Editorial Commentary: Blood Flow Restriction Therapy Prior to Anterior Cruciate Ligament Reconstruction: Small Effects Require Accurate Measurements.

A recent research study showed that blood flow restriction (BFR) therapy was safe and well tolerated but failed to demonstrate efficacy as a modality that provides greater gains in quadriceps strength when added to a standard home program in patients awaiting anterior cruciate ligament (ACL) reconstruction. Despite employing a validated method of measurement, the results were highly variable, indicating the need for measurements with sufficient accuracy to detect the small, but potentially meaningful, gains in quadriceps strength that's been attributed to BFR. The results inform future investigations of BFR prior to ACL surgery by demonstrating the need for accurate methods of measurements when the anticipated effects are small.

Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft With Lateral Compartment Meniscectomy or Chondroplasty Does Not Lead to Decreased Return to Sport and Activity Compared With No Lateral Pathology.

Purpose: To investigate the influence of lateral meniscal and cartilage pathology on the outcome after anterior cruciate ligament (ACL) reconstruction in patients who participate in pivoting sports. Methods: Using a single-surgeon patient registry, patients undergoing an anterior cruciate ligament reconstruction (ACLR) using bone-patellar tendon-bone autograft were evaluated with minimum 2-year patient reported outcomes evaluated using Marx, Tegner, Lysholm, and International Knee Documentation Committee scales. Patients were divided into 3 groups: isolated ACL surgery, ACLR with a partial lateral meniscectomy, or a ACLR with partial lateral meniscectomy and lateral compartment chondroplasty. Results: A total of 98 patients met inclusion criteria. Using the isolated ACL reconstruction group as a control, we found that Marx scores were greater in patients who additionally underwent a partial lateral meniscectomy at 1 year (P = .016). There were no significant differences between the ACL-only group and the ACL with partial lateral meniscectomy and chondroplasty group. Within the partial meniscectomy cohort comparing the patients with red-white zone tears with the patients with white-white zone tear, we found there were no significant differences when compared with the ACL-only control. There were no significant differences appreciated between groups using the International Knee Documentation Committee, Lysholm, and Tegner scales. Conclusions: ACL reconstruction using bone-patellar tendon-bone autograft with anteromedial portal drilling technique does not have any significant short-term (2-year outcome) differences in return to activity and patient-reported outcomes compared with if patients additionally have a partial lateral meniscectomy and/or lateral compartment chondroplasty. Additional partial lateral meniscectomy showed significantly greater Marx scores at 1 and 2 years' postoperatively. Level of Evidence: Level III, retrospective cohort study.

Body Mass Index Between 15 and 30 Does Not Influence Patient-Reported Outcomes After Anterior Cruciate Ligament Surgery Using a 10-mm-Diameter Bone-Tendon-Bone Graft.

Purpose: To investigate the relation between body mass index (BMI) and outcomes after anterior cruciate ligament reconstruction (ACLR) using 10-mm-diameter bone-patellar tendon-bone grafts. Methods: In this retrospective study, the Surgical Outcome System was used to measure patient-reported outcomes before and after ACLR between 2015 and 2019. The inclusion criteria consisted on patients undergoing primary ACLR performed by the senior surgeon, with recorded age of 15 years or older and BMI of 15.0 to 30. The exclusion criteria included revisions, concomitant procedures, age younger than 15 years, and unknown BMI. Patients were divided into cohorts to evaluate the Marx Activity Rating Scale (MARS), Tegner, International Knee Documentation Committee (IKDC), and Lysholm scores at various time points from injury to 2 years postoperatively. Results: A total of 137 patients (100 male and 37 female patients) with an average age of 33 years (95% confidence interval, 30.6-35.4 years) and average BMI of 23.58 (95% confidence interval, 23.1-24.0) were divided into those with a BMI of 15 to 23.4 (group A, n = 69) and those with a BMI of 23.5 to 30 (group B, n = 68). A significant difference in MARS scores was found between the BMI groups before treatment, with mean scores of 11.55 (group A) and 9.41 (group B) (P = .011), and Tegner scores showed significance at 2 years, with scores of 6.45 and 5.41 for groups A and B, respectively (P = .009). Daily function scores were all insignificant. Female patients exhibited no significant differences across any patient-reported outcome measures or time points. Contrarily, male patients showed a significant difference in pretreatment MARS scores (14.30 in group A vs 9.96 in group B, P = .011). Additionally, scores at 2 years depicted Tegner values of 7.40 in group A versus 5.30 in group B (P = .012) and IKDC values of 96.92 in group A versus 90.47 in group B (P = .048). All results for female and male patients aged 30 years or younger indicated no significance. Conclusions: Regardless of patient age or sex, BMI is not significantly associated with patient-reported outcomes after ACLR using 10-mm-diameter bone-patellar tendon-bone grafts. Level of Evidence: Level III, retrospective cohort study.

Anterior Cruciate Ligament Reconstruction Using Allograft in Adults Older Than the Age of 40 Years Shows Similar Patient-Reported Outcomes Between Male and Female Patients.

Purpose: To evaluate patient-reported outcomes in patients undergoing anterior cruciate ligament (ACL) reconstruction using allograft in patients 40 years of age or older divided by sex. Methods: Patients age 40 years of age or older who underwent ACL reconstruction by the same surgeon using allograft via anteromedial portal technique were retrospectively identified. Patient-reported outcomes (International Knee Documentation Committee [IKDC], Knee Injury and Osteoarthritis Outcome Score, Tegner, Lysholm, Marx, and Single Assessment Numeric Evaluation) were evaluated and recorded, and outcomes were analyzed by sex. Results: In total, 159 patients undergoing primary ACL reconstruction were reviewed. Two-year outcomes were obtained. All patients noted improvement in patient-reported outcome measures. Male patients had overall greater postoperative patient-reported outcomes measures at all time points for IKDC, Tegner, Lysholm, Marx, and Single Assessment Numeric Evaluation scores; however, the only significant time points were IKDC 6 months (P = .016), 1 year (P = .012) and Marx 1 year (P = .007) and 2 year (P = .016). Knee Injury and Osteoarthritis Outcome Score scores similarly showed greater postoperative scores at all time points and statistical significance at 3 months (P = .002), 6 months (P = .033), and 1 year (P = .031). Conclusions: ACL reconstruction in individuals older than the age of 40 years using allograft results in good outcomes compared with preoperative status. Patient-reported outcomes were similar between male and female patients regarding most patient-reported outcome measures. Level of Evidence: Level III, retrospective cohort study.

Establishing Normal Variances and Expectations for Quadriceps Limb Symmetry Index Benchmarks Based on Time from Surgery After Anterior Cruciate Ligament Reconstruction.

The anticipated timeline for muscle strength as well as return to running and sports are some of the most common inquiries by patients undergoing anterior cruciate ligament reconstruction. Despite the popularity of this procedure, the answers to these inquiries are not well described in the literature. The purpose of this study was to evaluate the range of quadriceps strength percentage and function benchmarks at various points after anterior cruciate ligament reconstruction surgery based on sex, age, and graft. Design: Observational Cohort Study. Methods: Patients who underwent anterior cruciate ligament reconstruction (ACLR) were evaluated at various points after their surgery with handheld dynamometer assessments. Additional hop and balance testing was performed and patients were evaluated for clearance for running and sport via a physical therapist directed functional movement assessment (FMA). The progression of quadriceps symmetry throughout the postoperative period was examined with multi-level models, estimates of time to reach 70%, 80%, and 90% quadriceps symmetry were obtained from the fitted model. Results: A total of 164 patients were evaluated. Patients either received bone-tendon-bone (BTB) autograft (n=118) or BTB allograft (n=46) for their ACL graft. Average age was 31.1 years-of-age (SD: 13.6). Males undergoing ACLR using BTB autograft (n=53) were able to achieve 80% quadriceps symmetry earlier than females (n=65) (5.7 months vs 7.1 months), were cleared to return to run sooner (5.6 months vs 6.8 months) and passed an FMA exam earlier (8.5 months vs 10 months). Males undergoing ACLR with allograft (n=13) were able to achieve 80% quadriceps symmetry earlier than females (n=33) (3.9 months vs 5.4 months) and were cleared to run sooner (4.5 months vs 5.8 months). Conclusion: Patients undergoing BTB autograft obtain 80% quadriceps symmetry at an average of 5.7 months for males and 7.1 months for females. Individuals under the age of 25 obtain their quadriceps symmetry faster and are cleared to return to running faster than individuals over 25. Male sex is associated with decreased amount of time to obtain clearance for running and for full activity. Male sex is associated with decreased amount of time to regain quadriceps symmetry however this was not significant. Level of Evidence: 4 (Case series).

Tramadol Provides Similar Pain Relief and a Better Side Effect Profile than Oxycodone (or Hydrocodone) Alone or in Combination With Tramadol After Anterior Cruciate Ligament Reconstruction or Arthroscopic Knee Debridement.

Purpose: To evaluate whether tramadol provides similar postoperative pain relief after anterior cruciate ligament (ACL) reconstruction surgery or arthroscopic debridement surgery compared to oxycodone (or hydrocodone) or a combination of tramadol and oxycodone. Methods: Patients over the age of 14 undergoing ACL surgery or arthroscopic debridement surgery performed by the same surgeon were provided a postoperative pain diary over the first 10 postoperative days. Patients were either provided tramadol, oxycodone (or hydrocodone), or a combination of tramadol in addition to oxycodone (or hydrocodone). Pain scores were measured on visual analog scale (VAS), including average pain, maximum pain, and minimum pain throughout the day. Additionally, side effects and number of over-the-counter analgesics were recorded. Results: 121 patient surveys were reviewed. Tramadol alone for ACL with autograft provided lower average pain scores on postoperative day 1-3 (VAS 3.3 vs oxycodone 6.1 and hybrid of 5.1) with lowest maximum pain on postoperative day 1 (VAS 5.3 vs oxycodone 6.6 and hybrid 5.1) and the lowest number of average nights awakened by knee pain (3.6 vs oxycodone 6.0 and hybrid 8.5). Tramadol alone provided the lowest number of days of constipation (3 vs oxycodone 4.68 and hybrid 4.08), nausea (0.42 vs oxycodone 1.48 and hybrid 1.72), and dizziness (0.68 vs oxycodone 0.84 vs hybrid 1.28). Individual medication group breakdown of ACL surgery with allograft, as well as arthrosopic knee debridements did not have a large enough quantity to have three separate comparison groups. Conclusions: Tramadol provides similar, and in most cases better, pain relief for ACL reconstruction and arthroscopic knee debridements compared to oxycodone (or hydrocodone) alone or a combination of tramadol with oxycodone (or hydrocodone), while providing a lower side-effect profile. Clinical Relevance: Alternative analgesic therapies outside of traditional opioids (like oxycodone and hydrocodone) are lacking in popularity or reputation. This retrospective comparative study cohort evaluation can help provide clinicians an alternative analgesic therapy for various knee surgeries that have comparable pain relief with less addictive properties and less side effects.

Fellow Efficiency During Anterior Cruciate Ligament Reconstruction Improves Over Time, Yet Is Less Than Experienced Physician Assistant But With No Significant Difference in Patient-Reported Outcomes.

Purpose: To evaluate the intraoperative efficiency and patient outcomes of anterior cruciate ligament reconstruction (ACLR) assisted by a sports medicine fellow over the course of the academic year compared with an experienced physician assistant (PA). Methods: A single-surgeon cohort of primary ACLRs with either bone-tendon-bone autograft or bone-tendon-bone allograft (without any other significant time-consuming procedures such as meniscectomy/repair) were evaluated using a patient registry system over 2 years assisted by an experienced PA compared with an orthopaedic surgery sports medicine fellow. There were 264 primary ACLRs included in this study. Outcomes included evaluation of surgical time, tourniquet time, and patient-reported outcome measures. Results: The surgical efficiency of the fellow (as measured by surgical time and tourniquet time) improved over each academic quarter. Patient-reported outcomes between the 2 first-assist groups showed no significant difference over 2 years with both ACL graft groups combined. ACLRs assisted by the PA showed shorter tourniquet times by 22.1% and shorter total surgical times by 11.9% compared with the sports medicine fellows when both grafts were combined (P < .001). The surgical and tourniquet times (minutes) for the fellow (standard deviation of surgical time 19.5-25.0 and tourniquet time 19.5-25.0) did not average out to be more efficient in any of the 4 quarters of the year compared with the PA-assisted group (standard deviation of surgical time 14.4-14.8 and tourniquet time 14.8-22.4). Autografts showed more efficient tourniquet (18.7%) and skin-to-skin surgical times (11.1%) in the PA group compared with the fellow group (P < .001). Allografts showed more efficient tourniquet (37.7%) and skin-to-skin surgical times (12.8%) in the PA group compared with the fellow group (P < .001). Conclusions: The surgical efficiency of the fellow during primary ACLRs improves over the academic year. Patient-reported outcomes are similar in cases assisted by the fellow compared with an experienced physician assistant. Cases assisted by the PA were performed more efficiently compared with the sports medicine fellow. Clinical Relevance: The intraoperative efficiency of a sports medicine fellow objectively improves over the academic year for primary ACLRs but may not be as efficient as an experienced advanced practice provider; however, there appears to be no significant differences in patient-reported outcome measures between the 2 groups. This helps quantify the time commitment for attendings and academic medical institutions as the "cost of education" of trainees such as fellows.

Effect of Tibiofemoral Rotation Angle on Graft Failure After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Coronal and sagittal malalignment of the knee are well-recognized risk factors for failure after anterior cruciate ligament (ACL) reconstruction (ACLR). However, the effect of axial malalignment on graft survival after ACLR is yet to be determined. PURPOSE: To evaluate whether increased tibiofemoral rotational malalignment, namely, tibiofemoral rotation angle (TFA) and tibial tubercle-trochlear groove (TT-TG) distance, is associated with graft failure after ACLR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: In this retrospective matched control study of a single center's database, 151 patients who underwent revision ACLR because of graft failure (ACLR failure group, defined as symptomatic patients with anterior knee instability and an ACL graft tear appreciated on magnetic resonance imaging [MRI] and confirmed during arthroscopic surgery) were compared with a matched control group of 151 patients who underwent primary ACLR with no evidence of failure after ≥2-year follow-up (intact ACLR group). Patients were matched by sex, age, and meniscal injury during primary ACLR. Axial malalignment was assessed on preoperative MRI through the TFA and the TT-TG distance. Sagittal alignment was measured through the posterior tibial slope on MRI. The optimal TFA cutoff associated with graft failure was identified by a receiver operating characteristic curve. The Kaplan-Meier curve with log-rank analysis was performed to evaluate the influence of the TFA on ACLR longevity. RESULTS: The mean age was 25.7 ± 10.4 years for the ACLR failure group and 25.9 ± 10.0 years for the intact ACLR group. Among all the included patients, 174 (57.6%) were male. In the ACLR failure group, the mean TFA was 5.8°± 4.5° (range, -5° to 16°), while it was 3.0°± 3.3° (range, -3° to 15°) in the intact ACLR group (P < .001). Neither the TT-TG distance nor the posterior tibial slope presented statistical differences between the groups. The receiver operating characteristic curve suggested an optimal TFA cutoff of 4.5° for graft failure (area under the curve = 0.71; P < .001; sensitivity, 68.2%; specificity, 75.5%). Considering this a threshold, patients who had a TFA ≥4.5° had 6.6 times higher odds of graft failure compared with patients with a TFA <4.5° (P < .001). Survival analysis demonstrated a 5-year survival rate of 81% in patients with a TFA <4.5°, while it was 44% in those with a TFA ≥4.5° (P < .001). CONCLUSION: An increased TFA was associated with increased odds of ACLR failure when the TFA was ≥4.5°. Measuring the TFA in patients with ACL tears undergoing reconstruction may inform the surgeon about additional factors that may require consideration before ACLR for a successful outcome.

Return to Sport after Surgical Treatment of Lisfranc Injuries in Athletes: A Retrospective Case Series.

INTRODUCTION: A Lisfranc injury can be a devastating injury in athletes, and if inadequately treated, may lead to chronic pain and loss of function. The purpose of this study was to determine the rate and time until return to sport after surgical fixation for a ligamentous Lisfranc injury. We hypothesized that open reduction and screw fixation of a ligamentous Lisfranc injury can be a successful treatment in the athletic population and allow patients to return to sport at close to their preinjury level of play. METHODS: All patients who were analyzed underwent repair of a ligamentous Lisfranc injury with open reduction and screw fixation by a single surgeon, were between 18 - 40 years old at time of their final follow up, and were identified as being an athlete (either recreational or competitive). Eligible patients were given a questionnaire that included if they were able to return to sport, time until return to sport, subjective percentage of pre-injury level of play, current pain (0 - 10), and complications. RESULTS: Eleven patients were identified as athletes. Ten (91%) were available for follow-up with a mean of 36.5 months (range, 14 - 60). The average age was 25.4 years (range, 15 - 37) at time of surgery. Eighty percent (8/10) were able to return to sport. The average time until return to sport was 29.4 weeks (range, 22 - 52) with an average subjective value of their pre-injury level of play of 87% (range, 70 - 100%). However, 67% (6/9) of the athletes had occasional pain with sport with an average pain level of 2.1 (range, 0 - 5). Two patients had complications, a superficial infection and a deep vein thrombosis. CONCLUSION: Most athletes were able to return to sport after undergoing open reduction and internal fixation of a ligamentous Lisfranc injury by less than 30 weeks post-surgery with a subjective value of 87% of their previous function. However, the majority of the patients also experienced some residual pain with their respective sport. These findings suggested that athletes with a ligamentous Lisfranc injury can have reliably good outcomes with operative repair.

Encapsulated Fat Necrosis Lesion Caused by Morel-Lavallée Lesion in a Professional Ice Hockey Player.

Morel-Lavallée (ML) lesions occur when subcutaneous tissue is stripped from fascia and replaced with hematoma or necrotic fat. Encapsulated fat necrosis lesions, which are rare, can occur with disruption of the blood supply in the subcutaneous area, which occurs with ML lesions. In this article, we report the case of a professional ice hockey player with an ML lesion that caused a symptomatic encapsulated fat necrosis lesion to develop. The encapsulated lesion required surgical removal.