Individualized Anatomic Anterior Cruciate Ligament Reconstruction

Arthroscopic anterior cruciate ligament reconstruction (ACL-R) is a technique that continues to evolve. Good results have been established with respect to reducing anteroposterior laxity. However, these results have come into question because nonanatomic techniques have been ineffective at restoring knee kinematics and raised concerns that abnormal kinematics may impact long-term knee health. Anatomic ACL-R attempts to closely reproduce the patient's individual anatomic characteristics. Measurements of the patient's anatomy help determine graft choice and whether anatomic reconstruction should be performed with a single- or double-bundle technique. The bony landmarks and insertions of the anterior cruciate ligament (ACL) are preserved to assist with anatomic placement of both tibial and femoral tunnels. An anatomic single- or double-bundle reconstruction is performed with a goal of reproducing the characteristics of the native ACL. Long-term outcomes for anatomic ACL reconstruction are unknown. By individualizing ACL-R, we strive to reproduce the patient's native anatomy and restore knee kinematics to improve patient outcomes

The REVision Using Imaging to Guide Staging and Evaluation (REVISE) in ACL Reconstruction Classification

Abstract Revision anterior cruciate ligament (ACL) procedures are increasing in incidence and possess markedly inferior clinical outcomes (76% satisfaction) and return-to-sports (57%) rates than their primary counterparts. Given their complexity, a universal language is required to identify and communicate the technical challenges faced with revision procedures and guide treatment strategies. The proposed REV ision using I maging to guide S taging and E valuation (REVISE) ACL (anterior cruciate ligament) Classification can serve as a foundation for this universal language that is feasible and practical with acceptable inter-rater agreement. A focus group of sports medicine fellowship-trained orthopaedic surgeons was assembled to develop a classification to assess femoral/tibial tunnel “usability” (placement, widening, overlap) and guide the revision reconstruction strategy (one-stage vs. two-stage) post–failed ACL reconstruction. Twelve board-certified sports medicine orthopaedic surgeons independently applied the classification to the de-identified computed tomographic (CT) scan data of 10 patients, randomly selected, who failed ACL reconstruction. An interclass correlation coefficient (ICC) was calculated (with 95% confidence intervals) to assess agreement among reviewers concerning the three major classifications of the proposed system. Across surgeons, and on an individual patient basis, there was high internal validity and observed agreement on treatment strategy (one-stage vs. two-stage revision). Reliability testing of the classification using CT scan data demonstrated an ICC (95% confidence interval) of 0.92 (0.80–0.98) suggesting “substantial” agreement between the surgeons across all patients for all elements of the classification. The proposed REVISE ACL Classification, which employs CT scan analysis to both identify technical issues and guide revision ACL treatment strategy (one- or two-stage), constitutes a feasible and practical system with high internal validity, high observed agreement, and substantial inter-rater agreement. Adoption of this classification, both clinically and in research, will help provide a universal language for orthopaedic surgeons to discuss these complex clinical presentations and help standardize an approach to diagnosis and treatment to improve patient outcomes. The Level of Evidence for this study is 3

Anterior Cruciate Ligament Healing and Advances in Imaging

Graft healing and maturation are important considerations during the rehabilitation process. Histologic studies have identified the stages of graft healing following anterior cruciate ligament (ACL) reconstruction. Correlations between histology and radiographic findings have allowed for the development of noninvasive methods to assess graft maturity. Important information regarding graft vascularity and incorporation of the graft to host bone can be obtained from imaging modalities. The role of noninvasive means in the evaluation of patients following ACL reconstruction continues to develop as these powerful tools evolve

Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group

Background: A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sport and their previous activity level. Purpose: The aim of the Panther Symposium ACL Injury Return to Sport Consensus Group was to provide a clear definition of RTS after ACL injury and a description of the RTS continuum as well as provide clinical guidance on RTS testing and decision-making. Study Design: Consensus statement. Methods: An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence. Results: Key points include that RTS is characterized by achievement of the preinjury level of sport and involves a criteria-based progression from return to participation to RTS and, ultimately, return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along an RTS continuum, with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors, and concomitant injuries. Conclusion: The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing, and methods for the biological assessment of healing and recovery