Subjective assessment reported by patients shows differences between single-bundle and double-bundle anterior cruciate ligament reconstruction, systematic review and meta-analysis.

To determine the functional recovery, active reincorporation, and anteroposterior and rotational stability of patients undergoing anterior cruciate ligament (ACL) reconstruction using arthroscopy techniques with simple-bundle (SB) or double-bundle (DB). The following databases were searched: PubMed, Embase (Elsevier platform), the Cochrane Central Register of Controlled Trials (Wiley platform), Web of Science, and CINAHL. Level I and II studies involving anterior cruciate ligament arthroscopy were included in the search. Records were screened by title and abstract and assessed the risk of bias of selected studies. Meta-analyses using RevMan 5.3 software were conducted on the following outcomes: knee functionality, objective measurements of knee stability, rotational knee stability and knee anterior stability, sports reincorporation, and subjective assessments. Twenty-four studies of patients undergoing ACL reconstruction were included in the qualitative and quantitative synthesis (1707 patients) for Lysholm score, Subjective International Knee Documentation Committee (IKDC) score, Tegner score, KT-1000/2000, Lachman test, Objective IKDC score, and Pivot-Shift test. A return to pre-injury level showed a significant decrease in the Lysholm score (mean difference, - 0.99; 95% CI - 1.71 to - 0.40; P = 0.007) and Tegner score (mean difference, - 0.07; 95% CI, - 0.13 to - 0.01; P = 0.02) at DB reconstruction, similar to the knee functionality outcome of the subjective IKDC score (mean difference - 1.42; 95% CI - 2.46 to - 0.38; P = 0.007). There is no clear or significant difference in clinical stability and knee function or in sports incorporation with the true difference occurring in the subjective assessment.

Online Videos Provide Poor Information Quality, Reliability, and Accuracy Regarding Rehabilitation and Return to Sport After Anterior Cruciate Ligament Reconstruction.

PURPOSE: To investigate the information quality available on YouTube regarding rehabilitation and return to sport (RTS) after anterior cruciate ligament reconstruction (ACLR). METHODS: By use of The Onion Router software and predefined search terms, 140 YouTube videos regarding rehabilitation and RTS after ACLR were systematically included. Three scoring systems were used to analyze the included videos: (1) Journal of the American Medical Association (JAMA) benchmark criteria; (2) Global Quality Score (GQS); and (3) self-developed scores for rehabilitation after ACLR and RTS after ACLR, following American Academy of Orthopaedic Surgeons guidelines and current evidence. RESULTS: The vast majority of the included videos offered poor information quality, reliability, and accuracy. Videos that were uploaded by medically trained professionals showed significantly higher information quality regarding rehabilitation (P = .006 for JAMA score, P < .001 for GQS, and P = .001 for rehabilitation score) and regarding RTS (P < .001 for JAMA score, P < .001 for GQS, and P < .001 for RTS score) compared with commercial videos or personal-testimony videos. Multivariate linear regression also revealed medically trained professionals as significant predictors of higher information quality regarding rehabilitation (ß = 0.496 [P < .001] for JAMA score, ß = 1.3 [P < .001] for GQS, and ß = 3.7 [P < .001] for rehabilitation score) and RTS (ß = 0.754 [P < .001] for JAMA score, ß = 1.3 [P < .001] for GQS, and ß = 5.3 [P < .001] for RTS score). CONCLUSIONS: The average information quality, reliability, and accuracy of YouTube videos regarding rehabilitation and RTS after ACLR are poor. The information quality of related YouTube videos from medically trained professionals is significantly higher compared with commercial videos or personal-testimony videos. CLINICAL RELEVANCE: Current YouTube videos regarding rehabilitation and RTS after ACLR do not meet the necessary quality standards. Physicians should also be able to provide alternative sources of high-quality information.

Inpatient admission following anterior cruciate ligament reconstruction is associated with higher postoperative complications.

PURPOSE: To compare the occurrence of short-term postoperative complications between inpatient and outpatient anterior cruciate ligament reconstruction. METHODS: The ACS National Surgical Quality Improvement Program (NSQIP) database was utilized to identify patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR) from 2007 to 2017. A total of 18,052 patients were available for analysis following application of exclusion criteria. Patients were categorized based on location of surgery. Inpatients and outpatient ACLR groups were matched by demographics and preoperative laboratory values and differences in 30-day complication rates following surgery were assessed. Significance was set with alpha < 0.05. RESULTS: From 2007 to 2017, there was an increasing frequency for outpatient ACLR (p < 0.001), while the incidence of inpatient ACLR remained largely constant (n.s). Groups were matched to include 1818 patients in each cohort. Within the first 30 days of surgery, patients in the inpatient ACLR group experienced significantly greater rates of superficial incisional SSI (0.6% vs 0.1%, p = 0.026) and composite surgical complications (0.6% vs 0.2%, p = 0.019), as well as a greater rate of reoperation (0.7% vs 0.2%, p = 0.029). Inpatient procedures also demonstrated a greater rate of deep surgical incisional SSI (0.2% vs 0.0%, n.s) and readmission to hospital (0.8% vs 0.7%, n.s).Outpatient ACLR procedures were also associated with a significantly greater relative value unit (RVU)/h compared with inpatient ACLRs (0.17 vs 0.14, p < 0.001). CONCLUSIONS: Inpatient ACLR may have an increased risk of postoperative complications compared to outpatient ACLR during the short-term postoperative period. Although some patients may require admission post-operatively for medical and/or pain management, doing so is not necessarily without a degree of risk. LEVEL OF EVIDENCE: III.

Technical Obstacles for Low-Volume Surgeons in Primary Anterior Cruciate Ligament Reconstruction.

A longer surgical time will lead to postoperative complications in orthopaedic surgery. According to previous reports, surgeon volume affects a surgical time in anterior cruciate ligament (ACL) reconstruction. However, little attention has been paid to difference of a surgical time between high- and low-volume surgeons in ACL reconstruction. The purpose of the present study was to investigate the surgical time for both high- and low-volume surgeons and to clarify technical obstacles as well as the important technique to reduce the surgical time in ACL reconstruction. A total of 103 knees in 103 patients with ACL tear were enrolled. All the procedures were performed by 13 different surgeons. The surgeons were divided into two surgeon groups (high- and low-volume groups) based on the number of annual cases. The operative technique was divided into the same five steps to perform comparisons of step-by-step surgical time between the surgeon groups of different volumes. The statistical comparison was done between high- and low-volume groups in terms of surgical time in each step. Total operation times were 87.8 ± 17.6 and 129.9 ± 42.9 minutes in high- and low-volume group, respectively. Low-volume surgeons took much time in tendon harvesting and bone tunnel creation using arthroscopy. Low-volume surgeons took more time for primary ACL reconstruction, especially in tendon harvesting, compared with high-volume surgeons. Tendon harvesting was extremely important, as well as bone tunnel creation, for low-volume surgeons to reduce surgical time in primary ACL reconstruction.

Procedure length is independently associated with overnight hospital stay and 30-day readmission following anterior cruciate ligament reconstruction.

PURPOSE: The purpose was to characterize the independent effect of procedure length on the rates of 30-day perioperative complications, hospital readmissions, and overnight hospital stay in patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR). We hypothesized that longer procedure length in primary ACLR increases the risk for post-operative complications. METHODS: Primary ACLR cases from 2005 to 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Patients were categorized into two cohorts based on procedure length, either less than or greater than 90 min. Two equal-sized propensity-matched cohorts were generated to account for differences in baseline and operative characteristics. Thirty-day clinical outcomes were compared using bivariate analyses between propensity-matched groups that controlled for patient-specific factors and concurrent meniscal repair. Multivariate logistic regression models were used to identify independent predictors of hospital readmission and overnight hospital stay. RESULTS: In total, 12,077 ACLR cases were identified. The rate of any 30-day complication was increased in longer procedures relative to shorter procedures (1.6% vs 0.9%, p = 0.006), as were the rates of returning to the operating room (0.6% vs 0.3%, p = 0.03), hospital readmission (1.0% vs 0.3%, p = 0.001), and overnight hospital stay (16.2% vs 6.0%, p < 0.001). Obesity was a risk factor for both hospital readmission and overnight hospital stay, while hypertension, diabetes, chronic obstructive pulmonary disease, and a smoking history were associated with increased rates of overnight hospital stay. The most common reasons for hospital readmission were deep vein thrombosis or pulmonary embolism (25.0% of all readmitted patients), surgical site infection (25.0%), and post-operative pain (14.1%). CONCLUSIONS: In this propensity-matched analysis adjusting for baseline patient characteristics and operative factors, procedure length of greater than or equal to 90 min in ACLR was independently associated with an increased risk of hospital readmission and overnight hospital stay. As a surrogate measure of surgical complexity, operative time may be a useful perioperative variable for post-operative risk stratification and patient counseling. LEVEL OF EVIDENCE: III.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of anterior cruciate ligament injury - Secondary publication.

BACKGROUND: This clinical guideline presents recommendations for the management of patients with anterior cruciate ligament (ACL) injury, endorsed by the Japanese Orthopaedic Association (JOA) and Japanese Orthopaedic Society of Knee, Arthroscopy and Sports Medicine (JOSKAS). METHODS: The JOA ACL guideline committee revised the previous guideline based on "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which proposed a desirable method for preparing clinical guidelines in Japan. Furthermore, the importance of "the balance of benefit and harm" was also emphasized. This guideline consists of 21 clinical questions (CQ) and 23 background questions (BQ). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design. RESULTS: We evaluated the objectives and results of each study in order to make a decision on the level of evidence so as to integrate the results with our recommendations for each CQ. For BQ, the guideline committee proposed recommendations based on the literature. CONCLUSIONS: This guideline is intended to be used by physicians, orthopedic surgeons, physical therapists, and athletic trainers managing ACL injuries. We hope that this guideline is useful for appropriate decision-making and improved management of ACL injuries.

Single-tunnel anatomic double-bundle anterior cruciate ligament reconstruction has the same effectiveness as double femoral, double tibial tunnel: A prospective randomized study.

PURPOSE: To investigate whether single femoral, single tibial tunnel anatomic double-bundle anterior cruciate ligament (ACL) reconstruction is equal to or superior to double femoral, double tibial tunnel ACL double-bundle anatomic reconstruction in terms of restoring the stability and functions of the knee joint. METHODS: A prospective clinical study was performed to compare 30 cases of single-tunnel ACL double-bundle anatomic reconstruction to 28 cases of double-tunnel ACL double-bundle anatomic reconstruction, with average follow-up of 36 months. All graft tendons were hamstring tendon autografts. Tunnel placements in all the cases were made anatomically. Clinical results were collected after reconstruction. Graft appearance, meniscus status and cartilage state under arthroscopy were compared and analyzed. RESULTS: Tunnel placements were in the anatomic positions in both groups. On the lateral pivot-shift test performed at 36 months postoperatively, there was no significant difference between groups. Clinical results such as International Knee Documentation Committee score, Tegner activity scale, and range of motion showed no significant differences between the groups. The mean thickness of anteromedial graft was reduced by 10.3% and that of the posterolateral graft was reduced by 11.1% from the original graft thickness evaluated by magnetic resonance imaging. No new meniscal tears were found either group; however, cartilage damage occurred in the double-tunnel group at 39.3%, and this rate was significantly higher than that in the single-tunnel group (10.0%). CONCLUSION: Single femoral, single tibial tunnel anatomic double-bundle ACL reconstruction has the same effectiveness as the double femoral, double tibial tunnel in restoring the knee's stability and functions.

Italian consensus statement for the use of allografts in ACL reconstructive surgery.

PURPOSE: Graft choice for primary anterior cruciate ligament reconstruction (ACL-R) is debated, with considerable controversy and variability among surgeons. Autograft tendons are actually the most used grafts for primary surgery; however, allografts have been used in greater frequency for both primary and revision ACL surgery over the past decade. Given the great debate on the use of allografts in ACL-R, the "Allografts for Anterior Cruciate Ligament Reconstruction" consensus statement was developed among orthopedic surgeons and members of SIGASCOT (Società Italiana del Ginocchio, Artroscopia, Sport, Cartilagine, Tecnologie Ortopediche), with extensive experience in ACL-R, to investigate their habits in the use of allograft in different clinical situations. The results of this consensus statement will serve as benchmark information for future research and will help surgeons to facilitate the clinical decision making. METHODS: In March 2017, a formal consensus process was developed using a modified Delphi technique method, involving a steering group (9 participants), a rating group (28 participants) and a peer-review group (31 participants). Nine statements were generated and then debated during a SIGASCOT consensus meeting. A manuscript has been then developed to report methodology and results of the consensus process and finally approved by all steering group members. RESULTS: A different level of consensus has been reached among the topics selected. Strong agreement has been reported in considering harvesting, treatment and conservation methods relevant for clinical results, and in considering biological integration longer in allograft compared to autograft. Relative agreement has been reported in using allograft as the first-line graft for revision ACL-R, in considering biological integration a crucial aspect for rehabilitation protocol set-up, and in recommending a delayed return to sport when using allograft. Relative disagreement has been reported in using allograft as the first-line graft for primary ACL-R in patients over 50, and in not considering clinical results of allograft superior to autograft. Strong disagreement has been reported in using allograft as the first-line graft for primary ACL-R and for skeletally immature patients. CONCLUSIONS: Results of this consensus do not represent a guideline for surgeons, but could be used as starting point for an international discussion on use of allografts in ACL-R. LEVEL OF EVIDENCE: IV, consensus of experts.

Post-operative 3D CT feedback improves accuracy and precision in the learning curve of anatomic ACL femoral tunnel placement.

PURPOSE: To evaluate the feedback from post-operative three-dimensional computed tomography (3D-CT) on femoral tunnel placement in the learning process, to obtain an anatomic anterior cruciate ligament (ACL) reconstruction. METHODS: A series of 60 consecutive patients undergoing primary ACL reconstruction using autologous hamstrings single-bundle outside-in technique were prospectively included in the study. ACL reconstructions were performed by the same trainee-surgeon during his learning phase of anatomic ACL femoral tunnel placement. A CT scan with dedicated tunnel study was performed in all patients within 48 h after surgery. The data obtained from the CT scan were processed into a three-dimensional surface model, and a true medial view of the lateral femoral condyle was used for the femoral tunnel placement analysis. Two independent examiners analysed the tunnel placements. The centre of femoral tunnel was measured using a quadrant method as described by Bernard and Hertel. The coordinates measured were compared with anatomic coordinates values described in the literature [deep-to-shallow distance (X-axis) 28.5%; high-to-low distance (Y-axis) 35.2%]. Tunnel placement was evaluated in terms of accuracy and precision. After each ACL reconstruction, results were shown to the surgeon to receive an instant feedback in order to achieve accurate correction and improve tunnel placement for the next surgery. Complications and arthroscopic time were also recorded. RESULTS: Results were divided into three consecutive series (1, 2, 3) of 20 patients each. A trend to placing femoral tunnel slightly shallow in deep-to-shallow distance and slightly high in high-to-low distance was observed in the first and the second series. A progressive improvement in tunnel position was recorded from the first to second series and from the second to the third series. Both accuracy (+52.4%) and precision (+55.7%) increased from the first to the third series (p < 0.001). Arthroscopic time decreased from a mean of 105 min in the first series to 57 min in the third series (p < 0.001). After 50 ACL reconstructions, a satisfactory anatomic femoral tunnel was reached. CONCLUSION: Feedback from post-operative 3D-CT is effective in the learning process to improve accuracy and precision of femoral tunnel placement in order to obtain anatomic ACL reconstruction and helps to reduce also arthroscopic time and learning curve. For clinical relevance, trainee-surgeons should use feedback from post-operative 3DCT to learn anatomic ACL femoral tunnel placement and apply it appropriately. LEVEL OF EVIDENCE: Consecutive case series, Level IV.

Comparison of artificial graft versus autograft in anterior cruciate ligament reconstruction: a meta-analysis.

BACKGROUND: Critically evaluation and summarization for the outcomes between autografts and artificial grafts using in anterior cruciate ligament (ACL) reconstruction have not been performed currently. The purpose of this study is to compare the clinical outcomes between artificial ligaments and autografts at a short- to mid-term follow-up. METHODS: A computerized search of the databases was conducted including Medline, Embase, and the Cochrane library. Only prospective or retrospective comparative studies with a minimum 2-year follow-up and a minimum sample size of 15 for each group were considered for inclusion. Two independent reviewers performed data extraction and methodological quality assessment. A Mantel-Haenszel analysis was used for pooling of results. Sensitivity analysis was performed in order to maintain the stability of results. RESULTS: Seven studies were included in this study. The total sample size was 403 (autograft group: 206 patients; synthetic graft group: 197 patients). Four studies were randomized controlled trials. Two studies were retrospective comparative studies and one study was non-randomized prospective comparative study. In terms of instrumented laxity, patient-oriented outcomes and complications, no significant difference was occurred between new artificial ligaments and autografts. But the results of IKDC grades and instrumented laxity were worsen in early artificial ligaments compared to autografts. CONCLUSIONS: The outcomes of new generation of artificial ligaments are similar to autografts at a short- to mid-term follow-up. However, the early artificial ligaments are not suggested for ACL reconstruction compared to autografts.

Improving ACL Reconstruction Outcomes.

Anterior cruciate ligament (ACL) reconstruction is a common and predominantly successful surgical intervention. But are there specific preoperative patient characteristics or intraoperative surgeon decisions that lead to better or worse outcomes? And can understanding brain function changes of patients after ACL reconstruction reveal insights into the ways that postsurgical rehabilitation can be improved to further enhance outcomes? These intriguing and clinically applicable questions are addressed in this webinar titled "Improving ACL Reconstruction Outcomes," hosted jointly by JOSPT and JBJS. The webinar is based on 2 published research articles-one from JBJS and the other from JOSPT. Participants in this continuing education activity are asked to read both articles carefully before watching the webinar. JBJS co-author Kurt Spindler, MD, discusses findings from a longitudinal analysis that identified certain baseline patient characteristics and intraoperative choices that predicted higher and lower SF-36 Physical Component scores after ACL reconstruction. JOSPT co-author Dustin Grooms, PhD, ATC, shares recently published results of a controlled laboratory study that employed functional MRI to investigate brain-activation differences between patients who did and did not undergo ACL reconstruction. Moderated by Kevin Wilk, PT, DPT, FAPTA, a leading authority on rehabilitation of sports injuries, the webinar includes additional insights from expert commentators Eric McCarty, MD, and Karin Grävare Silbernagel, PT, PhD, ATC.

Patient Understanding, Expectations, Outcomes, and Satisfaction Regarding Anterior Cruciate Ligament Injuries and Surgical Management.

Patient satisfaction has become an increasingly important outcome metric in orthopaedics and medicine in general as many initiatives at both the state and national levels aim to improve the efficiency and quality of health care. Anterior cruciate ligament injuries are among the most common injuries in orthopaedics, with anterior cruciate ligament reconstruction (ACLR) surgery consistently reported as one of the most frequently performed procedures by orthopaedic surgeons. Patient-reported outcomes are frequently used to evaluate outcomes from the patient's perspective, and many physicians also ask patients about their satisfaction with treatment. A growing volume of literature has investigated the relation between preoperative patient expectations and postoperative patient satisfaction. The quality of online resources, patient expectations for ACLR, and factors associated with and/or predictive of either poor or good to excellent outcomes after surgery are described. This article critically reviews the orthopaedic literature on this important topic and identifies variables that influence patient expectations and satisfaction to help treating physicians better counsel and evaluate patients and ultimately improve outcomes of and satisfaction with ACLR surgery.

What Makes a Successful Survey? A Systematic Review of Surveys Used in Anterior Cruciate Ligament Reconstruction.

PURPOSE: To characterize and assess the methodological quality of patient and physician surveys related to anterior cruciate ligament reconstruction, and to analyze the factors influencing response rate. METHODS: The databases MEDLINE, Embase, and PubMed were searched from database inception to search date and screened in duplicate for relevant studies. Data regarding survey characteristics, response rates, and distribution methods were extracted. A previously published list of recommendations for high-quality surveys in orthopaedics was used as a scale to assess survey quality (12 items scored 0, 1, or 2; maximum score = 24). RESULTS: Of the initial 1,276 studies, 53 studies published between 1986 and 2016 met the inclusion criteria. Sixty-four percent of studies were distributed to physicians, compared with 32% distributed to patients and less than 4% to coaches. The median number of items in each survey was 10.5, and the average response rate was 73% (range: 18% to 100%). In-person distribution was the most common method (40%), followed by web-based methods (28%) and mail (25%). Response rates were highest for surveys targeted at patients (77%, P < .0001) and those delivered in-person (94%, P < .0001). The median quality score was 12/24 (range = 8.5/24 to 21/24). There was high inter-rater agreement using the quality scale (intraclass correlation coefficient = 0.92), but there was no correlation with the response rate (Rho = -0.01, P = .97). CONCLUSIONS: Response rates vary based on target audience and distribution methods, with patients responding at a significantly higher rate than physicians and in-person distribution yielding significantly higher response rates than web or mail surveys. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Radiographic positions of femoral ACL, AM and PL centres: accuracy of guidelines based on the lateral quadrant method.

PURPOSE: Femoral tunnel positioning is an important factor in anatomical ACL reconstructions. To improve accuracy, lateral radiographic support can be used to determine the correct tunnel location, applying the quadrant method. Piefer et al. (Arthroscopy 28:872-881, 2012) combined various outcomes of eight studies applying this method to one guideline. The studies included in that guideline used various insertion margins, imaging techniques and measurement methods to determine the position of the ACL centres. The question we addressed is whether condensing data from various methods into one guideline, results in a more accurate guideline than the results of one study. METHODS: The accuracy of the Piefer's guideline was determined and compared to a guideline developed by Luites et al. (2000). For both guidelines, we quantified the mean absolute differences in positions of the actual anatomical centres of the ACL, AM and PL measured on the lateral radiographs of twelve femora with the quadrant method and the positions according to the guidelines. RESULTS: The accuracy of Piefer's guidelines was 2.4 mm (ACL), 2.7 mm (AM) and 4.6 mm (PL), resulting in positions significantly different from the actual anatomical centres. Applying Luites' guidelines for ACL and PL resulted in positions not significantly different from the actual centres. The accuracies were 1.6 mm (ACL) and 2.2 mm (PL and AM), which were significantly different from Piefer for the PL centres, and therefore more accurate. CONCLUSIONS: Condensing the outcomes of multiple studies using various insertion margins, imaging techniques and measurement methods, results in inaccurate guidelines for femoral ACL tunnel positioning at the lateral view. CLINICAL RELEVANCE: An accurate femoral tunnel positioning for anatomical ACL reconstruction is a key issue. The results of this study demonstrate that averaging of various radiographic guidelines for anatomical femoral ACL tunnel placement in daily practice, can result in inaccurate tunnel positions. LEVEL OF EVIDENCE: Diagnostic study, Level 1.

Reducing time to surgery after anterior cruciate ligament injury.

INTRODUCTION: Recent work suggests that reconstruction of the ruptured anterior cruciate ligament within 12 months of injury results in better outcomes. We present a complete audit cycle examining the effect of establishment of an Acute Knee Clinic on time to surgery. METHODS: Records of 20 anterior cruciate ligament reconstructions undertaken by the senior author between June 2003 and May 2004 were examined to identify the time to surgery. The Acute Knee Clinic was established in December 2004. Prospectively collected data on patients attending the Acute Knee Clinic between May 2005 and July 2007 and patients undergoing anterior cruciate ligament reconstruction from September 2006 to 2007 were reviewed with respect to referral route, time from injury to specialist review and time to surgery. RESULTS: Mean time from injury to surgery of the initial cohort was 14 months (range 3-56). After establishment of the Acute Knee Clinic, 90% of referrals from Accident and Emergency (A&E) were seen by a specialist within four weeks. Between September 2006 and September 2007, 49 patients underwent anterior cruciate ligament reconstruction: 21 came via the Acute Knee Clinic, with a mean time from injury to surgery of 6 months; 28 patients from the elective clinic had a mean time to surgery of 25 months. 95% of Acute Knee Clinic patients and 53 % of elective clinic patients had surgery within 12 months of injury. DISCUSSION: The Acute Knee Clinic has been shown to reduce the time from injury to anterior cruciate ligament reconstruction. The Acute Knee Clinic only accounts for the referral of 40% of anterior cruciate ligament reconstructions in this series: Further education work is required with A&E staff and GPs regarding the referral of knee injuries. Access to the Acute Knee Clinic could be extended to GPs, although this could create service overload.

Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture.

BACKGROUND: The decision as to whether or not an athlete is ready to return to sport (RTS) after ACL reconstruction is difficult as the commonly used RTS criteria have not been validated. PURPOSE: To evaluate whether a set of objective discharge criteria, including muscle strength and functional tests, are associated with risk of ACL graft rupture after RTS. MATERIALS AND METHODS: 158 male professional athletes who underwent an ACL reconstruction and returned to their previous professional level of sport were included. Before players returned to sport they underwent a battery of discharge tests (isokinetic strength testing at 60°, 180° and 300°/s, a running t test, single hop, triple hop and triple crossover hop tests). Athletes were monitored for ACL re-ruptures once they returned to sport (median follow-up 646 days, range 1-2060). RESULTS: Of the 158 athletes, 26 (16.5%) sustained an ACL graft rupture an average of 105 days after RTS. Two factors were associated with increased risk of ACL graft rupture: (1) not meeting all six of the discharge criteria before returning to team training (HR 4.1, 95% CI 1.9 to 9.2, p≤0.001); and (2) decreased hamstring to quadriceps ratio of the involved leg at 60°/s (HR 10.6 per 10% difference, 95% CI 10.2 to 11, p=0.005). CONCLUSIONS: Athletes who did not meet the discharge criteria before returning to professional sport had a four times greater risk of sustaining an ACL graft rupture compared with those who met all six RTS criteria. In addition, hamstring to quadriceps strength ratio deficits were associated with an increased risk of an ACL graft rupture.

Does revision ACL reconstruction measure up to primary surgery? A meta-analysis comparing patient-reported and clinician-reported outcomes, and radiographic results.

PURPOSE: To compare patient-reported and clinician-reported outcomes, and radiographic results between patients who had had revision ACL reconstruction and those who had had primary ACL reconstruction. DESIGN: Systematic review and meta-analysis DATA SOURCES: The MEDLINE, CINAHL, EMBASE and SPORTDiscus electronic databases were searched on 6 August 2015, using 3 main concepts: (1) revision ACL reconstruction, (2) primary ACL reconstruction and (3) treatment outcomes. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Articles that compared patient-reported or clinician-reported outcomes or radiographic results between patients who had had revision ACL reconstruction and those who had had primary surgery with a minimum of 2 years follow-up were included. The outcomes evaluated were the Lysholm Knee Scoring Scale, objective International Knee Documentation Committee (IKDC) classification, Tegner Activity Scale, side-to-side difference in anterior tibial translation measured with KT-1000/2000 arthrometer, pivot shift test, tibiofemoral osteoarthritis grading on plain radiographs and subsequent knee surgeries. RESULTS: 8 studies (300 revision ACL reconstructions and 413 primary ACL reconstructions) were included in the meta-analysis. Patients who had had revision surgery reported inferior Lysholm Knee Scoring Scale scores (mean difference: 7.8 points), had inferior clinician-reported knee function as assessed with the objective IKDC classification (IKDC category A: 27% vs 57%; IKDC category C or D: 22% vs 8%) and pivot shift test (grade II or III: 7% vs 2%), and more radiographic evidence of tibiofemoral osteoarthritis (50% vs 25%) compared with patients who had had primary surgery. CONCLUSIONS: Revision ACL reconstruction restored similar anterior-posterior knee laxity compared with primary ACL reconstruction. Patients who had had revision surgery reported inferior Lysholm Knee Scoring Scale scores, had inferior clinician-reported knee function and more radiographic signs of tibiofemoral osteoarthritis compared with patients with primary ACL reconstruction.