Reinjury Anxiety and Return to Sport After Anterior Cruciate Ligament Reconstruction: A Cluster Analysis and Prospective Study Among 162 Athletes.

BACKGROUND: Recent studies have investigated the effect of psychological factors on return to sport (RTS), but none has tested the existence of psychological profiles linked to reinjury anxiety and its links with RTS and reinjury. PURPOSE: To assess the effect of different psychological profiles on RTS and reinjury. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: The study screened patients who were involved in all types of sports for anterior cruciate ligament (ACL) reconstruction (hamstring and patellar tendon autografts). All participants were included during the RTS phase (90-180 days after ACL reconstruction). Reinjury anxiety, fear of reinjury, kinesiophobia, perceived stress, anxiety, depression, knee confidence, self-esteem, optimism, coping, and pain were measured. Hierarchical cluster analysis (Ward method) and analysis of variance were performed. In the second year after surgery, patients were recontacted by telephone to follow-up. RTS and reinjury were compared by profile type. RESULTS: A total of 162 athletes were initially included, of whom 123 responded regarding RTS and reinjury. Cluster analysis showed a 4-cluster solution (χ2[21] = 428.59; λ = .064; P < .001). Profile 1 (27.8%) was characterized by moderate reinjury anxiety and no depression. Profile 2 (22.8%) was characterized by moderate reinjury anxiety and minor anxious-depressive reaction. Profile 3 (30.9%) was characterized by no reinjury anxiety, no depression, and high confidence. Profile 4 (18.5%) was characterized by high anxiety, high depression, and low confidence. Profile 4 had the lowest self-esteem and optimism scores compared with profile 3 (P < .001). In addition, a higher percentage of men was found in profile 3 as opposed to profile 4 (χ2[3] = 11.35; P < .01). Profile 4 had the highest rate of non-RTS with 54.2% (profile 1: 14.3%, P = .001; profile 2: 25.0%, P = .031; profile 3: 22.2%, P = .011). Finally, patients with profile 3 had a higher risk of reinjury (13.9%) than those with profile 4 (0%) (P = .047), who had an extremely conservative RTS. CONCLUSION: The different profiles will affect RTS, but also the risk of reinjury exclusively for profiles 3 and 4. Rehabilitation management will probably require all stakeholders to understand psychological profiles of athletes to develop an on-demand rehabilitation plan.

Global knee function rating more strongly influences adolescent athletes that sustain a sports-related surgical ACL re-injury or contralateral ACL injury.

PURPOSE: This study evaluated differences between adolescent athletes who sustained a surgical anterior cruciate ligament (ACL) re-injury, or contralateral ACL injury following return to sports bridge programme participation (Group 1) compared to those that did not (Group 2). METHODS: At 19.9 ± 7 years of age, 198 athletes participated in this study. Groups were compared for time postsurgery, preprogramme and postprogramme Knee Outcome Survey Sports Activity Scale (KOS-SAS) and global rating of knee function (GRKF) during sports activities, postprogramme lower extremity physical function test performance and perceived sports performance compared to preinjury level. RESULTS: By 6.0 ± 3.2 years postsurgery, 11 (5.6%) sustained another ACL injury. Group 1 was younger (17.3 ± 1.7 years vs. 20.1 ± 6.8 years, p < 0.001). Postprogramme re-evaluation revealed that Group 1 had a greater GRKF compared to their programme initiation GRKF than Group 2 (32.6 ± 38 vs. 20.0 ± 23, p = 0.04). Group 1 also had a greater mean preprogramme to postprogramme GRKF change than Group 2 (51.3 ± 31 vs. 35.5 ± 21, p = 0.02) (effect size = 0.73). More Group 1 subjects also had a GRKF difference that exceeded the overall mean than Group 2 (p = 0.04). Group 1 had moderately strong relationships between preprogramme and postprogramme GRKF score change and the postprogramme GRKF score (r = 0.65, p = 0.04) and between preprogramme and postprogramme KOS-SAS score change and postprogramme GRKF score (r = 0.60, p = 0.04). CONCLUSION: Global rating scores had a stronger influence among adolescent athletes that sustained either surgical ACL re-injury or contralateral ACL injury. Since group physical function and neuromuscular control factors were similar, clinicians need to increase their awareness and understanding of other factors that may influence surgical ACL re-injury or contralateral ACL injury risk. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Risk factors of knee reinjury after anterior cruciate ligament reconstruction.

PURPOSE: This study aimed to investigate whether the return to level I sports, concomitant injuries, foot-related problems, and other factors would increase the risk of knee reinjury after anterior cruciate ligament reconstruction (ACLR). METHODS: This study used a prospective cohort study design. Online enrolment from August 2018 to January 2019 in ACL Community Indonesia recruited 148 patients who had undergone ACLR less than one month prior to injury. Knee injury occurrence after ACLR was diagnosed through a physical examination and positive MRI or arthroscopic findings. RESULTS: During the study, 55 knee reinjuries occurred. The proportional hazards model analysis revealed that the risk of knee reinjury at 12 and 24 months for patients who returned to level I sports (hazards ratio (HR)=3.17 and HR=3.90, respectively) was significantly higher than that of the patients who did not return to sports and that the risk for those who returned to level II/III sports did not significantly increase at 12 or 24 months. Patients with concomitant meniscus injury had a significantly higher risk of knee reinjury at 12 and 24 months (HR=3.33 and HR=2.25, respectively) than those without, and the risk of knee reinjury for patients with concomitant posterior cruciate ligament injury was significantly higher at 12 months (HR=3.05) but not at 24 months. Fewer knee symptoms after ACLR were significantly associated with a lower risk of knee reinjury (HR=0.98) at 12 and 24 months. CONCLUSIONS: The return to level I sports, concomitant meniscus and posterior cruciate ligament injury, and knee symptoms after ACLR may increase the risk of knee reinjury for post-ACLR patients.

Corticomuscular cross-recurrence analysis reveals between-limb differences in motor control among individuals with ACL reconstruction.

Surgical reconstruction of the anterior cruciate ligament (ACL) and subsequent physical therapy can help athletes return to competition; however, re-injury rates remain disproportionately high due, in part, to lingering biomechanical and neurological factors that are not fully addressed during rehabilitation. Prior reports indicate that individuals exhibit altered electrical activity in both brain and muscle after ACL reconstruction (ACLR). In this investigation, we aimed to extend existing approaches by introducing a novel non-linear analysis of corticomuscular dynamics, which does not assume oscillatory coupling between brain and muscle: Corticomuscular cross-recurrence analysis (CM-cRQA). Our findings indicate that corticomuscular dynamics vary significantly between involved (injured) and uninvolved legs of participants with ACLR during voluntary isometric contractions between the brain and both the vastus medialis and lateralis. This finding points to a potential lingering neural deficit underlying re-injury for athletes after surgical reconstruction, namely the dynamical structure of neuromuscular (brain to quad muscle) coordination, which is significantly asymmetric, between limbs, in those who have ACLR.

Factors Associated With Sports Function and Psychological Readiness to Return to Sports at 12 Months After Anterior Cruciate Ligament Reconstruction: A Cross-sectional Study.

BACKGROUND: Sports function and psychological readiness to return to sports (RTS) are important outcomes when evaluating rehabilitation after anterior cruciate ligament reconstruction (ACLR). It is, however, unclear which specific factors contribute most to these outcomes. PURPOSE: To determine associations between demographic characteristics, objective measurements of physical function, patient-reported outcome measure scores, sports-related function assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS) Sport and Recreation subscale, and psychological readiness to RTS assessed with the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale at 1 year after ACLR. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: At a mean of 12.5 ± 2.0 months after ACLR, 143 participants (50.3% female), with a mean age of 25.0 ± 5.7 years, were assessed for demographic characteristics, physical factors (hop performance, muscle strength, ankle and hip range of motion), and psychological factors (KOOS Pain and Symptoms subscales, Perceived Stress Scale, fear of reinjury) as well as the KOOS Sport and Recreation subscale and ACL-RSI scale. Backward linear regression models were used to evaluate factors associated with sports function and psychological readiness to RTS. RESULTS: Lower isokinetic knee extension peak torque (limb symmetry index) (B = 18.38 [95% CI, 3.01-33.75]), lower preinjury activity level (B = 2.00 [95% CI, 0.87-3.14]), greater knee pain (B = 0.90 [95% CI, 0.70-1.10]), shorter time between injury and reconstruction (B = 0.16 [95% CI, 0.05-0.26]), and greater fear of reinjury (B = 0.11 [95% CI, 0.01-0.20]) were associated with a worse KOOS Sport and Recreation subscore (R2 = 0.683). A shorter hop distance (B = 0.15 [95% CI, 0.00-0.29]) was associated with a lower ACL-RSI score (R2 = 0.245). CONCLUSION: A combination of knee muscle strength, activity level, knee pain, timing of surgery, and fear of reinjury accounted for approximately 70% of the variation in sports function at 1 year after ACLR. In contrast, there was only 1 weak association between physical function and psychological readiness to RTS at this time point. Thus, factors associated with current sports function are much better known than features related to psychological readiness to RTS.

Inconsistencies in reporting risk factors for ulnar collateral ligament reconstruction failure: a systematic review.

BACKGROUND: When return to sport (RTS) at a competitive level is desired, treatment of injury to the ulnar collateral ligament (UCL) frequently involves surgical reconstruction. Although RTS rates between 66% and 98% have been reported, there remains a paucity of comparative clinical studies, with far fewer reporting statistically significant risk factors for reconstruction failure. The goal of this study was to perform a systematic review of the literature to demonstrate the variety and inconsistency with which risk factors associated with reconstruction failure are reported. MATERIALS AND METHODS: A systematic review of the PubMed Central and MEDLINE databases was performed to identify clinical outcome studies reporting ≥1 statistically significant risk factor associated with failure of UCL reconstruction. Failure was defined as (1) reinjury, recurrent instability, or need for revision surgery; (2) failure show improvement in postoperative patient-reported outcomes (PROs); or (3) failure to RTS at the preinjury level (RSL). RESULTS: A total of 349 unique studies were initially identified, of which 12 were deemed eligible for inclusion in our study. Of these 12 studies, 4 defined outcomes based on recurrent instability, reinjury, or revision surgery; 2 defined outcomes based on PROs; and 6 defined outcomes based on RSL. In the group with instability, reinjury, or revision failure, 11 significant risk factors were identified across all studies: age, height, body mass index, professional experience, injury to the nondominant arm, history of competitive throwing, mechanism of injury, history of a psychiatric diagnosis, presence of preoperative instability or stiffness, postoperative workload, and time to RTS. In the PRO failure group, 12 risk factors were identified across all studies: age, status as a military cadet, injury to the nondominant arm, graft type, baseball position, current injury to the ipsilateral arm, current level of competition attributed to reconstruction surgery, shoulder surgery after reconstruction, no competitive throwing history, non-throwing mechanism of injury, history of a psychiatric diagnosis, and preoperative instability or stiffness. In the RSL failure group, 4 risk factors were identified across all studies: age, ulnar neuritis, level of professional play, and amount of time spent at the professional level. CONCLUSIONS: Age, level of professional play prior to surgery, postoperative workload, and time at the professional level are the most commonly reported risk factors associated with UCL reconstruction failure. There remains a paucity of data associating risk factors with patient-specific outcomes and marked levels of inconsistency and conflict among the studies that report such data.

[Progress in evaluation of return to sports after anterior cruciate ligament reconstruction].

Objective: To summarize the evaluation methods of return to sports (RTS) after anterior cruciate ligament reconstruction (ACLR) in recent years, in order to provide reference for clinical practice. Methods: The literature related to the RTS after ACLR was searched from CNKI, Wanfang, PubMed, and Foreign Medical Information Resources Retrieval Platform (FMRS) databases. The retrieval range was from 2010 to 2023, and 66 papers were finally included for review. The relevant literature was summarized and analyzed from the aspects of RTS time, objective evaluation indicators, and psychological evaluation. Results: RTS is the common desire of patients with ACL injury and doctors, as well as the initial intention of selecting surgery. A reasonable and perfect evaluation method of RTS can not only help patients recover to preoperative exercise level, but also protect patients from re-injury. At present, the main criterion for clinical judgement of RTS is time. It is basically agreed that RTS after 9 months can reduce the re-injury. In addition to time, it is also necessary to test the lower limb muscle strength, jumping, balance, and other aspects of the patient, comprehensively assess the degree of functional recovery and determine the different time of RTS according to the type of exercise. Psychological assessment plays an important role in RTS and has a good clinical predictive effect. Conclusion: RTS is one of the research hotspots after ACLR. At present, there are many related evaluation methods, which need to be further optimized by more research to build a comprehensive and standardized evaluation system.

Good clinical scores, no evidence of excessive anterior tibial translation, a high return to sport rate and a low re-injury rate is observed following anterior cruciate ligament reconstruction using autologous hamstrings augmented with suture tape.

INTRODUCTION: Augmented anterior cruciate ligament reconstruction (ACLR) techniques have been proposed to reduce the high reported re-injury rates and low rates of return to sport (RTS). This study reports clinical outcomes, RTS and re-injury rates in patients undergoing ACLR using autologous hamstrings augmented with suture tape. MATERIALS AND METHODS: A total of 53 patients were prospectively recruited, undergoing ACLR using hamstrings with suture tape augmentation, combined with a structured rehabilitation programme. Outcomes were collected to 24 months, including patient-reported outcome measures (PROMs), KT-1000 measurements, peak isokinetic knee strength and a four hop test battery. Limb Symmetry Indices (LSIs) were calculated for performance measures, whilst RTS rates, re-tears and re-operations were presented. RESULTS: There were no significant side-to-side differences in anterior tibial translation between the operated and non-operated knees at 6 months (p = 0.433), with no increase (p = 0.841) in side-to-side anterior tibial translation from 6 to 24 months. At 24 months, 98.0% of patients demonstrated normal (< 3 mm) or near normal (3-5 mm) side-to-side differences. LSIs for peak knee extensor torque (p < 0.0001) and the single (p = 0.001), triple (p = 0.001) and triple crossover (p < 0.0001) hop tests for distance significantly improved. All PROMs significantly improved (p < 0.0001), with 70.2% and 85.7% of patients actively participating in pivoting sports at 12 and 24 months, respectively. Three patients underwent secondary procedures for meniscal symptoms. One patient suffered an ACL re-tear (17 months), with no further ipsilateral or contralateral injuries. CONCLUSION: ACLR with suture tape augmentation demonstrated no evidence of excessive anterior tibial translation, high-scoring PROMs, sound performance scores, a high rate of RTS and low re-injury rate.

Secondary Anterior Cruciate Ligament Injury Prevention Training in Athletes: What Is the Missing Link?

After reconstruction, the return to full competition rate of athletes is low, while the re-injury rate remains high despite the completion of a rehabilitation programme. Primary ACL prevention programmes are well developed, yet few research papers focus on secondary ACL injury prevention. The aim of current review is to determine if current ACL secondary prevention training has a positive influence on the re-injury rate, the clinical or functional outcomes, or the risk of re-injury in athletes. Studies investigating secondary prevention of ACL were searched in PubMed and EBSCOhost, followed by a review of the references in the identified articles. The existing evidence suggests that neuromuscular training, eccentric strengthening, and plyometric exercises may have a potential impact on improving biomechanical, functional, and psychological outcomes in athletes; however, the studies on the prevention of second ACL injury in athletes is scarce and inconclusive. Future research is needed to investigate the effectiveness of secondary ACL prevention in reducing the re-injury rates. (PROSPERO Registration number: CRD42021291308).

Quantitative MRI Biomarkers to Predict Risk of Reinjury Within 2 Years After Bridge-Enhanced ACL Restoration.

BACKGROUND: Quantitative magnetic resonance imaging (qMRI) methods were developed to establish the integrity of healing anterior cruciate ligaments (ACLs) and grafts. Whether qMRI variables predict risk of reinjury is unknown. PURPOSE: To determine if qMRI measures at 6 to 9 months after bridge-enhanced ACL restoration (BEAR) can predict the risk of revision surgery within 2 years of the index procedure. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Originally, 124 patients underwent ACL restoration as part of the BEAR I, BEAR II, and BEAR III prospective trials and had consented to undergo an MRI of the surgical knee 6 to 9 months after surgery. Only 1 participant was lost to follow-up, and 4 did not undergo MRI, leaving a total of 119 patients for this study. qMRI techniques were used to determine the mean cross-sectional area; normalized signal intensity; and a qMRI-based predicted failure load, which was calculated using a prespecified equation based on cross-sectional area and normalized signal intensity. Patient-reported outcomes (International Knee Documentation Committee subjective score), clinical measures (hamstring strength, quadriceps strength, and side-to-side knee laxity), and functional outcomes (single-leg hop) were also measured at 6 to 9 months after surgery. Univariate and multivariable analyses were performed to determine the odds ratios (ORs) for revision surgery based on the qMRI and non-imaging variables. Patient age and medial posterior tibial slope values were included as covariates. RESULTS: In total, 119 patients (97%), with a median age of 17.6 years, underwent MRI between 6 and 9 months postoperatively. Sixteen of 119 patients (13%) required revision ACL surgery. In univariate analyses, higher International Knee Documentation Committee subjective score at 6 to 9 months postoperatively (OR = 1.66 per 10-point increase; P = .035) and lower qMRI-based predicted failure load (OR = 0.66 per 100-N increase; P = .014) were associated with increased risk of revision surgery. In the multivariable model, when adjusted for age and posterior tibial slope, the qMRI-based predicted failure load was the only significant predictor of revision surgery (OR = 0.71 per 100 N; P = .044). CONCLUSION: Quantitative MRI-based predicted failure load of the healing ACL was a significant predictor of the risk of revision within 2 years after BEAR surgery. The current findings highlight the potential utility of early qMRI in the postoperative management of patients undergoing the BEAR procedure.

Failure modes after anterior cruciate ligament reconstruction: a systematic review and meta-analysis.

PURPOSE: The reason for graft failure after anterior cruciate ligament reconstruction (ACLR) is multifactorial. Controversies remain regarding the predominant factor and incidence of failure aetiology in the literature. This review aimed to provide a meta-analysis of the literature to evaluate the relative proportion of various failure modes among patients with ACLR failure. METHODS: The PubMed, Embase, Cochrane Library, Web of Science, and EBSCO databases were searched for literature on ACLR failure or revision from 1975 to 2021. Data related to causes for ACLR surgical failure were extracted, and a random effects model was used to pool the results, which incorporates potential heterogeneity. Failure modes were compared between different populations, research methods, graft types, femoral portal techniques, and fixation methods by subgroup analysis or linear regression. Funnel plots were used to identify publication bias and small-study effects. RESULTS: A total of 39 studies were analyzed, including 33 cohort studies and six registry-based studies reporting 6578 failures. The results showed that among patients with ACLR failure or revision, traumatic reinjury was the most common failure mode with a rate of 40% (95% CI: 35-44%), followed by technical error (34%, 95% CI: 28-42%) and biological failure (11%, 95% CI: 7-15%). Femoral tunnel malposition was the most common cause of the technical error (29%, 95% CI: 18-41%), with more than two times higher occurrence than tibial tunnel malposition (11%, 95% CI: 6-16%). Traumatic reinjury was the most common factor for ACLR failure in European populations and in recent studies, while technical errors were more common in Asian populations, earlier studies, and surgery performed using the transtibial (TT) portal technique. Biological factors were more likely to result in ACLR failure in hamstring (HT) autografts compared to bone-patellar tendon-bone (BPTB) autografts. CONCLUSION: Trauma is the most important factor leading to surgical failure or revision following ACLR. Technical error is also an important contributing factor, with femoral tunnel malposition being the leading cause of error resulting in failure.

Joint effusion at 3 months after anterior cruciate ligament reconstruction is associated with reinjury.

PURPOSE: To evaluate whether joint effusion at 3 months after anterior cruciate ligament (ACL) reconstruction is associated with ACL reinjury. METHODS: The medical records of 227 consecutive patients who underwent single-bundle ACL reconstruction between 2015 and 2018 were reviewed in this retrospective single-center study. Demographic data such as sex and age at surgery, as well as data on preinjury Tegner activity scale score, time from injury to surgery, presence of meniscus and cartilage injuries, and the occurrence of ACL reinjury within 2 years, were collected. Joint effusion was defined as grade 3 (range 0-3) according to the ACL Osteoarthritis Score by magnetic resonance imaging at 3 months postoperatively. Multivariate logistic regression analysis was performed to control for potential confounders. RESULTS: A total of 176 patients (mean age 22.5 ± 9.9 years) were included. Among these patients, 18 (10.2%) had ACL reinjury. At the multivariate logistic regression analysis, higher Tegner activity scale (odds ratio [OR] 3.12; 95% confidence interval [CI] 1.61-6.04; p < 0.001) and presence of joint effusion (OR 34.5; 95% CI 6.63-179.7; p < 0.001) increased the odds of ACL reinjury, and older age (OR 0.68; 95% CI 0.51-0.92; p = 0.012) decreased the odds of ACL reinjury. CONCLUSIONS: Joint effusion with a larger fluid volume at 3 months postoperatively was one of the risk factors for ACL reinjury independent of confounders, such as age and activity level. This result suggests the possibility of postoperative intervention for ACL reinjury. LEVEL OF EVIDENCE: III.

Fear of reinjury following primary anterior cruciate ligament reconstruction: a systematic review.

PURPOSE: This review aims to elucidate the most commonly reported method to quantify fear of reinjury or kinesiophobia and to identify key variables that influence the degree of kinesiophobia following primary anterior cruciate ligament reconstruction (ACLR). METHODS: A systematic search across three databases (Pubmed, Ovid (MEDLINE), and EMBASE) was conducted from database inception to August 7th, 2022. The authors adhered to the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. Quality assessment of the included studies was conducted according to the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS: Twenty-six studies satisfied the inclusion criteria and resulted in 2,213 total patients with a mean age of 27.6 years and a mean follow-up time of 36.7 months post-surgery. The mean MINORS score of the included studies was 11 out of 16 for non-comparative studies and 18 out of 24 for comparative studies. Eighty-eight percent of included studies used variations of the Tampa Scale of Kinesiophobia (TSK) to quantify kinesiophobia and 27.0% used Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI). The results of this study shows a common association between higher kinesiophobia and poor patient-reported functional status measured using International Knee Documentation Committee (IKDC) Scores, Activity of Daily Living (ADL), Quality of Life (QOL), and Sports/Recreation (S/R) subscales of Knee Osteoarthritis and Outcome Score (KOOS) and Lysholm scores. Postoperative symptoms and pain catastrophizing measured using the KOOS pain and symptom subscales and Pain Catastrophizing Score (PCS) also influenced the degree of kinesiophobia following ACLR. Patients with an increased injury to surgery time and being closer to the date of surgery postoperatively demonstrated higher levels of kinesiophobia. Less common variables included being a female patient, low preoperative and postoperative activity status and low self-efficacy. CONCLUSION: The most common methods used to report kinesiophobia following primary ACLR were variations of the TSK scale followed by ACL-RSI. The most commonly reported factors influencing higher kinesiophobia in this patient population include lower patient-reported functional status, more severe postoperative symptoms such as pain, increased injury to surgery time, and being closer to the date of surgery postoperatively. Kinesiophobia following primary ACLR is a critical element affecting post-surgical outcomes, and screening should be implemented postoperatively to potentially treat in rehabilitation and recovery. LEVEL OF EVIDENCE: IV.

Progress in evaluation of return to sports after anterior cruciate ligament reconstruction / 中国修复重建外科杂志

OBJECTIVE@#To summarize the evaluation methods of return to sports (RTS) after anterior cruciate ligament reconstruction (ACLR) in recent years, in order to provide reference for clinical practice.@*METHODS@#The literature related to the RTS after ACLR was searched from CNKI, Wanfang, PubMed, and Foreign Medical Information Resources Retrieval Platform (FMRS) databases. The retrieval range was from 2010 to 2023, and 66 papers were finally included for review. The relevant literature was summarized and analyzed from the aspects of RTS time, objective evaluation indicators, and psychological evaluation.@*RESULTS@#RTS is the common desire of patients with ACL injury and doctors, as well as the initial intention of selecting surgery. A reasonable and perfect evaluation method of RTS can not only help patients recover to preoperative exercise level, but also protect patients from re-injury. At present, the main criterion for clinical judgement of RTS is time. It is basically agreed that RTS after 9 months can reduce the re-injury. In addition to time, it is also necessary to test the lower limb muscle strength, jumping, balance, and other aspects of the patient, comprehensively assess the degree of functional recovery and determine the different time of RTS according to the type of exercise. Psychological assessment plays an important role in RTS and has a good clinical predictive effect.@*CONCLUSION@#RTS is one of the research hotspots after ACLR. At present, there are many related evaluation methods, which need to be further optimized by more research to build a comprehensive and standardized evaluation system.

Bent Tibial Nail with Refracture: A Cost-Effective Removal Method: A Case Report.

CASE: A 45-year old man presented with a right open tibial fracture with a prominent, fixed deformity because of a retained right tibial intramedullary nail from a previous tibial fracture. After multiple futile intraoperative attempts to extract the bent nail, it was finally sectioned using an industrial drill bit that permitted its removal and revision tibial nailing. CONCLUSIONS: A tibial fracture resulting in a retained, bent nail presents unique challenges for nail extraction and subsequent exchange nailing. Failed implant removal can be limited by the equipment available in the operating theater. In this setting, the judicious use of inexpensive industrial materials and instruments may be effective in select cases.

One sixth of primary anterior cruciate ligament reconstructions may undergo reoperation due to complications or new injuries within 2 years.

PURPOSE: To analyse the incidence, types and risk factors for reoperation within 2 years of primary anterior cruciate ligament reconstruction (ACLR). METHODS: Our clinic registry was used to identify primary ACLRs, performed from 2005 to 2015, and reoperations performed on the ipsilateral knee within 2 years at our institution. Reoperations were identified using procedural codes and analysis of medical records. A logistic regression analysis was used to evaluate risk factors for reoperation. RESULTS: A total of 6030 primary ACLRs were included. A total of 1112 (18.4%) reoperations performed on 1018 (16.9%) primary ACLRs were identified. The most common reoperations were screw removal (n = 282, 4.7%), meniscus procedures (n = 238, 3.9%), cyclops removal/notchplasty (n = 222, 3.7%) and reoperations due to graft rupture (n = 146, 2.4%), including revision ACLR. Age < 30 years (OR 1.57; 95% CI 1.37-1.80; P < 0.001), female gender (OR 1.33; 95% CI 1.17-1.51; P < 0.001), medial meniscus repair (OR 1.55; 95% CI 1.23-1.97; P < 0.001), lateral meniscus resection (OR 1.26; 95% CI 1.07-1.49; P = 0.005) and lateral meniscus repair (OR 1.38; 95% CI 1.03-1.85; P = 0.02) at primary ACLR were found to be risk factors for reoperation. CONCLUSION: One sixth of all primary ACLRs underwent reoperation due to complications or new injuries within 2 years. The most common reoperations were screw removal, meniscus procedures, cyclops removal/notchplasty and reoperations due to graft rupture, including revision ACLR. Younger age (< 30 years), female gender, medial meniscus repair and lateral meniscus resection or repair at primary ACLR were associated with an increased risk of reoperation. This study provides clinicians with important data to inform patients about the short-term reoperation rates, the most common reoperation procedures and risk factors for reoperation after primary ACLR. LEVEL OF EVIDENCE: III.

A Novel Technique in Treatment of Calcaneocuboid Dislocation with Bifurcate Ligament Reconstruction Using a Semitendinosus Allograft: A Case Report.

CASE: A 19-year-old woman sustained a plantar flexion-inversion injury to her right ankle after a low-speed motor vehicle collision. Clinical examination demonstrated supinated, adducted deformity of the foot, and prominent calcaneus laterally. Radiographs revealed dislocation of the calcaneocuboid joint, a rare injury, which was successfully stabilized by a novel technique using a hamstring allograft. The presentations and clinical and surgical management of this rare condition are discussed. CONCLUSION: We present a technique that has shown good long-term results in a young patient with recurrent calcaneocuboid joint dislocations. Our novel ligament reconstruction technique using a semitendinosus allograft seems to be a promising treatment option in young patients with unstable calcaneocuboid joints.