Treatment After Anterior Cruciate Ligament Injury: Panther Symposium ACL Treatment Consensus Group

© The Author(s) 2020. Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best-practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance toward consensus opinions regarding the best available evidence on operative versus nonoperative treatment for ACL injury. The purpose of this study was to report the consensus statements on operative versus nonoperative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. There were 66 international experts on the management of ACL injuries, representing 18 countries, who were convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the scientific organizing committee and session chairs for the 3 working groups. Panel participants reviewed preliminary statements before the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Ultimately, 80% agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus nonoperative treatment of ACL injury reached consensus during the symposium. Overall, 9 statements achieved unanimous support, 2 reached strong consensus, 1 did not achieve consensus, and 1 was removed because of redundancy in the information provided. In highly active patients engaged in jumping, cutting, and pivoting sports, early anatomic ACL reconstruction is recommended because of the high risk of secondary meniscal and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight-plane activities, nonoperative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomic ACL reconstruction is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and nonoperative treatment with patients after an ACL injury

Rates and Determinants of Return to Play After Anterior Cruciate Ligament Reconstruction in NCAA Division 1 College Football Athletes: A Study of the ACC, SEC, and PAC-12 Conferences

For competitive athletes, return to play (RTP) and return to preinjury levels of performance after anterior cruciate ligament (ACL) reconstruction are the main goals of surgery. Although outcomes of ACL surgery are well studied, details on factors influencing RTP in elite college football players have not been evaluated thoroughly. To determine the rate of RTP following ACL surgery among National Collegiate Athletic Association (NCAA) Division 1 collegiate football athletes and to examine variables that may affect these rates. The hypothesis was that the RTP rate in this cohort will be influenced by factors reflecting skill and accomplishment; that is, athletes higher on the depth chart, those on scholarship, and those later in their careers will have higher RTP rates. It was also predicted that graft type and concomitant procedures may have an effect on RTP rates. Case series; Level of evidence, 4. Using athlete- and surgery-specific data from participating institutions in 3 major Division 1 college football conferences, information on athletes who had ACL reconstruction from 2004 through 2010 was collected. Statistical analyses were performed to determine the RTP rate as a function of the variables, such as depth chart position, in the data collected. Of the 184-player cohort, 82% of the athletes, including 94% of starters, were able to RTP. Rates were greater among athletes higher on the depth chart (P = .004) and on scholarship (P = .008). Year of eligibility also affected RTP rates (P = .047), which increased from the redshirt and freshman year to the sophomore and junior years, but then decreased slightly into the senior and fifth-year senior seasons. The use of an autograft versus allograft was associated with increased RTP (P = .045). There was no significant difference (P = .18) between players who underwent an isolated ACL reconstruction versus those who underwent additional procedures. More than 80% of football players at the Division 1 level were able to RTP following ACL reconstruction. Factors representative of a player's skill were associated with higher rates of RTP. Surgery-specific variables, in general, had no effect on RTP, except for the use of autograft, which was associated with a greater RTP rate

Minimally Invasive Quadriceps Tendon Harvest and Graft Preparation for All-Inside Anterior Cruciate Ligament Reconstruction

The quadriceps tendon is an infrequently used graft option for anterior cruciate ligament reconstruction despite favorable clinical results in the literature with low donor site morbidity. It is a versatile graft that can be harvested with bone or as a soft tissue graft alone. In addition, it can be used for anatomic, double-bundle, transtibial, and all-inside reconstructions. The unique characteristics of the quadriceps tendon allow for the ability to harvest a single-bundle large-diameter graft and minimize disruption of normal anatomy, which makes the quadriceps tendon an excellent choice for all-inside techniques. Recently developed minimally invasive harvest techniques described in this note allow for a reproducible predictable and efficient harvest through a small incision

Arthroscopic-Assisted Lateral Extra-Articular Tenodesis With Knotless Anchor Fixation

Recent studies have reported the biomechanical and clinical advantages of lateral extraarticular augmentation procedures including the modified lateral extra-articular tenodesis (LET) in the setting of anterior cruciate ligament reconstruction. LET has been shown to significantly decrease re-rupture rates in high-risk patients and decrease anterior cruciate ligament graft forces during pivoting loads and instrumented anterior laxity testing. Many variations of the modified LET approaches have been described. However, concerns including lateral hematoma, wound-healing complications, and increased operative time exist. This minimally invasive, arthroscopic-assisted approach using a knotless, all-suture anchor allows for direct visualization through a 2-cm incision and inherently decreases the morbidity associated with traditional LET techniques

Treatment after anterior cruciate ligament injury: Panther Symposium ACL Treatment Consensus Group

Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance towards consensus opinions regarding the best available evidence on operative versus non-operative treatment for ACL injury.The purpose of this study was to report the consensus statements on operative versus non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organising Committee and Session Chairs for the three working groups. Panel participants reviewed preliminary statements prior to the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty per cent agreement was defined a priori as consensus. A total of 11 of 13 statements on operative veresus non-operative treatment of ACL injury reached consensus during the symposium. Nine statements achieved unanimous support; two reached strong consensus; one did not achieve consensus; and one was removed due to redundancy in the information provided.In highly active patients engaged in jumping, cutting and pivoting sports, early anatomical anterior cruciate ligament reconstruction (ACLR) is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability or when episodes of giving way occur, anatomical ACLR is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and non-operative treatment with patients after an ACL injury.Level of evidence: V

Treatment after anterior cruciate ligament injury: Panther Symposium ACL Treatment Consensus Group

Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance toward consensus opinions regarding the best available evidence on operative vs. non-operative treatment for ACL injury. The purpose of this study is to report the consensus statements on operative vs. non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, were convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organizing Committee and Session Chairs for the three working groups. Panel participants reviewed preliminary statements prior to the meeting and provided the initial agreement and comments on the statement via an online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty percent agreement was defined a-priori as consensus. A total of 11 of 13 statements on operative v. non-operative treatment of ACL injury reached the consensus during the Symposium. Nine statements achieved unanimous support, two reached strong consensus, one did not achieve consensus, and one was removed due to redundancy in the information provided. In highly active patients engaged in jumping, cutting, and pivoting sports, early anatomic ACL reconstruction is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomic ACL reconstruction is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and non-operative treatments with patients after an ACL injury.Level of evidence V

Standardized Opioid Counseling Is Underperformed Before and After Anterior Cruciate Ligament Reconstruction

Purpose: To characterize contemporary pain management strategies after anterior cruciate ligament reconstruction (ACLR) within the US and international orthopaedic community. Methods: This was a cross-sectional survey-based study disseminated to a consortium of expert orthopaedic surgeons in the management of anterior cruciate ligament injuries. The survey was a 27-question, multiple choice–style questionnaire with question topics ranging from demographic characteristics and practice characteristics to surgeon-specific pain management strategies in the postoperative period after ACLR. Specific topics of interest included the use of preoperative opioid education and/or counseling sessions, implementation of standardized pain management regimens, use of pain tracking systems, and use of any adjunct non-narcotic analgesic modalities. Results: A total of 34 completed surveys were collected, representing a 73.9% response rate. Over 85% of respondents reported prescribing opioids as a standardized postoperative regimen after ACLR. Surgeons reported prescribing 5- to 10-mg doses, with the tablet count ranging anywhere from fewer than 10 tablets to more than 20 tablets, often instructing their patients to stop opioid use 2 to 4 days postoperatively. Prescribed dosages remained stable or decreased over the past 6 months with increased use of non-narcotic adjuncts. Only one-third of respondents reported using standardized preoperative opioid counseling, with even fewer discussing postoperative discontinuation protocols. Conclusions: Over 85% of respondents prescribe opioids as a standardized postoperative regimen after ACLR, with only 15% providing non-narcotic pain regimens. However, prescribed dosages have remained stable or decreased over the past 6 months with increased use of non-narcotic adjuncts. Only one-third of respondents use standardized preoperative opioid counseling, with even fewer discussing postoperative discontinuation protocols. Clinical Relevance: The ongoing opioid epidemic has created an urgent need to identify the most effective pain management strategies after orthopaedic procedures, especially ACLR. This study provides important information about current pain management practices for patients who have undergone ACLR

Rates and Determinants of Return to Play after Anterior Cruciate Ligament Reconstruction in Division 1 College Football Athletes: A Study of the ACC, SEC, and PAC-12

OBJECTIVES: In competitive athletes, return to play (RTP) and return to pre-injury levels of performance are the main goals of anterior cruciate ligament (ACL) surgery. RTP has been studied in several athletic populations, such as the National Football League. However, to our knowledge, RTP has not been comprehensively evaluated in Division 1 college football. This study aimed to determine the rate of RTP amongst players in three major Division 1 college football conferences, and to investigate several athlete and surgery related variables that may affect RTP. We hypothesized that rates of RTP would be higher than those previously reported in the National Football League and that graft choice and history of concomitant menisectomy would affect RTP. We also hypothesized that players with more experience, at higher depth chart positions, and/or on scholarship would RTP at higher rates than other players. METHODS: Head team orthopaedists and athletic trainers at institutions in the Atlantic Coast Conference, Southeastern Conference, and Pacific 12 Conference were contacted to request their participation in the study. Following IRB approval participating institutions were sent a standardized data collection spreadsheet that asked for RTP and other athlete- and surgery-specific information on all football players undergoing ACL reconstruction from 2004-2010. RTP was defined as an athlete participating in a full practice or official game after the date of his surgery. Athletes whose eligibility expired while injured were excluded from our analysis. Data from each institution was pooled and Chi-square and Fisher Exact tests were used to test the association between any categorical variables and RTP rates. RESULTS: Data from a total of 184 athletes was obtained. The overall rate of RTP was 82% amongst all athletes. 76% of athletes were able to return to a level of play equal or higher than before their injury. Player’s depth chart position before injury did have a significant (p = .0049) association with RTP, with 73% of players who rarely played, 88% of utilized players, and 95% of starters returning to play after surgery. Athletes on scholarship returned to play at a higher rate (88%), than those not on scholarships (69%) (p = .014). Years of experience also had a significant (p = .047) effect on RTP, with freshman RTP at 83%, sophomores at 94%, juniors at 89%, seniors at 73%, and fifth year seniors at 75%. The use of autograft vs. allograft and the specific choice of autograft did not have a significant impact on RTP rates. Players who underwent a menisectomy returned to play at a rate (79%) similar to those who did not have a concomitant menisectomy (84%) (p = .56). CONCLUSION: The overall rate of RTP in our Division 1 college football athlete cohort was higher than that previously reported in professional football players. Athletes at higher positions on the depth chart and those on scholarship returned to play at higher rates. Year in school also had a significant effect on RTP rates, while the type of ACL graft and the performance of menisectomy did not