No effect of graft size or body mass index on risk of revision after ACL reconstruction using hamstrings autograft.

PURPOSE: The current study investigated the distribution of hamstrings graft size and body mass index and any potential effect on the risk of revision surgery in a large prospective cohort of patients undergoing ACL reconstruction. More specifically, the aim of the study was to investigate whether larger graft size or smaller BMI would decrease the risk of revision after ACL reconstruction. METHODS: A total of 4029 patients, prospectively registered in the Norwegian Knee Ligament Registry, were included in the study. Univariate Kaplan-Meier survival analyses (with log-rank tests) and the Cox proportional hazard (PH) regression model were applied to compare risk of revision between groups of patients. Mutual adjustment for gender, age, activity at the time of injury and fixation method of the graft was performed. RESULTS: Graft sizes spanned from 5.5 to 11.0 mm and the median of 8.0 mm was reported in 42% of patients in the cohort. BMI was reported from 15 to 57 with a median of 25. 46% of patients were classified as overweight (WHO standards), while 23% of patients were obese. At a median of 2.5 years after surgery, 150 patients had undergone revision surgery. Although certain effects were seen in the unadjusted analyses, neither graft size (diameter) nor patient BMI did affect the risk of undergoing revision surgery in the adjusted analyses. CONCLUSIONS: Graft size and BMI was not found to be independent risk factors for undergoing ACL revision surgery. In contrast to other studies, graft size of 8 mm or larger did not have a better outcome than smaller graft sizes. A relatively large group of overweight patients undergoing ACL surgery reflects the general increase in weight seen in Western societies. Although the current study differs from previous findings, it might indicate that graft diameter is less important than previously stated. LEVEL OF EVIDENCE: Cohort study, II.

Correction to: No effect of graft size or body mass index on risk of revision after ACL reconstruction using hamstrings autograft.

Unfortunately, the author Jon Olav Drogset was incorrectly published in the original version and updated here. The original article has been corrected.

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.

Preoperative NSAIDs, non-acute onset and long-standing symptoms predict inferior outcome at long-term follow-up after rotator cuff repair.

PURPOSE: To evaluate mid- to long-term results after arthroscopic rotator cuff repair and to explore possible predictors of inferior outcome. METHODS: Patients treated for full-thickness supraspinatus and/or infraspinatus tears from 2004 to 2008, using a uniform single-row arthroscopic technique, were included in the study. Pre- and post-operative QuickDASH were used as the primary outcome measure, and VAS of pain, function and satisfaction were also collected. An additional questionnaire explored demographic and preoperative factors like onset and duration of symptoms, preoperative treatment and smoking habits. RESULTS: One hundred and forty-seven patients (82 %) were available at 6-9 years after surgery. All outcomes improved significantly from the preoperative values. A total of 8 % of patients had undergone additional surgery to the same shoulder during the follow-up period. Long-standing symptoms (>12 months) (P < 0.01), non-acute onset of symptoms (P < 0.01) and preoperative use of NSAIDs (P = 0.01) were correlated with inferior outcome at follow-up. No other factors investigated (i.e. gender, age, smoking and steroid injections) were found to affect the primary outcome (QuickDASH). CONCLUSION: The current study is one of few reports of mid- to long-term outcomes after arthroscopic single-row repair of full-thickness rotator cuff tears. Global improvement in symptoms and function was found between the preoperative and the 6-9 years evaluation, and the technique therefore seems like a viable approach for treating tears of the supra- and the infraspinatus tendon. Several predictors of inferior long-term outcome after rotator cuff repair were, however, identified: preoperative use of NSAIDs, long-standing symptoms before surgery and non-acute onset of shoulder symptoms. In light of the current findings, accurate diagnosis and prompt treatment seem important in optimizing outcomes after rotator cuff surgery. LEVEL OF EVIDENCE: IV.

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.

An in vitro analysis of medial structures and a medial soft tissue reconstruction in a constrained condylar total knee arthroplasty.

PURPOSE: The aim of this study was to quantify the medial soft tissue contributions to stability following constrained condylar (CC) total knee arthroplasty (TKA) and determine whether a medial reconstruction could restore stability to a soft tissue-deficient, CC-TKA knee. METHODS: Eight cadaveric knees were mounted in a robotic system and tested at 0°, 30°, 60°, and 90° of flexion with ±50 N anterior-posterior force, ±8 Nm varus-valgus, and ±5 Nm internal-external torque. The deep and superficial medial collateral ligaments (dMCL, sMCL) and posteromedial capsule (PMC) were transected and their relative contributions to stabilising the applied loads were quantified. After complete medial soft tissue transection, a reconstruction using a semitendinosus tendon graft was performed, and the effect on kinematic behaviour under equivocal conditions was measured. RESULTS: In the CC-TKA knee, the sMCL was the major medial restraint in anterior drawer, internal-external, and valgus rotation. No significant differences were found between the rotational laxities of the reconstructed knee to the pre-deficient state for the arc of motion examined. The relative contribution of the reconstruction was higher in valgus rotation at 60° than the sMCL; otherwise, the contribution of the reconstruction was similar to that of the sMCL. CONCLUSION: There is contention whether a CC-TKA can function with medial deficiency or more constraint is required. This work has shown that a CC-TKA may not provide enough stability with an absent sMCL. However, in such cases, combining the CC-TKA with a medial soft tissue reconstruction may be considered as an alternative to a hinged implant.

Arthroscopic Treatment of Lateral Epicondylitis: Tenotomy Versus Debridement.

PURPOSE: To compare the outcome of 2 arthroscopic techniques for treating recalcitrant lateral epicondylitis. METHODS: The study included patients undergoing arthroscopic treatment of lateral epicondylitis during 2 different time periods: April 2005 to October 2007 (tenotomy) and May 2009 to June 2010 (debridement). By using a patient-administered form, baseline information including QuickDASH (disabilities of the arm, shoulder and hand) score (primary outcome), visual analog scale (VAS) of pain, and VAS of function was recorded prospectively. To have the same follow-up period of minimum 4 years in the 2 groups, the follow-up was conducted at 2 different points of time. RESULTS: Of a total of 326 patients fulfilling the requirements for inclusion in the study, 283 patients (87%) were followed up (144 male and 139 female, median age 46 [21 to 65] years), 204 (87%) in the tenotomy group and 79 (88%) in the debridement group. In both groups, a significant improvement in the QuickDASH was found at the follow-up compared with baseline: from 60 to 12 in the debridement group (P < .001) and from 59 to 13 in the tenotomy group (P < .001). No statistically significant difference was found in baseline or follow-up QuickDASH, VAS of pain, VAS of function, or failure (reoperation) rate between the 2 groups. The mean length of sick leave was 2 weeks shorter in the debridement only group (P = .007). CONCLUSIONS: Both arthroscopic methods lead to a significant improvement of pain and function, and no statistically significant difference was found in any outcome parameters between the 2 techniques at this minimum 4-year evaluation. The results indicate that tenotomy of the extensor carpi radialis brevis may be an unnecessary step in the arthroscopic treatment of lateral epicondylitis Debridement only is a potentially less costly procedure, and the current finding of a mean 2 weeks shorter sick leave in the debridement only group proposes a substantial cost saving in a societal perspective. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Long-term outcome after all-inside meniscal repair using the RapidLoc system.

PURPOSE: The purpose of the present study was to evaluate the outcome at a minimum of 7 years following meniscal repair using the RapidLoc (suture anchor) system. It was hypothesized that most patients would have an intact meniscus, as has been reported in several short- and medium-term studies. METHODS: In the time period from 2002 to 2007, all patients with a vertical longitudinal tear of the meniscus that was judged to be repairable were treated with rasping of the tear area and nearby parameniscal synovium and fixation of the torn part with the use of RapidLoc implants. Using a surgeon-administered form, baseline information about the arthroscopic findings and procedures performed was recorded (at the time of surgery). A median 10-year (range 7-12 years) follow-up was conducted in 2014-2015, and surgical procedures to the knee following the (index) meniscal repair were registered. Treatment failure was defined as a new surgical procedure to the same meniscus. RESULTS: At the time of follow-up, 39 out of 82 patients (48 %) had undergone further surgery to the repaired meniscus (failures). Nine of these occurred within the first 6 months after surgery, 21 within the first 12 months and 26 within the first 24 months. Thus, the failure rate was 11 % at 6 months, 23 % at 12 months and 28 % at 2 years. One-third (N = 13) of the failures occurred 2 years or later after the (index) meniscal repair. CONCLUSIONS: Long-term results of meniscal repair using the RapidLoc implants were found to be poor with a high failure rate. In a large proportion of the cases, re-rupture appeared several years after the index surgery, and a commonly used follow-up period of 2 years would therefore fail to detect them. In the day-by-day clinical work, of interest to orthopaedic surgeons is that meniscal repair using an all-inside technique similar to the one used by the authors may not solve the problem in the long run. LEVEL OF EVIDENCE: IV.

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.

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.

Differences Between Traumatic and Degenerative Medial Meniscus Posterior Root Tears: A Systematic Review.

BACKGROUND: Intact meniscus roots are a prerequisite for normal meniscal function, including even distribution of compressive forces across the knee joint. An injury to the root disrupts the hoop strength of the meniscus and may lead to its extrusion and the development of osteoarthritis. A medial meniscus posterior root tear (MMPRT) is often thought to have a primary degenerative pathogenesis. However, there is mention of some cases of MMPRTs where the patients have a solely traumatic injury to a previously healthy meniscus. PURPOSE: To describe a subpopulation of patients with traumatic MMPRT. STUDY DESIGN: Systematic review; Level of evidence, 5. METHODS: The Web of Science database (www.webofscience.com) was queried using the Medical Subject Headings term "medial root tear." Articles were reviewed, and those evaluated for MMPRTs in a degenerative meniscus were excluded. A total of 25 articles describing cases of acute traumatic causes were included in this study. For these articles, the patient characteristics, injury mechanisms, and concomitant injuries evaluated were recorded and pooled. RESULTS: The search revealed 660 articles, and 25 were selected for inclusion. A total of 113 patients with a traumatic MMPRT were identified and included in this review. The study population had a mean age of 27.1 years and a high share of men (64%). Also, this review displays how most patients with traumatic MMPRTs also suffer concomitant injuries (68%). CONCLUSION: The findings in this review support our hypothesis that there is a unique subgroup with acute traumatic MMPRTs that have unique patient characteristics, injury mechanisms, and combined injuries, compared with previously published reviews on MMPRTs.

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.

It is time to target psychological readiness (or lack of readiness) in return to sports after Anterior Cruciate Ligament tears.

Functional recovery has for long been the focus of rehabilitation after an Anterior Cruciate Ligament (ACL) injury. It is now increasingly recognized that more attention should be given to patients` mental recovery, their psychological readiness for returning to sport, after such an injury. Within this relatively new field of science, clinicians need clarity on when and how psychological factors should be monitored and how inexpedient psychological responses may be addressed during rehabilitation. In this Expert Opinion suggestions on how targeting psychological readiness may improve rehabilitation and return-to-sport evaluations are made based on current evidence-and issues in need of further clarification are addressed.