Higher return to pre-injury type of sports after revision anterior ligament reconstruction with lateral extra-articular tenodesis compared to without lateral extra-articular tenodesis

PurposeTo evaluate the rate of return to pre-injury type of sports (RTS type) in patients after revision anterior cruciate ligament reconstruction (ACLR) with lateral extra-articular tenodesis (LET) compared to patients after revision ACLR without LET.MethodsSeventy-eight patients who underwent revision ACLR with an autologous ipsilateral bone-patellar tendon-bone autograft with and without LET were included at least one year after surgery (mean follow-up: 43.9, SD: 29.2 months). All patients filled in a questionnaire about RTS type, the Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee subjective form (IKDCsubjective), and the Tegner activity score.ResultsThe RTS type for revision ACLR with LET was 22 of 42 (52%), whereas 11 of 36 (31%) of the patients who underwent revision ACLR without LET returned to the pre-injury type of sport (p = 0.05). No significant differences were found in KOOS subscores, IKDCsubjective, and Tegner activity scores.ConclusionAn additional LET increases the rate of RTS type after revision ACLR

Higher return to pre-injury type of sports after revision anterior ligament reconstruction with lateral extra-articular tenodesis compared to without lateral extra-articular tenodesis

PurposeTo evaluate the rate of return to pre-injury type of sports (RTS type) in patients after revision anterior cruciate ligament reconstruction (ACLR) with lateral extra-articular tenodesis (LET) compared to patients after revision ACLR without LET.MethodsSeventy-eight patients who underwent revision ACLR with an autologous ipsilateral bone-patellar tendon-bone autograft with and without LET were included at least one year after surgery (mean follow-up: 43.9, SD: 29.2 months). All patients filled in a questionnaire about RTS type, the Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee subjective form (IKDCsubjective), and the Tegner activity score.ResultsThe RTS type for revision ACLR with LET was 22 of 42 (52%), whereas 11 of 36 (31%) of the patients who underwent revision ACLR without LET returned to the pre-injury type of sport (p = 0.05). No significant differences were found in KOOS subscores, IKDCsubjective, and Tegner activity scores.ConclusionAn additional LET increases the rate of RTS type after revision ACLR

Meniscal Tears, Posterolateral and Posteromedial Corner Injuries, Increased Coronal Plane, and Increased Sagittal Plane Tibial Slope All Influence Anterior Cruciate Ligament–Related Knee Kinematics and Increase Forces on the Native and Reconstructed Anterior Cruciate Ligament: A Systematic Review of Cadaveric Studies

Purpose: To obtain a comprehensive list of pathologies that cause increased anterior cruciate ligament (ACL) forces and pathologic knee kinematics to evaluate for in both primary and revision ACL reconstruction to decrease the risk of subsequent graft overload. Methods: An electronic search was performed in the Embase and MEDLINE databases for the period between January 1, 1990, and December 10, 2020. All articles investigating medial and lateral meniscal injury, (postero)lateral corner injury, (postero)medial corner/medial collateral ligament injury, valgus alignment, varus alignment, and tibial slope in relation to ACL (graft) force and knee kinematics were included. Results: Data of 43 studies were included. The studies reported that high-volume medial and lateral meniscectomies, peripheral meniscus tears, medial meniscus ramp tears, lateral meniscus root tears, posterolateral corner injuries, medial collateral ligament tears, increased tibial slope, and valgus and varus alignment were reported to have a significant impact on ACL (graft) force and related knee kinematics. Conclusions: This systematic review on biomechanical cadaver studies provides a rationale to systematically identify and treat pathologies in ACL-injured knees, because when undiagnosed or left untreated, these specific concomitant pathologies could lead to ACL graft overload in both primary and revision ACL-reconstructed knees. Clinical Relevance: it is necessary that orthopaedic surgeons who treat ACL-injured knees understand the surgically relevant biomechanical consequences of additional pathologies and use this knowledge to optimize treatment in ACL-injured patients

Superior return to sports rate after patellar tendon autograft over patellar tendon allograft in revision anterior cruciate ligament reconstruction

PURPOSE: After revision anterior cruciate ligament reconstruction (ACLR), the rate of return to the pre-injury type of sport (RTS type) is low and graft choice might be an important factor. The aim of this study was to determine whether there is a difference in outcome after revision ACLR using a patellar tendon allograft compared to an ipsilateral patellar tendon autograft. It was hypothesized that the rate of RTS type using an ipsilateral patellar tendon autograft will be superior to using patellar tendon allograft. METHODS: The design is a retrospective cohort study. Inclusion criteria were patients who underwent revision ACLR with a minimum follow-up of 1 year after revision using a patellar allograft or ipsilateral autograft. Primary study parameter was rate of RTS type. Secondary study parameters were RTS level, subscores of the KOOS, the IKDCsubjective, the Tegner score and reasons for no RTS. RESULTS: Eighty-two patients participated in this study (36 allografts and 46 autografts). In patients with a minimum follow-up of 1 year, rate of RTS type was 51.4% for the patellar tendon allograft and 62.8% for the patellar tendon autograft group (n.s.). In patients with a minimum follow-up rate of 2 years, rate of RTS type was 43.3 versus 75.0%, respectively (p = 0.027). No differences in secondary study parameters were found. In patients with a minimum follow-up of 1 year, rate of RTS type was significantly higher (p = 0.025) for patients without anxiety compared to patients who were anxious to perform certain movements. CONCLUSION: After a minimum follow-up of 2 years, rate of RTS type is in favour of using an ipsilateral patellar tendon autograft when compared to using a patellar tendon allograft in patients undergoing revision ACLR; after a minimum follow-up of 1 year, no significant difference was found. In revision ACLR, the results of this study might influence graft choice in favour of autologous graft when the use of an allograft or autograft patellar tendon is considered. LEVEL OF EVIDENCE: III

Acute Anterior Cruciate Ligament Rupture: Repair or Reconstruction? Five-Year Results of a Randomized Controlled Clinical Trial

Background: High-level evidence for short–term outcomes of contemporary anterior cruciate ligament (ACL) suture repair (ACLSR) in comparison with those of ACL reconstruction (ACLR) is scarce. High-level evidence for mid- and long–term results is lacking, whereas outcomes of ACLSR in several historical studies were shown to deteriorate at midterm follow–up after initial good short–term outcomes. Hypothesis: Contemporary ACLSR is noninferior to ACLR in the treatment of acute ACL rupture in terms of patient self–reported outcomes at 5 years postoperatively. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 48 patients were enrolled in the study and, after stratification and randomization, underwent either dynamic augmented (DA) ACLSR or anatomic single–bundle ACLR. The primary outcome measure was the International Knee Documentation Committee 2000 (IKDC) subjective score (IKDCs). Furthermore, the Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner Activity Scale score (TAS), visual analog scale score for satisfaction (VASs), IKDC physical examination score (IKDCpe), limb symmetry index for quadriceps (LSIq) and hamstrings (LSIh) strength and jump test battery (LSIj), Kellgren-Lawrence grade of osteoarthritis (OA), and rate of adverse events were recorded. Analyses were based on an intention–to–treat principle. Results: The lower limit of the 2–sided 95% CI for the median IKDCs of the DA ACLSR group (n = 23; 75.9) was lower than the prespecified noninferiority margin (n = 21; 86.6). Therefore, the null hypothesis was rejected. However, the upper limit of the 2–sided 95% CI of the DA ACLSR group (100.0) was higher than the median IKDCs of the ACLR group (96.6), rendering the result for noninferiority inconclusive. No statistical difference was found between groups for median IKDCs (repair, 90.2; reconstruction, 96.6). Furthermore, no statistically significant differences were found for any of the secondary outcome measures for the DA ACLSR compared with the ACLR group: KOOS Symptoms, 92.9 versus 96.4; KOOS Pain, 100 versus 97.2; KOOS Activities of Daily Living, 100 versus 100; KOOS Sport and Recreation, 85.0 versus 100; TAS score, 7.0 versus 6.5; VASs, 9.2 versus 8.7; IKDCpe, 81.8% versus 100%; LSIq, ≥91.6 versus ≥88.2; LSIh, ≥95.1 versus ≥90.7; LSIj, ≥94.2 versus ≥97.6; OA grade 0, 90.9% versus 77.8%; clinical ACL failure rate, 20.8% versus 27.2%; and repeat surgery rate, 37.5% versus 20.0%, respectively. Conclusion: It remains inconclusive whether the effectiveness of DA ACLSR is noninferior to that of ACLR in terms of subjective patient–reported outcomes as measured using the IKDCs. Although DA ACLSR may be a viable treatment option for patients with acute ACL rupture, caution must be exercised when considering this treatment for young, active patients, corresponding to the present study population

Self-reported functional recovery after reconstruction versus repair in acute anterior cruciate ligament rupture (ROTOR): a randomized controlled clinical trial

Abstract Background Anterior cruciate ligament (ACL) reconstruction is today’s surgical gold standard for ACL rupture. Although it provides satisfactory results, not all patients return to their previous activity level and moreover, early posttraumatic osteoarthritis is not prevented. As such, a renewed interest has emerged in ACL suture repair combined with dynamic augmentation. Compared to ACL reconstruction, the hypothesized advantages of ACL suture repair are earlier return to sports, reduction of early posttraumatic osteoarthritis and preservation of the patient’s native ACL tissue and proprioceptive envelope of the knee. In recent literature, ACL suture repair combined with dynamic augmentation tends to be at least equally effective compared to ACL reconstruction, but no randomized comparative study has yet been conducted. Methods/design This study is a prospective, stratified, block randomized controlled trial. Forty-eight patients with an ACL rupture will be assigned to either a suture repair group with dynamic augmentation and microfracture of the femoral notch, or an ACL reconstruction group with autologous semitendinosis graft and all-inside technique. The primary objective is to investigate the hypothesis that suture repair of a ruptured ACL results in at least equal effectiveness compared with an ACL reconstruction in terms of patient self-reported outcomes (IKDC 2000 subjective scale) 1 year postoperatively. Secondary objectives are to evaluate patient self-reported outcomes (IKDC 2000, KOOS, Tegner, VAS), re-rupture rate, rehabilitation time required for return to daily and sports activities, achieved levels of sports activity, clinimetrics (Rolimeter, LSI, Isoforce) and development of osteoarthritis, at short term (6 weeks, 3, 6 and 9 months and 1 year), midterm (2 and 5 years) and long term (10 years) postoperatively. Discussion A renewed interest has emerged in ACL suture repair combined with dynamic augmentation in the treatment of ACL rupture. Recent cohort studies show good short- and midterm results for this technique. This randomized controlled trial has been designed to compare the outcome of suture repair of a ruptured ACL, combined with DIS as well as microfracture of the femoral notch, with ACL reconstruction using autologous semitendinosus. Trial registration Clinical Trials Register NCT02310854 (retrospectively registered on December 1st, 2014)

Accuracy, inter- and intrarater reliability, and user-experience of high tibial osteotomy angle measurements for preoperative planning: manual planning PACS versus semi-automatic software programs

PURPOSE: To compare the accuracy, inter- and intrarater reliability, and user-experience of manual and semi-automatic preoperative leg-alignment measurement planning software for high tibial osteotomy (HTO). METHODS: Thirty patients (31 lower limbs) who underwent a medial opening wedge HTO between 2017 and 2019 were retrospectively included. The mechanical lateral distal femur angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), and planned correction angle were measured on preoperative long-leg full weight-bearing radiographs utilising PACS Jivex Review® v5.2 manual and TraumaCad® v2.4 semi-automatic planning software. Independent measurements were performed by four raters. Two raters repeated the measurements. Accuracy in the standard error of measurement (SEM), inter- and intrarater reliability, and user-experience were analysed. Additionally, measurements errors of more than 3° were remeasured and reanalysed. RESULTS: The SEMs of all measured varus malalignment angles and planned correction angle were within 0.8° of accuracy for both software programs. Measurements utilising the manual software demonstrated moderate interrater intraclass correlation coefficient (ICC)-values for the mLDFA and mMPTA, and an excellent interrater ICC-value for the correction angle (0.810, 0.779, and 0.981, respectively). Measurements utilising the semi-automatic software indicated excellent interrater ICC-values for the mLDFA, mMPTA, and correction angle (0.980, 0.909, and 0.989, respectively). The intrarater reliability varied substantially per angle, presenting excellent intrarater agreements by both raters (ICC >  0.900) for the correction angle in each software program as well as poor-to-excellent ICC-values for the mLDFA (0.282-0.951 and 0.316-0.926) and mMPTA (0.893-0.934 and 0.594-0.941) in both the manual planning and semi-automatic software. Regarding user-experience, semi-automatic software was preferred by two raters, while the other two raters had no distinctive preference. After remeasurement of five outliers, excellent interrater ICC-values were found for the mLDFA (0.913) and mMPTA (0.957). CONCLUSIONS: Semi-automatic software outperforms the manual software when user-experience and outliers are considered. However, both software programs provide similar performance after remeasurement of the human-related erroneous outliers. For clinical practice, both programs can be utilised for HTO planning. LEVEL OF EVIDENCE: Diagnostic study, Level III