ACL Study Group presents the global trends in ACL reconstruction: biennial survey of the ACL Study Group.

OBJECTIVES: The primary objective of this survey was to gauge the current global trends in anterior cruciate ligament reconstruction (ACLR) as reported by the members of the Anterior Cruciate Ligament (ACL) Study Group (SG). METHODS: A survey was created and distributed among the members of the ACL SG consisting of 87 questions and 16 categories related to ACLR, including member demographics, preoperative management, primary ACLR techniques and graft choice, use of concomitant procedures and biological augmentation, postoperative rehabilitation, and more. RESULTS: The survey was completed by the 140 members of the ACL SG. Fifty per cent of members are from Europe, 29% from the USA, 15% from the Asia-Pacific and the remaining 6% are from Latin America, the Middle East, New Zealand and Africa. Most (92%) do not believe there is a role for non-operative management of ACL tears in higher level athletes; conversely, most agree there is a role for non-operative management in lower impact athletes (92%). A single-bundle (90%) technique with hamstring autograft (53%) were most common for primary ACLR. Tunnel position varied among respondents. Sixty-one per cent do not use allograft for primary ACLR. Fifty per cent of respondents use cortical suspensory fixation on the femur, with variable responses on the tibia. Most (79%) do not use biologics in primary ACLR, while 83% think there is a selective role for extra-articular augmentation in primary ACLR. Fifty per cent prefer bone-tendon-bone autograft for revision ACLR and extra-articular augmentation is more commonly used (13% always, 26% often) than in primary ACLR (0% always, 15% often). A majority (53%) use a brace after primary ACLR. The most common responses for minimal time to return to play after primary ACLR were 6-8 months (44%) and 8-12 months (41%). CONCLUSION: We presented the thoughts and preferences of the ACL SG on the management of ACL injuries. This survey will help to facilitate an ongoing discussion with regard to ACLR by providing global insights into the current surgical trends in ACLR. LEVEL OF EVIDENCE: Level V, Expert Opinion.

ACL Study Group survey reveals the evolution of anterior cruciate ligament reconstruction graft choice over the past three decades.

PURPOSE: Anterior cruciate ligament reconstruction (ACLR) aims to restore knee function and stability, allowing patients to return to the activities they enjoy and minimize further injury to the meniscus and cartilage and their ultimate progression to osteoarthritis. This study aims to present the evolution of graft choice over the last three decades according to members of the ACL Study Group (SG). METHODS: Prior to the January 2020 ACL SG biannual meeting, a survey was administered consisting of 87 questions and 16 categories, including ACLR graft choice. A similar questionnaire has been administered prior to each meeting and survey results from the past 14 meetings (1992 through 2020, excluding 1994) are included in this work. Survey responses are reported as frequencies in percentages to quantify changes in practice over the surgery period. RESULTS: In 1992, the most frequent graft choice for primary ACLR was bone-patellar tendon-bone (BTB) autograft, at nearly 90%. Hamstring tendon (HT) autografts have increased in popularity, currently over 50%, followed by just under 40% BTB autograft. Recently, quadriceps tendon (QT) autograft has increased in popularity since 2014. CONCLUSION: Autograft (HT, BTB, QT) is an overwhelming favorite for primary ACLR over allograft. The preference for HT autograft increased over the study period relative to BTB autograft, with QT autograft gaining in popularity in recent years. Graft selection should be individualized for each patient and understanding the global trends in graft choice can help orthopaedic surgeons discuss graft options with their patients and determine the appropriate graft for each case. LEVEL OF EVIDENCE: Level V, Expert Opinion.

Lorecivivint, a Novel Intraarticular CDC-like Kinase 2 and Dual-Specificity Tyrosine Phosphorylation-Regulated Kinase 1A Inhibitor and Wnt Pathway Modulator for the Treatment of Knee Osteoarthritis: A Phase II Randomized Trial.

OBJECTIVE: To assess the safety and efficacy of a novel Wnt pathway modulator, lorecivivint (SM04690), for treating pain and inhibiting structural progression in moderately to severely symptomatic knee osteoarthritis (OA). METHODS: Subjects in this 52-week, phase IIa, multicenter, randomized, double-blind, placebo-controlled, dose-ranging trial received a single 2-ml intraarticular injection of lorecivivint (dose of 0.03 mg, 0.07 mg, or 0.23 mg) or placebo. Efficacy was assessed based on change from baseline on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score subscales for pain and function (scale 0-100 for each) and change from baseline in the radiographic medial joint space width (JSW). Baseline-adjusted analysis of covariance with multiple imputation was performed separately to evaluate efficacy. This proof-of-concept study evaluated the intent-to-treat population as well as a prespecified group of subjects with unilateral symptoms of knee OA (designated UNI) and an additional post hoc subgroup of subjects with unilateral symptoms but without widespread pain (designated UNI WP-). RESULTS: In this trial, 455 subjects were randomized to a treatment group. The primary end point, significant improvement in the WOMAC pain score compared with placebo at week 13, was not met by any lorecivivint dose group (mean ± SD change from baseline, -23.3 ± 2.2 in the 0.03 mg group, -23.5 ± 2.1 in the 0.07 mg group, -21.3 ± 2.2 in the 0.23 mg group, and -22.1 ± 2.1 in the placebo group; each P > 0.05 versus placebo). All groups (including placebo) demonstrated clinically meaningful (≥20-point) improvements from baseline in the WOMAC pain score. The durability of response was evaluated through week 52. In the prespecified UNI group and post hoc UNI WP- group at week 52, treatment with 0.07 mg lorecivivint significantly improved the WOMAC pain score (between-group difference versus placebo, -8.73, 95% confidence interval [95% CI] -17.44, -0.03 [P = 0.049] and -11.21, 95% CI -20.99, -1.43 [P = 0.025], respectively) and WOMAC function score (between-group difference versus placebo, -10.26, 95% CI -19.82, -0.69 [P = 0.036] and -13.38, 95% CI -24.33, -2.43 [P = 0.017], respectively). Relative to baseline, the mean change in the medial JSW at week 52 was -0.04 mm in the 0.03 mg cohort, -0.09 mm in the 0.07 mg cohort, -0.16 mm in the 0.23 mg cohort, and -0.14 mm in the placebo cohort; no treatment group achieved a significant change in medial JSW compared with placebo at week 52. In both unilateral symptom subgroups, the 0.07 mg lorecivivint dose significantly increased medial JSW compared with placebo at week 52 (medial JSW 0.39 mm, 95% CI 0.06, 0.72 in the UNI group [P = 0.021] and 0.42 mm, 95% CI 0.04, 0.80 in the UNI WP- group [P = 0.032]). Changes observed in the 0.03 mg and 0.23 mg dose groups were not significantly different from those in the placebo group for any of these measures. Lorecivivint appeared safe and well tolerated. CONCLUSION: This phase IIa, proof-of-concept trial in patients with symptomatic knee OA did not meet its primary end point. Nevertheless, the study identified a target population in whom to evaluate the potential efficacy of lorecivivint for the treatment of knee OA.

An analysis of specific lower extremity injury rates on grass and FieldTurf playing surfaces in National Football League Games: 2000-2009 seasons.

BACKGROUND: Players in the National Football League (NFL) sustain injuries every season as the result of their participation. One factor associated with the rate of injury is the type of playing surface on which the players participate. HYPOTHESIS: There is no difference in the rate of knee sprains and ankle sprains during NFL games when comparing rates of those injuries during games played on natural grass surfaces with rates of those injuries during games played on the artificial surface FieldTurf. STUDY DESIGN: Descriptive epidemiology study. METHODS: The NFL records injury and exposure (ie, game) data as part of its injury surveillance system. During the 2000-2009 NFL seasons, there were 2680 games (5360 team games) played on grass or artificial surfaces. Specifically, 1356 team games were played on FieldTurf and 4004 team games were played on grass. We examined the 2000-2009 game-related injury data from those games as recorded by the injury surveillance system. The data included the injury diagnosis, the date of injury, and the surface at the time of injury. The injury data showed that 1528 knee sprains and 1503 ankle sprains occurred during those games. We calculated injury rates for knee sprains and ankle sprains-specifically, medial collateral ligament (MCL) sprains, anterior cruciate ligament (ACL) sprains, eversion ankle sprains, and inversion ankle sprains-using incidence density ratios (IDRs). We used a Poisson model and logistic regression odds ratios to validate the IDR analysis. A multivariate logistic regression model was used to adjust the odds ratio for weather conditions. RESULTS: The observed injury rate of knee sprains on FieldTurf was 22% (IDR = 1.22, 95% confidence interval [CI], 1.09-1.36) higher than on grass, and the injury rate of ankle sprains on FieldTurf was 22% (IDR = 1.22, 95% CI, 1.09-1.36) higher than on grass. These differences are statistically significant. Specifically, the observed injury rates of ACL sprains and eversion ankle sprains on FieldTurf surfaces were 67% (P < .001) and 31% (P < .001) higher than on grass surfaces and were statistically significant. The observed injury rates of MCL sprains and inversion ankle sprains were also not significantly higher on FieldTurf surfaces (P = .689 and .390, respectively). CONCLUSION: Injury rates for ACL sprains and eversion ankle sprains for NFL games played on FieldTurf were higher than rates for those injuries in games played on grass, and the differences were statistically significant.

Potential market for new meniscus repair strategies: evaluation of the MOON cohort.

This study aimed to determine the incidence of meniscal tears and describe the tear morphology and selected treatment in patients undergoing anterior cruciate ligament (ACL) reconstruction. We also will discuss the potential market for future tissue engineering aimed at preserving meniscal function. A multicenter cohort of 1014 patients undergoing ACL reconstruction between January 2002 and December 2003 was evaluated. Data on patient demographics, presence of a meniscus tear at time of ACL reconstruction, tear morphology, and meniscal treatment were collected prospectively. Meniscal tears were categorized into 3 potential tissue engineering treatment strategies: all-biologic repair, advanced repair, and scaffold replacement. Of the knees, 36% had medial meniscal tears and 44% had lateral meniscal tears. Longitudinal tears were the most common tear morphology. The most frequent treatment method was partial meniscectomy. Thirty percent of medial meniscal tears and 10% of lateral meniscal tears are eligible for all-biologic repair; 35% of medial meniscal tears and 35% of lateral meniscal tears are eligible for an advanced repair technique; and 35% of medial meniscal tears and 55% of lateral meniscal tears are eligible for scaffold replacement. Although meniscal preservation is generally accepted in the treatment of meniscal tears, most tears in this cohort were not repairable, despite contemporary methods. The results of this cohort will hopefully stimulate and focus future research and development of new tissue engineering strategies for meniscus repair.

Success of meniscal repair at anterior cruciate ligament reconstruction.

BACKGROUND: Meniscal repair is performed in an attempt to prevent posttraumatic arthritis resulting from meniscal dysfunction after meniscal tears. The socioeconomic implications of premature arthritis are significant in the young patient population. Investigations and techniques focusing on meniscus preservation and healing are now at the forefront of orthopaedic sports medicine. HYPOTHESIS: Concomitant meniscal repair with anterior cruciate ligament reconstruction is a durable and successful procedure at 2-year follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All unilateral primary anterior cruciate ligament reconstructions entered in 2002 in a cohort who had meniscal repair at the time of anterior cruciate ligament reconstruction were evaluated. Validated patient-oriented outcome instruments were completed preoperatively and then again at the 2-year postoperative time point. Reoperation after the index procedure was also documented and confirmed by operative reports. RESULTS: A total of 437 unilateral primary anterior cruciate ligament reconstructions were performed with 82 concomitant meniscal repairs (54 medial, 28 lateral) in 80 patients during the study period. Patient follow-up was obtained on 94% (77 of 82) of the meniscal repairs, allowing confirmation of meniscal repair success (defined as no repeat arthroscopic procedure) or failure. The overall success rate for meniscal repairs was 96% (74 of 77 patients) at 2-year follow-up. CONCLUSION: Meniscal repair is a successful procedure in conjunction with anterior cruciate ligament reconstruction. When confronted with a "repairable" meniscal tear at the time of anterior cruciate ligament reconstruction, orthopaedic surgeons can expect an estimated >90% clinical success rate at 2-year follow-up using a variety of methods as shown in our study.

A systematic review of anterior cruciate ligament reconstruction rehabilitation: part I: continuous passive motion, early weight bearing, postoperative bracing, and home-based rehabilitation.

Anterior cruciate ligament (ACL) reconstruction is a common surgical knee procedure that requires intensive postoperative rehabilitation by the patient. A variety of randomized controlled trials have investigated aspects of ACL reconstruction rehabilitation. A systematic review of English language level 1 and 2 studies identified 54 appropriate randomized controlled trials of ACL rehabilitation. Topics discussed in this part of the article include continuous passive motion, early weight bearing in motion, postoperative bracing, and home-based rehabilitation.

A systematic review of anterior cruciate ligament reconstruction rehabilitation: part II: open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics.

Anterior cruciate ligament (ACL) reconstruction is a common surgical knee procedure that requires intensive postoperative rehabilitation by the patient. A variety of randomized controlled trials have investigated aspects of ACL reconstruction rehabilitation. A systematic review of English language level 1 and 2 studies identified 54 appropriate randomized controlled trials of ACL rehabilitation. This part of the article discusses open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics.

Risk of tearing the intact anterior cruciate ligament in the contralateral knee and rupturing the anterior cruciate ligament graft during the first 2 years after anterior cruciate ligament reconstruction: a prospective MOON cohort study.

BACKGROUND: The risk of tear of the intact anterior cruciate ligament in the contralateral knee after anterior cruciate ligament reconstruction of the opposite knee and the incidence of rupturing the anterior cruciate ligament graft during the first 2 years after surgery have not been extensively studied in a prospective manner. Clinicians have hypothesized that the opposite normal knee is at equal or increased risk compared with the risk of anterior cruciate ligament graft rupture in the operated knee. HYPOTHESIS: The risk of anterior cruciate ligament graft rupture and contralateral normal knee anterior cruciate ligament rupture at 2-year follow-up is equal. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: The Multicenter Orthopaedic Outcome Network (MOON) database of a prospective longitudinal cohort of anterior cruciate ligament reconstructions was used to determine the number of anterior cruciate ligament graft ruptures and tears of the intact anterior cruciate ligament in the contralateral knee at 2-year follow-up. Two-year follow-up consisted of a phone interview and review of operative reports. RESULTS: Two-year data were obtained for 235 of 273 patients (86%). There were 14 ligament disruptions. Of these, 7 were tears of the intact anterior cruciate ligament in the contralateral knee (3.0%) and 7 were anterior cruciate ligament graft failures (3.0%). CONCLUSION: The contralateral normal knee anterior cruciate ligament is at a similar risk of anterior cruciate ligament tear (3.0%) as the anterior cruciate ligament graft after primary anterior cruciate ligament reconstruction (3.0%).

Pronation-external rotation ankle fractures in 3 professional football players.

We found no reports of ankle fracture management in professional football players in the orthopedic literature. In this small series of ankle fractures in professional football players, all 3 had the same pronation-external rotation injury pattern. Given the high demands placed on the ankle by these professional athletes, we chose to use a 4.5-mm screw for fixation of the syndesmosis and a 3.5-mm reconstruction plate for fibular fixation to provide the most stable fixation. All 3 athletes were able to return to preinjury levels of athletic participation in the NFL without residual pain or stiffness.

Return to play issues in upper extremity injuries.

OBJECTIVE: The purpose of this paper is to outline general treatment and return to play (RTP) strategies as they pertain to athletes with various upper extremity injuries. It is not intended to be a comprehensive review of these injuries. DATA SOURCES/SYNTHESIS: A review of the literature plus expert opinion served as the basis for recommendations made regarding management strategies for returning the athlete to play after upper extremity injury. A Medline search was performed using the following key words: upper extremity injury, return to play, glenohumeral dislocation, acromioclavicular joint sprains, elbow dislocation, scaphoid fracture, metacarpal fracture, finger dislocation, tendon injury, hand, mallet finger, and jersey finger. These and other related terms were crossed using the Medline database from 1966 to 2005. RESULTS: Review of book chapters, articles generated from the Medline search, and expert opinion led to the recommendations that are presented here. There is general agreement regarding the treatment of many of the injuries discussed, but controversies do exist. RTP guidelines are largely dependent on the severity of initial injury, rates of healing, and return of strength. CONCLUSIONS: Each athlete with a particular injury to the upper extremity needs to be approached as an individual as no single set of treatment or RTP guidelines applies to all injuries or all individuals. Factors such as age, injury severity, hand dominance, type of sport participation, method of treatment, and chronicity of injury are among the many issues that must be considered when developing a treatment and RTP strategy for a particular athlete.

A biomechanical comparison of posterior cruciate ligament reconstructions using single- and double-bundle tibial inlay techniques.

BACKGROUND: The efficacy of using a double-bundle versus single-bundle graft for posterior cruciate ligament reconstruction has not been demonstrated. HYPOTHESIS: A double-bundle graft restores knee kinematics better than a single-bundle graft does in tibial inlay PCL reconstructions. STUDY DESIGN: Controlled laboratory study. METHODS: Eight cadaveric knees were subjected to 6 cycles from a 40-N anterior reference point to a 100-N posterior translational force at 10 degrees , 30 degrees , 60 degrees , and 90 degrees of flexion. Testing was performed for the intact and posterior cruciate deficient knee as well as for both reconstructed conditions. Achilles tendons, divided into 2 equal sections, were prepared as both single-bundle and double-bundle grafts. Both grafts were employed in the same knee, and the order of graft reconstruction was randomized. RESULTS: There were no statistical differences in translation between the intact state and either of the reconstructions (P > .05) or between either of the reconstructions at any flexion angle (P > .05). CONCLUSION: No differences in translation between the 2 graft options were identified. CLINICAL RELEVANCE: The use of a double-bundle graft may not offer any advantages over a single-bundle graft for tibial inlay posterior cruciate reconstructions.

Evaluation and treatment of posterior cruciate ligament injuries: revisited.

Current knowledge and treatment of posterior cruciate ligament injuries continue to lag behind that of anterior cruciate ligament injuries. This is the result of the relative infrequency of posterior cruciate ligament injuries and the lack of consensus with respect to its natural history, surgical indications, technique, and postoperative rehabilitation. Recent anatomical and biomechanical studies have improved our understanding of the posterior cruciate ligament in an attempt to reproduce its anatomy and function during reconstruction. The following is a comprehensive review on the evaluation and treatment of posterior cruciate ligament injuries with special focus on the current surgical techniques.

Plantar ganglion cyst associated with stress fracture of the third metatarsal.

Ganglion cysts of the foot and ankle occur relatively infrequently. Metatarsal stress fractures occur in a variety of athletes who subject their lower extremities to repetitive loading. In this article, we report the case of a professional football player with a plantar forefoot ganglion cyst associated with a stress fracture of the third metatarsal. After the cyst resolved with aspiration, the stress fracture healed with conservative, nonsurgical treatment.

Jumping versus nonjumping anterior cruciate ligament injuries: a comparison of pathology.

OBJECTIVE: To compare pathology in knees with an anterior cruciate ligament (ACL) injury as a result of a jumping mechanism with knees injured from a nonjumping mechanism. DESIGN: This was a prospective study of 263 consecutive patients with a complete ACL tear and no subsequent giving way episodes nor reinjuries prior to undergoing an ACL reconstruction. The patients were placed into one of two groups: those with knees injured as a result of a jumping injury, and those with knees injured as a result of a nonjumping injury. SETTING: This study was performed at the Cleveland Clinic Foundation, Cleveland, Ohio. PATIENTS: Anterior cruciate ligament-deficient knees undergoing ACL reconstruction. Two hundred thirty-eight (91%) of the patients were injured while participating in sports. MAIN OUTCOME MEASURED: Intra-articular pathology documented prospectively at the time of arthroscopy. RESULTS: Knees injured as a result of a jumping mechanism had a higher incidence of medial (p = 0.05) and lateral (p = 0.03) meniscal tears and a lower incidence of medial collateral ligament injuries (p = 0.05). No difference in arthroscopic articular cartilage injuries was seen between the two groups. CONCLUSIONS: We believe that identifying jumping as a mechanism of ACL tears is important, since a jumping mechanism is associated with a significantly increased meniscus tear rate and may predispose this population to future degenerative changes.

Non-linear fitting of mechanical data for efficacy determination of single versus double bundle Achilles tendon grafts for PCL reconstructions.

The Posterior Cruciate Ligament (PCL) consists of two primary bundles and is the primary restraint to posterior tibial translation. The emergence of the Posterior Tibial Inlay Technique (PTIT) has demonstrated a mechanical advantage over the commonly used Tibial Tunnel Method (TTM). This study was designed to investigate the effects on knee mechanics from both a Single-bundle (SB) and Double-bundle (DB) Achilles tendon PCL reconstruction using a PTIT. The investigators hypothesized that a DB graft demonstrates a mechanical advantage compared to the SB graft. A materials testing machine provided six sequential loading cycles of 100 N while total translation was measured. The testing was conducted at 90 degrees, 60 degrees, 30 degrees and 10 degrees of flexion in neutral tibial rotation. While the mechanical advantages of the DB graft were detected, specifically at small laxity values and in the physiological range of normal gait, the additional complexity of the technique may clinically outweigh the mechanical advantages.