‘I was young, I wanted to return to sport, and re-ruptured my ACL’ – young active female patients’ voices on the experience of sustaining an ACL re-rupture, a qualitative study

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Clinical outcomes after anterior cruciate ligament injury: panther symposium ACL injury clinical outcomes consensus group

© 2020, The Author(s). Purpose: A stringent outcome assessment is a key aspect for establishing evidence-based clinical guidelines for anterior cruciate ligament (ACL) injury treatment. The aim of this consensus statement was to establish what data should be reported when conducting an ACL outcome study, what specific outcome measurements should be used and at what follow-up time those outcomes should be assessed. Methods: To establish a standardized approach to assessment of clinical outcome after ACL treatment, a consensus meeting including a multidisciplinary group of ACL experts was held at the ACL Consensus Meeting Panther Symposium, Pittsburgh, PA; USA, in June 2019. The group reached consensus on nine statements by using a modified Delphi method. Results: In general, outcomes after ACL treatment can be divided into four robust categories—early adverse events, patient-reported outcomes, ACL graft failure/recurrent ligament disruption and clinical measures of knee function and structure. A comprehensive assessment following ACL treatment should aim to provide a complete overview of the treatment result, optimally including the various aspects of outcome categories. For most research questions, a minimum follow-up of 2 years with an optimal follow-up rate of 80% is necessary to achieve a comprehensive assessment. This should include clinical examination, any sustained re-injuries, validated knee-specific PROs and Health-Related Quality of Life questionnaires. In the mid- to long-term follow-up, the presence of osteoarthritis should be evaluated. Conclusion: This consensus paper provides practical guidelines for how the aforementioned entities of outcomes should be reported and suggests the preferred tools for a reliable and valid assessment of outcome after ACL treatment. Level of evidence: V

Young age and high BMI are predictors of early revision surgery after primary anterior cruciate ligament reconstruction: a cohort study from the Swedish and Norwegian knee ligament registries based on 30,747 patients

Purpose To analyse patient-related risk factors for 2-year ACL revision after primary reconstruction. The hypothesis was that younger athletes would have a higher incidence of an early ACL revision. Methods This prospective cohort study was based on data from the Norwegian and Swedish National Knee Ligament Registries and included patients who underwent primary ACL reconstruction from 2004 to 2014. The primary end-point was the 2-year incidence of ACL revision. The impact of activity at the time of injury, patient sex, age, height, weight, BMI, and tobacco usage on the incidence of early ACL revision were described by relative risks (RR) with 95% confidence intervals (CI). Results A total of 58,692 patients were evaluated for eligibility and 30,591 patients were included in the study. The mean incidence of ACL revision within 2 years was 2.82% (95% CI 2.64–3.02%). Young age (13–19) was associated with an increased risk of early ACL revision (males RR = 1.54 [95% CI 1.27–1.86] p < 0.001 and females RR = 1.58 [95% CI 1.28–1.96] p < 0.001). Females over 1 SD in weight ran an increased risk of early ACL revision (RR = 1.82, [95% CI 1.15–2.88] p = 0.0099). Individuals with a BMI of over 25 ran an increased risk of early ACL revision (males: RR = 1.78, [95% CI 1.38–2.30] p < 0.001 and females: RR = 1.84, [95% CI 1.29–2.63] p = 0.008). Conclusion Young age, a BMI over 25, and overweight females were risk factors for an early ACL revision. Level of evidence II

Minimally Invasive Versus Open Repair for Acute Achilles Tendon Rupture: Meta-Analysis Showing Reduced Complications, with Similar Outcomes, After Minimally Invasive Surgery

BACKGROUND: There is no consensus on the optimal technique for repairing an acute Achilles tendon rupture. The purpose of this meta-analysis was to compare the complications, subjective outcomes, and functional results between minimally invasive surgery and open repair of an Achilles tendon rupture. METHODS: A systematic literature search of MEDLINE/PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), EBSCOhost, and ClinicalTrials.gov was performed. Eligible studies were randomized controlled trials (RCTs) comparing minimally invasive surgery and open repair of acute Achilles tendon ruptures. A meta-analysis was performed, while bias and the quality of the evidence were rated according to the Cochrane Database questionnaire and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. The meta-analysis was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. RESULTS: Eight studies, with 182 patients treated with minimally invasive surgery and 176 treated with open repair, were included. The meta-analysis showed a significantly decreased risk ratio (RR) of 0.21 (95% confidence interval [CI] = 0.10 to 0.40, p = 0.00001) for overall complications and 0.15 (95% CI = 0.05 to 0.46, p = 0.0009) for wound infection after minimally invasive surgery. Patients treated with minimally invasive surgery were more likely to report good or excellent subjective results (RR = 1.18, 95% CI = 1.04 to 1.33, p = 0.009). No differences between groups were found with respect to reruptures, sural nerve injury, return to preinjury activity level, time to return to work, or ankle range of motion. The overall quality of evidence was generally low because of a substantial risk of bias, heterogeneity, indirectness of outcome reporting, and evaluation of a limited number of patients. CONCLUSIONS: There was a significantly decreased risk of postoperative complications, especially wound infection, when acute Achilles tendon rupture was treated with minimally invasive surgery compared with open surgery. Patients treated with minimally invasive surgery were significantly more likely to report a good or excellent subjective outcome. Current evidence is associated with high heterogeneity and a considerable risk of bias. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence

Pseudo-patella baja: a minor yet frequent complication of total knee arthroplasty

Purpose: One of the complications in total knee arthroplasty (TKA) is pseudo-patella baja (PPB). PPB is present when there is no shortening of the patellar tendon, but the joint line is elevated. The purpose of this study is to investigate the incidence of PPB after TKA and its clinical effects. Methods: A case series of 158 patients undergoing TKA surgery between 1999 and 2012 at the 2nd Department of Orthopaedics and Traumatology, Pisa were retrospectively reviewed. Surgeries were performed by three senior surgeons, using the same surgical procedure for the implantation of a cemented posterior stabilized prosthesis. Lateral radiographs at 30° knee flexion were evaluated and the presence of PPB defined as modified Blackburne–Peel Index (mBPI) of &lt; 0.54. All the patients were clinically evaluated using the Knee Society Score (KSS) and the Western Ontario and McMaster Universities Osteoarthritis Index score (WOMAC). Anterior knee pain was evaluated by visual analogue scale (VAS) and range of motion (ROM) was assessed through clinical examination. Results: The cohort group consisted of 158 patients, 109 (69.0%) female and 49 (31.0%) male. Median age at time of surgery was 74 years (range 36–87) and median follow-up was 66 months (range 12–163 months). Bilateral TKA surgery was performed in 50 patients, resulting in a total of 208 implants for investigation. On radiological evaluation, 139 (66.8%) showed no abnormalities (no joint line elevation and no patellar tendon shortening) and 55 (26.4%) presented joint line elevation with absence of patellar tendon shortening (PPB). No significant differences were found between the groups in terms of the KSS, WOMAC score, VAS or ROM. Conclusion: Post TKA PPB is a relatively common complication. Careful preoperative planning, adequate soft tissue release, optimal cutting of bone components, on the femoral side in particular, and the use of thin polyethylene inserts can help to avoid this complication. Level of evidence: IV. © 2017, European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA)

Factors that affect patient reported outcome after anterior cruciate ligament reconstruction-a systematic review of the Scandinavian knee ligament registers

Objective: To perform a systematic review of findings from the Scandinavian knee ligament registers with regard to factors that affect patient reported outcome after anterior cruciate ligament (ACL) reconstruction. Design: Systematic review. Data sources: Four electronic databases: PubMed, EMBASE, the Cochrane Library and AMED were searched, and 157 studies were identified. Two reviewers independently screened the titles, abstracts and full text articles for eligibility. A modified version of the Downs and Black checklist was applied for quality appraisal. Eligibility criteria for selecting studies: Studies published from the Scandinavian registers from their establishment in 2004 and onwards that documented patient reported outcome and provided information on concomitant injuries were eligible. Results: A total of 35 studies were included. Younger age at ACL reconstruction, male sex, not smoking and receiving a hamstring tendon autograft positively influenced patient reported outcome. Patients with concomitant cartilage and meniscal injuries reported inferior subjective knee function compared with patients with an isolated ACL tear. One study reported that patients treated non-reconstructively reported inferior knee function compared with patients who had ACL reconstruction. Conclusion: Younger age, male sex, not smoking, receiving a hamstring tendon autograft and the absence of concomitant injuries were associated with superior patient reported outcomes after ACL reconstruction

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

OBJECTIVES 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 sports and their previous activity level. The aim of the Panther Symposium ACL Injury RTS Consensus Group was to provide a clear definition of RTS after ACL injury and description of the RTS continuum, as well as provide clinical guidance on RTS testing and decision-making. 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 characterised 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

Factors associated with additional anterior cruciate ligament reconstruction and register comparison: a systematic review on the Scandinavian knee ligament registers

Objective: To present an overview of the Scandinavian knee ligament registers with regard to factors associated with additional ACL reconstruction, and studies comparing the Scandinavian registers with other knee ligament registers. Design: Systematic review. Data sources: Four electronic databases: PubMed, EMBASE, the Cochrane Library and AMED were searched, and 157 studies were identified. Two reviewers independently screened titles, abstracts and full-text studies for eligibility. A modified version of the Downs and Black checklist was applied for quality appraisal. Eligibility criteria for selecting studies: Eligible studies were those published since the establishment of the Scandinavian registers in 2004, which reported factors associated with additional ACL reconstruction and compared data from other registers. Results: Thirty-one studies met the inclusion criteria and generally displayed good reporting quality. Adolescent age (<20 years) was the most common factor associated with additional ACL reconstruction. The choice of hamstring tendon graft compared with patella tendon, transportal femoral tunnel drilling, smaller graft diameter and utilisation of suspensory fixation devices were associated with additional ACL reconstruction. Concomitant cartilage injury decreased the likelihood of additional ACL reconstruction. Patient sex alone did not influence the likelihood. The demographics of patients undergoing ACL reconstruction in the Scandinavian registers are comparable to registers in other geographical settings. However, there are differences in surgical factors including the presence of intra-articular pathology and graft choice. Summary: The studies published from the Scandinavian registers in general have a high reporting quality when regarded as cohort studies. Several factors are associated with undergoing additional ACL reconstruction. The results from the registers may help facilitate treatment decisions

Timing of hip hemiarthroplasty and the influence on prosthetic joint infection

Introduction Previous research suggested that patients have increased risk of infection with increased time from presentation with a femoral neck fracture to treatment with a hip hemiarthroplasty (HHA). The purpose of this study was to determine if rates of prosthetic joint infections within 3 months of surgery was affected by the time from patient presentation with a femoral neck fracture to the time of treatment with HHA. Materials and methods Acute hip fractures treated with HHA between 2005 and 2017 at three centres in Norway were enrolled in the study. Multi-trauma patients were excluded. Univariable analysis was performed to determine any significant effect of pre-operative waiting time on infection rate. Two pre-planned analyses dichotomizing pre-operative waiting time cut-offs were performed. Results There were 2300 patients with an average age of 82 (range, 48–100) years included of which 3.4% experienced a prosthetic joint infection within 3 months. The primary analysis found no significant difference in infection rate depending on time to surgery (OR = 1.06 (95% CI 0.94–1.20, p = 0.33)). The secondary analyses showed no significant differences in infection rates when comparing pre-operative waiting time of <24 hours vs �24 hours (OR = 0.92 (95% CI 0.58–1.46, p = 0.73)) and <48 hours vs �48 hours (OR = 1.39 (95% CI 0.81– 2.38, p = 0.23)). Conclusion Based off of a large retrospective Norwegian database of hip fractures there did not appear to be a significant difference in infection rate based on pre-operative wait time to surgery