addressing? Experiences from sports physical therapists.

Psychological impairments can follow an anterior cruciate ligament (ACL) injury and can impact the rehabilitation process. Our aim was to investigate experiences of sports physical therapists (PTs) in addressing psychological impairments in patients after ACL injury. We conducted four focus group interviews with fourteen sports PTs. The PTs' experiences of working with psychological impairments after ACL injury were summarized in four main categories: (1) "Calling for a guiding light", where PTs stated that the most common method of acquiring knowledge on addressing psychological impairments was through discussions with colleagues, and, at the same time, PTs expressed an insufficient knowledge of how to address psychological impairments; (2) "Meeting the burden of psychological impairments" where PTs stated that psychological impairments are greater than physical; (3) "Trying to balance physical and psychological aspects" where patient education and assessments were reported to be important in order to understand psychological impairments during rehabilitation; and (4) "Goal setting: a helpful challenge" where sports PTs expressed a need for specific knowledge of the rehabilitation of psychological impairments following ACL injury. To help provide the current best practice, we encourage researchers to develop psychologically centered interventions for rehabilitation after an ACL injury, and PTs to stay up-to-date with the literature published on the subject, including to implement eventual interventions.

Treatment after ACL injury: Panther Symposium ACL Treatment Consensus Group.

Treatment strategies for ACL injuries continue to evolve. Evidence supporting best practice guidelines to manage ACL injury is largely based on studies with low-level evidence. An international consensus group of experts was convened determine consensus regarding best available evidence on operative versus non-operative treatment for ACL injury. The purpose of this study is to report the consensus statements on operative versus non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organising Committee and Session Chairs. Panel participants reviewed preliminary statements prior to the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty per cent agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus non-operative treatment of ACL injury reached consensus during the Symposium. Nine statements achieved unanimous support, two reached strong consensus, one did not achieve consensus, and one was removed due to redundancy in the information provided. In highly active patients engaged in jumping, cutting and pivoting sports, early anatomical ACL reconstruction is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomical ACL reconstruction is indicated. The consensus statements derived from international leaders in the field may assist clinicians in deciding between operative and non-operative treatment with patients after an ACL injury Level of evidence: Level V.

Graft Choice for Anterior Cruciate Ligament Reconstruction With a Concomitant Non-surgically Treated Medial Collateral Ligament Injury Does Not Influence the Risk of Revision.

PURPOSE: To compare the risk of anterior cruciate ligament (ACL) revision and the patient-reported outcome after ACL reconstruction with a concomitant non-surgically treated medial collateral ligament (MCL) injury with regard to 3 ACL graft choices; the use of semitendinosus (ST), the use of semitendinosus-gracilis (ST-G), and the use of patellar tendon (PT) autograft. It was hypothesized that the use of ST-G would be associated with a greater risk of ACL revision and poorer patient-reported knee function. METHODS: Patients older than 15 years of age registered for a primary ACL reconstruction with a concomitant non-surgically treated MCL injury in the Swedish National Knee Ligament Registry were assessed for eligibility. Three groups were created according to ACL autograft choice; the ST, the ST-G, and the PT group. The primary outcomes were ACL revision and the 1- and 2-year Knee injury and Osteoarthritis Outcome Score (KOOS), including the KOOS patient acceptable symptom state (PASS). Cox regression analysis was applied to determine the proportional hazard ratio (HR) of primary ACL reconstruction survival. The KOOS was compared using the Mann-Whitney U test and Fisher exact test. RESULTS: A total of 622 patients (mean age 29.7 years, 42.4% women) were included. There was no difference in the risk of ACL revision for either the ST group (HR 1.354; 95% confidence interval [CI] 0.678-2.702 or the PT group (HR 0.837; 95% CI 0.334-2.100), compared with the ST-G group. The ST group reported a greater mean 2-year KOOS sports and recreation (68.5, standard deviation [SD] 28.5) than the ST-G group (57.4 [SD 27.6], P = .010) and the PT group (54.1 [SD 30.3], P = .006). The ST group was superior in terms of achieving PASS in sports and recreation (55.3%; 95% CI 44.1-66.1%) compared with both the ST-G (37.4%; 95% CI 29.8-45.5%; P = .014) and the PT group (33.9%; 95% CI 22.1-47.4%; P = .009). CONCLUSIONS: The risk of ACL revision did not differ between HT and PT autografts in patients undergoing ACL reconstruction with a non-surgically treated MCL injury. However, the use of ST-G was associated with poorer 2-year patient-reported knee function compared with the ST. LEVEL OF EVIDENCE: Retrospective comparative trial, Level III.

Understanding limitations in sport 1 year after an Achilles tendon rupture: a multicentre analysis of 285 patients.

PURPOSE: The purpose of this study was to determine patient-related and treatment-related predictors of superior and inferior function in sport and recreational activities 1 year after an Achilles tendon rupture. METHODS: This study is based on a multicentre cohort from 4 previous randomised controlled trials. All the patients who had responded to the Foot and Ankle Outcome Score (FAOS) at the 1-year follow-up were included. All the patients had a clinically verified Achilles tendon rupture and patients who underwent surgery were treated within 96 h of the time of rupture. Patients were excluded in the event of a previous Achilles tendon rupture or the presence of other lifestyle diseases. The primary outcomes of the study were reported in the 20th and 80th percentiles of the FAOS subscale, function in sports and recreational activities. RESULTS: A total of 285 (84% men) patients with an average age of 40.0 (SD 8.4) years were included. Smoking increased the odds of superior self-reported FAOS sport and recreation [OR 4.59 (95% CI 1.58-13.32), p = 0.005] compared with non-smoking, while being female [OR 0.38 (95% CI 0.16-0.93), p = 0.035] and every increment of one unit in BMI [OR 0.89 (95% CI 0.81-0.99), p = 0.029] reduced the odds. No variable was statistically significant when attempting to predict which patients report inferior FAOS sport and recreation. The recovery of symmetry in heel-rise tests had no effect on 1-year FAOS sport and recreation. Patient-reported outcomes had a good-to-excellent explanatory capacity of superior and inferior 1-year function in sport and recreational activities (AUC = 0.87-0.93). CONCLUSION: BMI is a modifiable risk factor, which, when lowered, may be associated with less impairment in sports 1 year after an Achilles tendon rupture. Females appear to perceive more limitations than males. Unexpectedly, smokers experience less limitations in foot and ankle function. Patients who report no functional limitation in sport are characterised by an overall perception of adequate foot, ankle and Achilles function, despite not having recovered symmetry in the heel-rise test. LEVEL OF EVIDENCE: I.

Strength in numbers? The fragility index of studies from the Scandinavian knee ligament registries.

PURPOSE: The fragility index (FI) is a metric to evaluate the robustness of statistically significant results. It describes the number of patients who would need to change from a non-event to an event to change a result from significant to non-significant. This systematic survey aimed to evaluate the feasibility of applying the FI to findings related to anterior cruciate ligament (ACL) reconstruction in the Scandinavian knee ligament registries. METHODS: The PubMed, EMBASE, Cochrane Library and AMED databases were searched. Studies from the Scandinavian knee ligament registers were eligible if they reported a statistically significant result (p < 0.05) for any of the following dichotomous outcomes; ACL revision, contralateral ACL reconstruction or the presence of postoperative knee laxity. Only studies with a two-arm comparative analysis were included. Eligibility assessment, data extraction and quality assessment were performed by two independent reviewers. The dichotomous analyses were stratified according to the grouping variable for the two comparative arms as follows; age, patient sex, activity at injury, graft choice, drilling technique, graft fixation, single- versus double-bundle, concomitant cartilage injury and country. The two-sided Fisher's exact test was used to calculate the FI of all statistically significant analyses. RESULTS: From 158 identified studies, 13 studies were included. They reported statistical significance for a total of 56 dichotomous analyses, of which all but two had been determined by a time-to-event analysis. The median sample size for the arms was 5540 (range 92-38,666). The mean FI for all 56 dichotomous analyses was 80.6 (median 34.5), which means that a mean of 80.6 patients were needed to change outcome status to generate a non-significant result instead of a significant one. Seventeen analyses (30.4%) immediately became non-significant when performing the two-sided Fisher's exact test and, therefore, had an FI of 0. The analyses related to age were the most robust, with a mean FI of 178.5 (median 116, range 1-1089). The mean FI of the other grouping variables ranged from 0.5 to 48.0. CONCLUSION: There was large variability in the FI in analyses from the Scandinavian knee ligament registries and almost one third of the analyses had an FI of zero. The FI is a rough measurement of robustness when applied to registry studies, however, future studies are needed to determine the most appropriate metric for robustness in registry studies. The use of the FI can provide clinicians with a deeper understanding of significant study results and promotes an evidence-based approach in the clinical care of patients. LEVEL OF EVIDENCE: Systematic review of prospective cohort studies, Level II.

Clinical outcomes after anterior cruciate ligament injury: panther symposium ACL injury clinical outcomes consensus group.

PURPOSE: A stringent outcome assessment is a key aspect for establishing evidence-based clinical guidelines for anterior cruciate ligament (ACL) injury treatment. The aim of this consensus statement was to establish what data should be reported when conducting an ACL outcome study, what specific outcome measurements should be used and at what follow-up time those outcomes should be assessed. METHODS: To establish a standardized approach to assessment of clinical outcome after ACL treatment, a consensus meeting including a multidisciplinary group of ACL experts was held at the ACL Consensus Meeting Panther Symposium, Pittsburgh, PA; USA, in June 2019. The group reached consensus on nine statements by using a modified Delphi method. RESULTS: In general, outcomes after ACL treatment can be divided into four robust categories-early adverse events, patient-reported outcomes, ACL graft failure/recurrent ligament disruption and clinical measures of knee function and structure. A comprehensive assessment following ACL treatment should aim to provide a complete overview of the treatment result, optimally including the various aspects of outcome categories. For most research questions, a minimum follow-up of 2 years with an optimal follow-up rate of 80% is necessary to achieve a comprehensive assessment. This should include clinical examination, any sustained re-injuries, validated knee-specific PROs and Health-Related Quality of Life questionnaires. In the mid- to long-term follow-up, the presence of osteoarthritis should be evaluated. CONCLUSION: This consensus paper provides practical guidelines for how the aforementioned entities of outcomes should be reported and suggests the preferred tools for a reliable and valid assessment of outcome after ACL treatment. LEVEL OF EVIDENCE: V.

Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group.

PURPOSE: A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sports and their previous activity level. The aim of the Panther Symposium ACL Injury RTS Consensus Group was to provide a clear definition of RTS and description of the RTS continuum, as well as to provide clinical guidance on RTS testing and decision-making. METHODS: An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence. RESULTS: Key points include that RTS is characterized by achievement of the pre-injury level of sport and involves a criteria-based progression from return to participation to return to sport, and ultimately return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along a RTS continuum with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors and concomitant injuries. CONCLUSION: The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing and methods for the biologic assessment of healing and recovery. LEVEL OF EVIDENCE: IV.

Treatment after anterior cruciate ligament injury: Panther Symposium ACL Treatment Consensus Group.

Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance toward consensus opinions regarding the best available evidence on operative vs. non-operative treatment for ACL injury. The purpose of this study is to report the consensus statements on operative vs. non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, were convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organizing Committee and Session Chairs for the three working groups. Panel participants reviewed preliminary statements prior to the meeting and provided the initial agreement and comments on the statement via an online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty percent agreement was defined a-priori as consensus. A total of 11 of 13 statements on operative v. non-operative treatment of ACL injury reached the consensus during the Symposium. Nine statements achieved unanimous support, two reached strong consensus, one did not achieve consensus, and one was removed due to redundancy in the information provided. In highly active patients engaged in jumping, cutting, and pivoting sports, early anatomic ACL reconstruction is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomic ACL reconstruction is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and non-operative treatments with patients after an ACL injury.Level of evidence V.

Use of the World Health Organization Checklist-Swedish Health Care Professionals' Experience: A Mixed-Method Study.

PURPOSE: The purpose was to describe health care professionals' experience of using the World Health Organization (WHO) surgical safety checklist. DESIGN: A descriptive cross-sectional mixed-method study, including health care professionals from two clinics at the same university hospital in the western part of Sweden was conducted. METHODS: Data were collected from one hundred ninety-six health care professionals using a self-administered questionnaire that contained 12 questions. The Mantel-Haenszel and Pearson χ2 tests were used for ordered and unordered categorical variables. The text analysis was inspired by Malterud. FINDINGS: The most statistically significant difference between the clinics related to the responsibility for administering the checklist (P = .0010) and always using the checklist in all emergency situations (P = .045). Among the health care professionals who were educated and trained in using checklists, 63% and 65.5% stated that the checklist was adapted to the department. Sixty four percent stated that the assistant nurses were responsible for implementing the checklist. The health care professionals also mentioned a large number of positive and negative aspects of using the WHO checklist. CONCLUSIONS: The health care professionals had difficulties using the WHO checklist in the Swedish health care system. More research is needed to determine why specific items are overlooked and whether these items could form the basis of the further elaboration of a modified checklist. An increased understanding of why the checklist is important, as well as updated knowledge on the content could produce greater compliance and thereby increase patient safety.

Factors associated with additional anterior cruciate ligament reconstruction and register comparison: a systematic review on the Scandinavian knee ligament registers.

OBJECTIVE: To present an overview of the Scandinavian knee ligament registers with regard to factors associated with additional ACL reconstruction, and studies comparing the Scandinavian registers with other knee ligament registers. DESIGN: Systematic review. DATA SOURCES: Four electronic databases: PubMed, EMBASE, the Cochrane Library and AMED were searched, and 157 studies were identified. Two reviewers independently screened titles, abstracts and full-text studies for eligibility. A modified version of the Downs and Black checklist was applied for quality appraisal. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Eligible studies were those published since the establishment of the Scandinavian registers in 2004, which reported factors associated with additional ACL reconstruction and compared data from other registers. RESULTS: Thirty-one studies met the inclusion criteria and generally displayed good reporting quality. Adolescent age (<20 years) was the most common factor associated with additional ACL reconstruction. The choice of hamstring tendon graft compared with patella tendon, transportal femoral tunnel drilling, smaller graft diameter and utilisation of suspensory fixation devices were associated with additional ACL reconstruction. Concomitant cartilage injury decreased the likelihood of additional ACL reconstruction. Patient sex alone did not influence the likelihood. The demographics of patients undergoing ACL reconstruction in the Scandinavian registers are comparable to registers in other geographical settings. However, there are differences in surgical factors including the presence of intra-articular pathology and graft choice. SUMMARY: The studies published from the Scandinavian registers in general have a high reporting quality when regarded as cohort studies. Several factors are associated with undergoing additional ACL reconstruction. The results from the registers may help facilitate treatment decisions.

Factors that affect patient reported outcome after anterior cruciate ligament reconstruction-a systematic review of the Scandinavian knee ligament registers.

OBJECTIVE: To perform a systematic review of findings from the Scandinavian knee ligament registers with regard to factors that affect patient reported outcome after anterior cruciate ligament (ACL) reconstruction. DESIGN: Systematic review. DATA SOURCES: Four electronic databases: PubMed, EMBASE, the Cochrane Library and AMED were searched, and 157 studies were identified. Two reviewers independently screened the titles, abstracts and full text articles for eligibility. A modified version of the Downs and Black checklist was applied for quality appraisal. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies published from the Scandinavian registers from their establishment in 2004 and onwards that documented patient reported outcome and provided information on concomitant injuries were eligible. RESULTS: A total of 35 studies were included. Younger age at ACL reconstruction, male sex, not smoking and receiving a hamstring tendon autograft positively influenced patient reported outcome. Patients with concomitant cartilage and meniscal injuries reported inferior subjective knee function compared with patients with an isolated ACL tear. One study reported that patients treated non-reconstructively reported inferior knee function compared with patients who had ACL reconstruction. CONCLUSION: Younger age, male sex, not smoking, receiving a hamstring tendon autograft and the absence of concomitant injuries were associated with superior patient reported outcomes after ACL reconstruction.

Preoperative and Intraoperative Predictors of Long-Term Acceptable Knee Function and Osteoarthritis After Anterior Cruciate Ligament Reconstruction: An Analysis Based on 2 Randomized Controlled Trials.

PURPOSE: To determine preoperative predictors of long-term acceptable knee function and the development of osteoarthritis (OA) in long-term follow-up after anterior cruciate ligament (ACL) reconstruction. METHODS: This study is a long-term follow-up of 2 previous randomized controlled trials that included 193 patients who underwent unilateral ACL reconstruction with ipsilateral hamstring tendon or patellar tendon autografts. Patients who suffered multiligament injuries, major meniscal injuries, chondral lesions requiring surgical treatment, or had a previous ACL reconstruction were excluded. Patient demographics, preoperative clinical assessments, and intraoperative findings were used to create stepwise multivariable regression models to determine the patient-acceptable symptom state (PASS) in the International Knee Documentation Committee and the development of OA defined as a Kellgren-Lawrence grade ≥2. Knee laxity measurements, hop performance, patient-reported outcome, and concomitant injuries were determined as variables. RESULTS: A total of 147 patients (63.7% men) were eligible for inclusion, with a mean follow-up of 16.4 ± 1.3 years. The patients were an average age of 27.9 ± 8.3 years at the time of ACL reconstruction. One-half of the cohort reported an International Knee Documentation Committee evaluation system score above the PASS cutoff. The presence of a concomitant injury at operation (odds ratio [OR], 2.61; 95% confidence interval [CI], 1.10-6.21; P = .030) and greater preoperative anteroposterior laxity (OR, 1.87; 95% CI, 1.05-3.35; P = .034) increased the likelihood of achieving a PASS. A longer period between ACL injury and reconstruction (OR, 2.25; 95% CI, 1.02-5.00; P = .046) and older age at reconstruction (OR, 2.28; 95% CI, 1.34-3.86; P = .0023) increased the odds of developing OA at follow-up. CONCLUSIONS: Patients who were older at the time of ACL reconstruction and had waited >1 year between the injury and reconstruction ran an increased risk of having OA 16 years after reconstruction. One in 2 patients reported acceptable long-term knee function, but no risk factor for poorer subjective knee function was identified. Patients who had a minor concomitant injury and increased preoperative anteroposterior knee laxity had increased odds of reporting an acceptable long-term knee function. LEVEL OF EVIDENCE: Level II; prospective comparative study.

Young age and high BMI are predictors of early revision surgery after primary anterior cruciate ligament reconstruction: a cohort study from the Swedish and Norwegian knee ligament registries based on 30,747 patients.

PURPOSE: To analyse patient-related risk factors for 2-year ACL revision after primary reconstruction. The hypothesis was that younger athletes would have a higher incidence of an early ACL revision. METHODS: This prospective cohort study was based on data from the Norwegian and Swedish National Knee Ligament Registries and included patients who underwent primary ACL reconstruction from 2004 to 2014. The primary end-point was the 2-year incidence of ACL revision. The impact of activity at the time of injury, patient sex, age, height, weight, BMI, and tobacco usage on the incidence of early ACL revision were described by relative risks (RR) with 95% confidence intervals (CI). RESULTS: A total of 58,692 patients were evaluated for eligibility and 30,591 patients were included in the study. The mean incidence of ACL revision within 2 years was 2.82% (95% CI 2.64-3.02%). Young age (13-19) was associated with an increased risk of early ACL revision (males RR = 1.54 [95% CI 1.27-1.86] p < 0.001 and females RR = 1.58 [95% CI 1.28-1.96] p < 0.001). Females over 1 SD in weight ran an increased risk of early ACL revision (RR = 1.82, [95% CI 1.15-2.88] p = 0.0099). Individuals with a BMI of over 25 ran an increased risk of early ACL revision (males: RR = 1.78, [95% CI 1.38-2.30] p < 0.001 and females: RR = 1.84, [95% CI 1.29-2.63] p = 0.008). CONCLUSION: Young age, a BMI over 25, and overweight females were risk factors for an early ACL revision. LEVEL OF EVIDENCE: II.

No correlation between femoral tunnel orientation and clinical outcome at long-term follow-up after non-anatomic anterior cruciate ligament reconstruction.

PURPOSE: This study aimed to determine the influence of femoral tunnel orientation on long-term clinical outcome and osteoarthritis in patients undergoing ACL reconstruction and to test the reliability of the implemented radiographic measurement methods. It was hypothesized that a more horizontal femoral tunnel would correlate with superior clinical outcome. METHODS: A cohort of 193 patients who underwent non-anatomic ACL reconstruction was examined. In this specific study, non-anatomic is defined by the surgeons' pursuit of optimal isometry, not to emulate the native ACL anatomy. At follow-up, the Lachman test, the KT-1000, the pivot-shift test, the one-leg-hop test and the IKDC-2000 were evaluated. Osteoarthritis was evaluated radiographically. Posteroanterior and lateral radiographs were used to determine the position of the femoral tunnel in the coronal and sagittal planes and the angle of the tunnel in the coronal plane. A method for determining femoral rotation on the lateral radiographs was developed and its reliability was evaluated. The femoral tunnel orientation was analyzed to examine its influence on clinical outcome and osteoarthritis. RESULTS: A total of 101 patients were analyzed at a mean of 16.4 (± 1.3) years postoperatively. The reliability of the measurement methods was regarded as good to excellent (ICC 0.57-0.97). The mean coronal femoral tunnel angle was 9.6° (± 9.4°). The coronal femoral tunnel was positioned at a mean of 43% (± 3.5%) of the distance measured from lateral to medial. The mean sagittal femoral tunnel position, measured using the quadrant method, was 40% (± 6.4%) from posterior to anterior. No significant associations were found between tunnel orientation and the clinical outcome variables. CONCLUSIONS: The orientation of the femoral tunnel did not predict the long-term subjective outcome, functional outcome or the development of osteoarthritis in patients undergoing non-anatomic ACL reconstruction. The method for determining femoral rotation on lateral radiographs was found to be reliable. LEVEL OF EVIDENCE: Retrospective cohort study, level of evidence IV.