Responsiveness of the Various Short-Form Versions of the Knee Injury and Osteoarthritis Outcome Score Between 2 and 5 Years After Anterior Cruciate Ligament Reconstruction.

Background: Various short-form versions of the Knee injury and Osteoarthritis Outcome Score (KOOS) have been developed in an attempt to minimize responder burden. However, the responsiveness of these short-form measures in patients who have undergone anterior cruciate ligament (ACL) reconstruction has not been compared at midterm follow-up. Purpose: To determine the responsiveness of 3 short-form versions of the KOOS (KOOS-12, KOOS-Global, and KOOS-ACL) in patients who have undergone ACL reconstruction. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: In 276 patients (149 male, 127 female), we administered the KOOS and a measure of overall knee function at both 2 and 5 years after ACL reconstruction. From the full KOOS, the following short-form versions were calculated: KOOS-12, KOOS-Global, and KOOS-ACL. Responsiveness was assessed using several distribution and anchor-based methods for each of the short-form versions. From distribution statistics the standardized response mean (SRM) and smallest detectable change (SDC) were calculated. Using the anchor-based method, the minimally important change (MIC) that was associated with an improvement in knee function was determined using receiver operating characteristic (ROC) analysis. Results: High ceiling effects were present for all measures. KOOS-Global scores increased significantly over time, whereas KOOS-12 and KOOS-ACL did not change. The KOOS-Quality of Life (QOL) subscale, which can be derived from both KOOS-Global and KOOS-12, also increased significantly between assessments. Both these increases were associated with a small (0.2-0.3) SRM. The MIC was smallest for KOOS-Global (3.2 points) and largest for KOOS-QOL (9.4 points), and, for all measures, the MIC was larger than the SDC at a group level. KOOS-Global was the only measure for which the mean difference between the 2- and 5-year assessments exceeded both the SDC (group level) and the MIC. Conclusion: Of the 3 short-form versions of the KOOS currently available, the KOOS-Global had the greatest responsiveness to change between the 2- and 5-year assessments after ACL reconstruction. High ceiling effects were present for all versions.

Effect of Age and Femoral Tunnel Drilling Technique on the Prevalence of Intra-articular Pathology at Both Primary and Revision ACL Reconstruction.

Background: Studies have shown that meniscal and chondral lesions are more common at the time of revision anterior cruciate ligament reconstruction (ACLR) compared with primary surgery; however, few have evaluated the same patients through both primary and revision surgery. Purpose: To describe the prevalence of meniscal and chondral lesions at the time of primary and subsequent revision ACLR and to determine the effect of age and femoral tunnel drilling technique on the development of intra-articular pathology over time. Study Design: Case series; Level of evidence, 4. Methods: All patients who had primary and subsequent revision ACLR in the same knee between 1997 and 2022 were identified from a prospectively collated database. The grading of chondral surfaces in each compartment, the presence of any meniscal tears, and treatment performed were recorded. Patients were grouped according to age and femoral tunnel drilling technique to allow subgroup analysis. Results: Overall, 262 patients were included. Median age at primary surgery was 20.2 years. Lateral meniscal tears were more prevalent than medial tears at both primary (34.7% vs 28.2%; P = .11) and revision surgery (44.3% vs 40.8%; P = .43). Chondral lesions were most frequently found on the patella (8.8%) and the medial femoral condyle (MFC; 8.0%) at primary surgery. Between surgeries, new lesions developed most commonly on the MFC (13.0%) and the lateral femoral condyle (LFC; 11.1%). It was significantly more common for lateral meniscal tears treated with repair or left in situ at primary surgery to be healed at the time of revision surgery than medial tears (P = .01). Significantly more patients who had transtibial drilling of the femoral tunnel had a new meniscal tear at revision surgery (P = .001). Age did not have a significant influence on the prevalence of meniscal pathology. Conclusion: The prevalence of intra-articular pathology increased between primary and revision ACLR. Lateral meniscal tears were more prevalent than medial tears at both surgeries. At revision surgery, new chondral lesions were more commonly found on the MFC than the LFC. The higher incidence of new meniscal tears observed in the transtibial group may reflect the more vertical graft orientation with this technique and its inferior ability to control rotation.

The Resolution of Kaplan Fiber Injuries Is Observed in a Majority of Cases at 9 Months After Acute Primary Anterior Cruciate Ligament Reconstruction: A Radiological Study.

BACKGROUND: The natural history of Kaplan fiber (KF) injuries after acute primary anterior cruciate ligament (ACL) reconstruction (ACLR) remains unknown. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the temporal change in the magnetic resonance imaging (MRI) appearance of the KF complex after acute primary ACLR. It was hypothesized that KF injuries would resolve with time. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective MRI analysis was conducted on 89 patients with ACL-injured knees to assess the change in the radiological appearance of KFs after primary ACLR. Patients who had undergone index MRI and ACLR within 90 days of the injury and further MRI at 9 months after surgery were included. Diagnostic criteria to identify radiological evidence of a KF injury and its subsequent resolution were applied, including the presence of high signal intensity on fluid-sensitive sequences, which is indicative of a pathological process radiologically. The proximity of KFs to the femoral cortical suspensory device (CSD) was noted on MRI scans and quantified in millimeters. RESULTS: A KF injury was identified in 30.3% (27/89) of patients, with isolated high signal intensity observed in an additional 18.0% (16/89). At 9 months, MRI evidence of the reconstitution of the KF complex was found in 51.9% (14/27) of patients, with persistent discontinuity in the remaining patients (13/27). All patients (16/16) with isolated high signal intensity had complete resolution on repeat MRI scans. KF thickening was observed in 26.1% (12/46) of patients with previously healthy KFs and in 25.0% (4/16) with isolated high signal intensity. The CSD was positioned in close proximity (≤6 mm) to the center of the KF attachment in 61.8% (55/89) of patients, and this was associated with increased rates of KF thickening. CONCLUSION: The KF injury resolved radiologically in over half of the patients at 9 months after acute primary ACLR. High signal intensity in the region of the KFs on index MRI scans resolved in all cases, with evidence of residual KF thickening in only one-quarter of cases on repeat MRI scans, equivalent to the rate in those with healthy KFs. As such, it is not advisable to use high signal intensity on preoperative MRI scans as the sole criterion for the diagnosis of a KF injury. The position of the CSD after ACLR was intimately related to the KF attachment in the majority of patients, which was associated with KF thickening on postoperative MRI scans.

Comparison of Return-to-Sports Rates Between Male and Female Australian Athletes After ACL Reconstruction.

Background: Return to sports (RTS) is a goal for most patients who undergo anterior cruciate ligament reconstruction (ACLR). Although it has been reported that women RTS at a significantly lower rate compared with men, demographic and contextual factors that may be associated with this have not been investigated. Purpose: To compare RTS rates between men and women and investigate factors that may be associated with different rates of RTS in an Australian context. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 1338 patients who underwent primary ACLR between January 2014 and December 2017 were invited to complete a detailed sports participation questionnaire 2 to 7 years after surgery. RTS rates were calculated and compared between men and women overall and after stratifying by age at surgery (<20, 20-29, 30-39, or ≥40 years) and geographical location (metropolitan or rural). Contingency analysis was performed to compare factors associated with rates of RTS. Results: The survey completion rate was 81% (1080/1338). Overall, women had a significantly lower RTS rate compared with men (65.4% vs 74.9%; P = .001). However, when patients were grouped by age, the lower rate of RTS for women was significant only in the 20- to 29-year age group (P = .01). For athletes who returned to sports, there was no sex-based difference when comparing the levels of RTS. When grouping patients based on geographical location, there was a significantly lower rate of RTS in metropolitan-based women compared with metropolitan-based men (P < .001) and rural-based women (P = .042). Conclusion: Although women returned to sports at a lower rate than men overall, this difference was predominantly seen in the 20- to 29-year age bracket and in those who lived in metropolitan areas. There was no difference between men and women regarding the RTS level.

Impact of Occupation on 12-Month Outcomes After Anterior Cruciate Ligament Reconstruction in Male Patients.

Background: The impact of a physically demanding occupation on clinical outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR) is largely unknown. Purpose/Hypothesis: The purpose of this study was to assess the influence of occupation on 12-month outcomes after ACLR in male patients. It was hypothesized that patients undertaking manual work would not only have better functional outcomes in terms of strength and range of motion but also higher rates of joint effusion and greater anterior knee laxity. Study Design: Cohort study; Level of evidence, 3. Methods: From an initial cohort of 1829 patients, we identified 372 eligible patients aged 18 to 30 years who underwent primary ACLR between 2014 and 2017. Based on a preoperative self-assessment, 2 groups were established: patients engaged in heavy manual occupations and those engaged in low-impact occupations. Data were collected from a prospective database including effusion, knee range of motion (using side-to-side difference), anterior knee laxity, limb symmetry index for single hop and triple hop, International Knee Documentation Committee (IKDC) subjective score, and complications up to 12 months. Because of the significantly lower rate of female patients undertaking heavy manual occupations compared to low-impact occupations (12.5% and 40.0%, respectively), data analysis was focused on male patients. Outcome variables were assessed for normality, and statistical comparisons were made between the heavy manual and low-impact groups using either an independent-samples t test or the Mann-Whitney U test. Results: Of 230 male patients, 98 were included in the heavy manual occupation group, and 132 were included in the low-impact occupation group. Patients in the heavy manual occupation group were significantly younger than those in the low-impact occupation group (mean age, 24.1 vs 25.9 years, respectively; P < .005). There was a greater range of active and passive knee flexion in the heavy manual occupation group than in the low-impact occupation group (mean active, 3.38° vs 5.33°, respectively [P = .021]; mean passive, 2.76° vs 5.00°, respectively [P = .005]). There was no difference in effusion, anterior knee laxity, limb symmetry index, IKDC score, return-to-sport rate, or graft rupture rate at 12 months. Conclusion: At 12 months after primary ACLR, male patients engaged in heavy manual occupations had a greater range of knee flexion, with no difference in the effusion rate or anterior knee laxity, compared with those engaged in low-impact occupations.

Genetic variants within the COL5A1 gene are associated with ligament injuries in physically active populations from Australia, South Africa, and Japan.

Previous small-scale studies have shown an association between the COL5A1 gene and anterior cruciate ligament (ACL) injury risk. In this larger study, the genotype and allele frequency distributions of the COL5A1 rs12722 C/T and rs10628678 AGGG/deletion (AGGG/-) indel variants were compared between participants: (i) with ACL injury in independent and combined cohorts from South-Africa (SA) and Australia (AUS) vs controls (CON), and (ii) with any ligament (ALL) or only ACL injury in a Japanese (JPN) cohort vs CON. Samples were collected from SA (235 cases; 232 controls), AUS (362 cases; 80 controls) and JPN (500 cases; 1,403 controls). Genomic DNA was extracted and genotyped. Distributions were compared, and inferred haplotype analyses performed. No independent associations were noted for rs12722 or rs10628678 when the combined SA + AUS cohort was analysed. However, the C-deletion (rs12722-rs10628678) inferred haplotype was under-represented (p = 0.040, OR = 0.15, CI = 0.04-0.56), while the T-deletion inferred haplotype was over-represented in the female SA + AUS ACL participants versus controls (p < 0.001, OR = 4.74, CI = 1.66-13.55). Additionally, the rs12722 C/C genotype was under-represented in JPN CON vs ACL (p = 0.039, OR = 0.52, 0.27-1.00), while the rs10628678 -/- genotype was associated with increased risk of any ligament injuries (p = 0.035, OR = 1.31, CI = 1.02-1.68) in the JPN cohort. Collectively, these results highlight that a region within the COL5A1 3'-UTR is associated with ligament injury risk. This must be evaluated in larger cohorts and its functional relevance to the structure and capacity of ligaments and joint biomechanics be explored.Highlights The COL5A1 T-deletion inferred haplotype (rs12722-rs10628678) was associated with an increased risk of ACL rupture in the combined SA and AUS female participants.The COL5A1 C-deletion inferred haplotype (rs12722-rs10628678) was associated with a decreased risk of ACL rupture in the combined SA and AUS female participants.The COL5A1 rs12722 C/C and rs10628678 -/- genotypes were associated with increased risk of ACL rupture and of ligament injuries in JPN, respectively.A region within the COL5A1 3'-UTR is associated with risk of ligament injury, including ACL rupture, and therefore the functional significance of this region on ligament capacity and joint biomechanics requires further exploration.

Anterior Knee Pain Following Primary Unilateral Total Knee Arthroplasty With Posterior-Stabilized Prosthesis and Patellar Resurfacing: Prevalence and Clinical Implications.

BACKGROUND: Anterior knee pain following total knee arthroplasty (TKA) is associated with patient dissatisfaction. Factors related to postoperative anterior knee pain and its impact on patient outcomes are poorly understood. The following are the aims of this study: (1) to report the prevalence of anterior knee pain before and after TKA using a posterior-stabilized prosthesis with routine patellar resurfacing; (2) to investigate the association of preoperative clinical factors with the presence of anterior knee pain after TKA; and (3) to explore the association of postoperative anterior knee pain with postoperative self-reported function and quality of life. METHODS: This retrospective study included 506 patients who had undergone elective primary unilateral TKA with a posterior-stabilized prosthesis and patellar resurfacing. Outcome measures prior to and 12 months after TKA included self-reported anterior knee pain, knee function, and quality of life. RESULTS: Prevalence of anterior knee pain was 72% prior to and 15% following TKA. Patients who had preoperative anterior knee pain had twice the risk of experiencing anterior knee pain after TKA than patients who did not have preoperative anterior knee pain (risk ratio: 2.37, 95% CI 1.73-2.96). Greater severity of preoperative anterior knee pain and worse self-reported function were associated with the presence of postoperative anterior knee pain (rho = 0.15, P < .01; rho = 0.13, P < .01, respectively). Preoperative age, gender, and quality of life were not associated with postoperative anterior knee pain. Greater severity of postoperative anterior knee pain was associated with worse knee function at 12 months postoperative (rho = 0.49, P < .01). CONCLUSION: One in 7 patients reported anterior knee pain 12 months following posterior-stabilized and patella-resurfaced TKA. The presence of preoperative anterior knee pain and worse self-reported function are associated with postoperative anterior knee pain.

Effect of Radiological Evidence of Kaplan Fiber Injury on the Clinical and Functional Outcomes After Acute Anterior Cruciate Ligament Reconstruction.

BACKGROUND: A paucity of information is available regarding the clinical outcomes of patients with radiological evidence of Kaplan fiber (KF) injury who undergo anterior cruciate ligament (ACL) reconstruction (ACLR). PURPOSE/HYPOTHESIS: The purpose was to compare clinical and functional outcomes in patients undergoing acute primary ACLR with and without magnetic resonance imaging (MRI) evidence of KF injury. The hypothesis was that there would be no difference in clinical or functional outcomes in patients with versus those without radiological evidence of KF injury. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: MRI analysis was conducted on patients in a longitudinal prospective study of ACL injury. Only patients who had an MRI scan and had undergone isolated primary ACLR within 60 days of injury were included. MRI was performed using standard knee protocols, and diagnostic criteria were applied to identify KF injury. A total of 32 patients with KF injury (mean age, 24.2 years; 21 male, 11 female) were identified and matched for sex, age, graft type, and preinjury activity with 90 patients who had intact KF. Patients were followed up at 12 months with KT-1000 arthrometer measurements of side-to-side difference in anterior knee laxity, single- and triple-hop limb symmetry index (LSI), Marx activity and International Knee Documentation Committee (IKDC) scores, and return to sport (RTS) rates at 12 months and 24 months. RESULTS: No differences were found in anterior knee laxity and single- and triple-hop LSI values between the KF-intact and KF-injured cohorts at 12 months. No differences in Marx and IKDC scores were found between the groups at 12 months and 2 years. The overall rate of RTS within 24 months was 75% (92/122), and 5 patients (2 KF-injured; 3 KF-intact) had a subsequent graft rupture. CONCLUSION: We found no difference in clinical or functional outcomes in patients with and without radiological evidence of KF injury who underwent acute primary ACLR. Based on these findings, the radiological presence of KF injury at the time of acute ACL injury should not be regarded as a risk factor for a negative prognosis after ACLR.

Familial Predisposition to Anterior Cruciate Ligament Injury: A Systematic Review with Meta-analysis.

BACKGROUND: Having a family history of anterior cruciate ligament (ACL) injury has been investigated in the literature but few studies have focused on this factor specifically or reported their outcomes by sex. OBJECTIVE: We aimed to systematically review family history as a risk factor for sustaining a primary ACL injury and the impact it has on ACL graft rupture or contralateral ACL injury in male and female individuals. METHODS: A literature search was completed in seven databases from inception until March 2021 to investigate primary and subsequent ACL injuries in those with a family history of ACL injury. Articles were screened by prespecified inclusion criteria, and the methodological quality of each study was determined. Study results were combined using an odds ratio (OR) meta-analysis. Subgroup analysis was also completed by sex for primary ACL injury, as well as by graft rupture and contralateral ACL injury for subsequent ACL injuries. RESULTS: Twelve studies were acquired for systematic review and meta-analysis. Four studies that investigated primary ACL injury, seven that investigated ACL graft and/or contralateral ACL ruptures and one study that investigated both primary and subsequent ACL injury. Having a family history of ACL injury increased the odds of injury across all outcomes. Those with a family history had a 2.5 times greater odds for sustaining a primary ACL injury (OR 2.53 [95% confidence interval [CI] 1.96-3.28, p < 0.001)]. There was no significant difference of injury odds for primary ACL injury when analysed by sex. Family history of ACL injury was found to increase the odds of subsequent ACL injury by 2.38 (95% CI 1.64-3.46, p < 0.001) and was significant for both graft ruptures (OR 1.80 [95% CI 1.20-2.71, p = 0.005]) and contralateral ACL injuries (OR 2.28 [95% CI 1.28-4.04, p = 0.005]). When compared directly, the odds of sustaining a graft rupture versus a contralateral ACL injury were similar for those with a family history. Outcomes were not frequently reported by sex for subsequent ACL injuries. CONCLUSIONS: Having a family history of ACL injury more than doubles the odds of sustaining a primary or subsequent ACL injury. However, if a family history of ACL injury is present, the sex of the athlete does not increase the risk for primary injury nor is there a difference in the risk for a subsequent graft rupture compared to a contralateral ACL injury. CLINICAL TRIAL REGISTRATION: PROSPERO: CRD42020186472.

Is There an Association in Young Patients Between Quadriceps or Hamstring Strength After ACL Reconstruction and Graft Rupture?

Background: Younger patients who sustain anterior cruciate ligament (ACL) ruptures are at high risk for reinjury after ACL reconstruction. Restoring muscle strength before return to sports (RTS) is regarded as an important factor in reducing the reinjury risk, and quadriceps and hamstring strength assessment is commonly included in RTS testing. However, it is not clear whether reduced strength is a risk factor for subsequent graft rupture in this patient population. Purpose: To investigate the association between quadriceps and hamstring strength at 12 months after primary ACL reconstruction and ACL graft rupture in young patients. Study Design: Case-control study; Level of evidence, 3. Methods: The cohort consisted of 210 patients (100 men and 110 women) who were younger than 20 years at the time of primary ACL reconstruction with a hamstring tendon autograft and who had no previous contralateral ACL injury. Isokinetic strength testing (60 and 180 deg/s) of knee flexors and extensors was performed at 12 months postoperatively, and the limb symmetry index (LSI) for each strength outcome was calculated. RTS rates and the incidence of further ACL graft ruptures were recorded. Results: Measures of central tendency (mean and median) of LSI values ranged from 88 to 98. The percentage of patients with LSI ≥90 was 57% to 69% for quadriceps strength and 45% to 47% for hamstring strength. Overall, 19 patients (9%) sustained an ACL graft rupture. No significant differences were found between the patients who sustained an ACL graft rupture and those who did not in terms of quadriceps and hamstring strength at 12 months. No significant associations were found between achieving LSI ≥90 for quadriceps peak torque and subsequent ACL graft rupture. Conclusion: In young patients who underwent an ACL reconstruction, no association was noted between quadriceps and hamstring strength at 12 months postoperatively and subsequent graft ruptures. The role of strength testing as part of the RTS criteria after ACL reconstruction, and specifically the use of limb symmetry thresholds, warrants further investigation and clarification.

Choice of Patient-Reported Outcome Measures for Midterm Assessment After Anterior Cruciate Ligament Reconstruction Surgery.

BACKGROUND: Patient-reported outcome measures (PROMs) have become increasingly popular for assessing subjective elements of a patient's condition. Two frequently used knee-related PROMs after anterior cruciate ligament reconstruction (ACLR) surgery are the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) and the Knee injury and Osteoarthritis Outcome Score (KOOS). However, completing the full versions of both measures represents a considerable responder burden. PURPOSE: To compare a variety of KOOS short forms with each other as well as the IKDC-SKF in a large sample of ACLR patients between 2 and 6 years after surgery. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 2. METHODS: The KOOS and IKDC-SKF were administered between 2 and 6 years (mean, 3 years) after ACLR surgery to a cohort of 832 patients (men, n = 489; women, n = 343). Two single-item assessment numerical evaluations were also completed for knee function and satisfaction. The following short form versions were calculated from the full KOOS: the KOOS-12 short form, KOOS-Physical Function Short form (KOOS-PS), KOOS-Joint Replacement Short form (KOOS-JR), and KOOS-Global. Descriptive statistics were calculated for all PROMs and associations between measures were explored using nonparametric (Spearman rho) correlations. Floor or ceiling effects were considered present if >15% of patients reported the worst (floor effect) or best (ceiling effect) possible score. Age and sex comparisons were also made for each PROM. RESULTS: Ceiling effects were present for all KOOS short form versions. They were highly evident for the KOOS-JR and KOOS-PS (37%-44%), but they were only marginally above the threshold for the KOOS-12 and KOOS-Global (16%). The KOOS-12 and KOOS-Global had the highest correlation with the IKDC-SKF but only explained 58% to 59% of the variance in scores. The KOOS-12 and KOOS-Global were very highly correlated (ρ = 0.98). Only moderate correlations were seen between the single-item assessments and the IKDC-SKF or various KOOS short forms. There was a negligible association between patient age and PROM scores, but there was no significant sex difference for any of the PROMs. CONCLUSION: The IKDC-SKF together with either the KOOS-Global or KOOS-12 may provide a comprehensive range of knee-related PROMs with minimized responder burden at 2 to 6 years after ACLR.

Understanding the psychological mechanisms of return to sports readiness after anterior cruciate ligament reconstruction.

PURPOSE: The psychological response to an Anterior Cruciate Ligament (ACL) injury is significant and can negatively impact return to sports outcomes. This study aimed to quantify the association between factors associated with return to sport using network analysis. METHODS: 441 participants who underwent primary ACL reconstruction. The 12-item ACL Return to Sport after Injury (ACL-RSI) scale was administered to all participants 12 months after surgery. Three network analyses were used to quantify the adjusted correlations between the 12 items of the ACL-RSI scale, and to determine the centrality indices of each item (i.e., the degree of connection with other items in the network). Further subgroup network analyses were conducted for those who had (n = 115) and had not returned (n = 326) to their pre-injury level of sport. RESULTS: The greatest adjusted correlation was between Q7 and Q9 (fear of re-injury and afraid of accidentally injuring knee) of the ACL-RSI (group 0.48 (95%CI [0.40 to 0.57])) across all three networks. The most important item in the network was Q12 (relaxed about sport) across all three networks. Individuals who did return to sport had greater Strength centrality for Q8 (confidence in knee, P = 0.014) compared to those who did not return to sport. CONCLUSION: Fear of re-injury and being relaxed about playing sport were the two most important nodes in the network models that describe the return to sport readiness. The importance of knee confidence at influencing psychological readiness was greater in athletes who did return to sport compared to those who did not. Our findings provide candidate therapeutic targets that could inform future interventions designed to optimize return to sport rates in athletes post ACL reconstruction.

Rates and Determinants of Returning to Australian Rules Football in Male Nonprofessional Athletes After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Return to sport is a goal for most patients who undergo anterior cruciate ligament (ACL) reconstruction. However, at a nonelite level, there are limited sport-specific data regarding rates or factors associated with return to play. PURPOSE: To report rates and determinants of returning to play Australian Rules football after ACL reconstruction in male nonprofessional athletes. STUDY DESIGN: Case-series; Level of evidence, 4. METHODS: A total of 354 male nonprofessional Australian Rules football players who had undergone primary ACL reconstruction were asked to complete detailed sports activity questions at 12 months and 2 to 5 years (mean, 3 years) after surgery. Rates of return to play were calculated for both timepoints, along with preoperative patient expectations and postoperative sport performance. The following predictors of return to play were examined: age at surgery; height; weight; frequency of weekly football participation; sport participation level; psychological readiness to return to sport; and knee-related quality of life. Further ACL injuries were also documented. Descriptive statistics were used to summarize return-to-play data and contingency analysis for predictors of return to sport. RESULTS: The rate of return to any level of play was 35% (95% CI, 30%-41%; n = 284) at the 12-month follow-up and 78% (95% CI, 72%-83%; n = 233) at the 2- to 5-year follow-up. Overall, 64% (95% CI, 57%-70%) of the patients were able to return to their same or higher level of play. Before surgery, 92% of the patients expected to return to their same preinjury level of Australian Rules football participation. At the 2- to 5-year follow-up, 61% who returned to play felt that they could perform as well as they could before their ACL injury. A greater psychological readiness to return to sport preoperatively and higher level of sport participation were significant predictors of a return at 2 to 5 years. Further ACL injuries were sustained by 21% of the cohort (15% graft rupture; 6% contralateral ACL injury). CONCLUSION: Most male athletes who participate in Australian Rules football returned to some level of play after ACL reconstruction; however, only 64% returned to preinjury levels. Preoperative expectations were not met, and high reinjury rates are a cause for concern.

The Modified Ellison Technique: A Distally Fixed Iliotibial Band Transfer for Lateral Extra-articular Augmentation of the Knee.

Lateral extra-articular augmentation (LEA) of anterior cruciate ligament reconstructions significantly reduces graft failure rates. Currently, proximally fixed LEA procedures are popular techniques. However, there are concerns about these techniques regarding anterior cruciate ligament tunnel collision, kinematic overconstraint, and increasing lateral-compartment contact forces. These issues are potentially avoided by the modified Ellison procedure, which is a distally fixed LEA technique. This article describes the surgical details of this easily reproducible technique.

Knee strength deficits following anterior cruciate ligament reconstruction differ between quadriceps and hamstring tendon autografts.

PURPOSE: To compare patient reported outcomes and functional knee recovery following anterior cruciate ligament (ACL) reconstruction using either a quadriceps tendon (QT) or hamstring tendon (HT) autograft. METHODS: Thirty-five QT patients (age 20; range 15-34 years) participated in this study and were matched for gender, age and pre-injury activity level to 70 HT (age 20; range 15-32 years) patients. The following assessments were performed at 6 and 12 months post-operatively; standardized patient-reported outcome measures (IKDC, KOOS-QOL, ACL-RSI, Marx activity, anterior knee pain), knee range of motion (passive and active), anterior knee laxity, hop tests (single and triple crossover hop for distance), and isokinetic strength of the knee extensors and flexors. All dependent variables were analysed using a two-way mixed ANOVA model, with within (Time; 6 and 12 months) and between-subject (Graft; QT and HT) factors. RESULTS: Patient reported outcome measures and hop performance improved between 6 and 12 months (p < 0.001), however no significant differences in either patient-reported outcomes or hop performance were found between the two grafts. Isokinetic strength testing showed both groups improved their peak knee extensor strength in the operated limb between 6 and 12 months (p < 0.001), but the QT group had significantly lower knee extensor strength symmetry at both time points compared to HT at 60 deg/s (p < 0.001) and 180 deg/s (p < 0.01). In contrast, the QT group had significantly greater knee flexor strength symmetry at both time points compared to HT at 60 deg/s (p < 0.01) and 180 deg/s (p = 0.01), but knee flexor strength limb symmetry did not significantly improve over time in either group. CONCLUSION: Recovery of knee function following either QT or HT ACL reconstruction continues between 6 and 12 months after surgery. However, knee extensor strength deficits in the QT group and knee flexor strength deficits in the HT persisted at 12 months. This may have implications for decisions regarding return to sport. LEVEL OF EVIDENCE: III.

[Anterolateral stabilization using the modified ellison technique-Treatment of anterolateral instability and reduction of ACL re-rupture risk]. / Anterolaterale Stabilisierung mittels modifizierter Ellison-Technik ­ Behandlung anterolateraler Instabilitäten und Verminderung des VKB-Rerupturrisikos.

OBJECTIVE: The goal of the modified Ellison operation as a supplement to a conventional anterior cruciate ligament (ACL) reconstruction is to decrease anterolateral rotational instability of a knee joint after ACL rupture, to improve the stability and prevent ACL re-rupture. INDICATIONS: An ACL rupture with high risk of re-rupture (young age, high-performance sport, hyperlaxity, contralateral ACL rupture in history), increased subjective and objective anterolateral rotational instability of the knee after ACL rupture, ACL re-rupture. CONTRAINDICATIONS: Gonarthrosis, additive instabilities (e.g. posterolateral, medial), non-anatomical ACL reconstruction with persistent instability, general contraindications to surgery (e.g. infections), chronic irritation of the knee joint. SURGICAL TECHNIQUE: Supine position. Mark the typical landmarks. Incision from Gerdy's tubercle extending proximally along the iliotibial tract (ITT) to the lateral collateral ligament (approx. 5 cm). Incise the ITT in the line of its fibers about 10 mm anterior to its posterior border and continue the incision proximally to 5 mm proximal to the LCL. Make a parallel incision 10-12 mm anterior to the first incision. Use sharp subperiosteal dissection to elevate the strip of the ITT from Gerdy's tubercle. Secure the distal end of the ITT strip with a nonabsorbable suture (e.g. FiberWire No. 2, Arthrex, Naples, USA). Expose the LCL and pass the ITT strip deep to the LCL from proximal to distal and back to Gerdy's tubercle. Reattach the distal end of the strip of the ITT to its original position at Gerdy's tubercle with a bone anchor. The defect in the ITT can be closed with an absorbable suture (e.g. Vicryl, Ethicon, USA) in the proximal part. Layered closure. POSTOPERATIVE MANAGEMENT: Knee brace for at least 6 weeks, movement limitation of 0­0-90° for 6 weeks, 2 weeks 20 kg partial weight bearing. RESULTS: A total of 36 patients (mean age 18.9 years) with a high risk of ACL re-rupture have been treated with ACL reconstruction and modified Ellison procedure. Follow-up over 2 years. Of the patients 35 returned to the previous sports level, 1 patient suffered a re-rupture, 2 patients had cyclops resection and 1 patient contralateral ACL rupture.

Psychological Readiness to Return to Sport After Anterior Cruciate Ligament Reconstruction in the Adolescent Athlete.

CONTEXT: Psychological readiness to return to sport has been shown to be associated with future play after anterior cruciate ligament (ACL) reconstruction surgery but has not been extensively studied in adolescent athletes. OBJECTIVE: To investigate the psychometric properties of the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale in adolescent athletes at multiple time points after ACL reconstruction surgery and determine whether psychological readiness scores at 6 months predict return to competition sport at 12 months. DESIGN: Case series. SETTING: Private orthopaedic clinic. PATIENTS OR OTHER PARTICIPANTS: A total of 115 adolescent athletes (65 girls, 50 boys) 17 years and younger who had undergone primary unilateral ACL reconstruction. MAIN OUTCOME MEASURE(S): The ACL-RSI scale was administered at 6 and 12 months after surgery, and return-to-sport status was also documented. Factor analysis was undertaken and predictive validity assessed using between-groups comparisons and receiver operating characteristic (ROC) curve statistics. RESULTS: The ACL-RSI scores increased between 6 and 12 months (55 to 71; P < .001, effect size = 0.98). No floor or ceiling effects were present, and the scale had high internal consistency (Cronbach α at 6 months = 0.91 and at 12 months = 0.94). Principal component analysis showed that 2 factors were present: the first represented performance confidence and risk appraisal and the second, emotions. For the full-scale ACL-RSI, scores at 6 months had acceptable predictive ability for a return to play at 12 months (area under the ROC curve = 0.7, P = .03). When the 2 identified factors were analyzed separately, the emotions factor also had acceptable predictive ability (area under the ROC curve = 0.73, P = .009), but the confidence in performance and risk appraisal factors had poor predictive ability (area under the ROC curve = 0.59, P = .09). CONCLUSIONS: Greater psychological readiness was associated with return to sport in adolescent athletes after ACL reconstruction, with the athletes' emotional response appearing to be more influential than their confidence in their performance or their appraisal of risk.

Effect of COVID-19 Social Isolation Policies on Rehabilitation After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: The coronavirus 2019 (COVID-19) pandemic has had a profound impact on health care in Australia. To contain the spread of the virus, strict physical distancing and social isolation policies were implemented from late March 2020. This presented a situation in which patients recovering from anterior cruciate ligament (ACL) reconstruction had limited access to face-to-face supervised rehabilitation and rehabilitation facilities. PURPOSE: To explore the impact of social distancing and isolation policies on postoperative rehabilitation in patients after ACL reconstruction. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Patients who had ACL reconstruction from October 2019 until the end of March 2020 (6 months before the implementation of COVID-19 restrictions) completed an online self-report questionnaire containing 5 sections: utilization of health care professionals for rehabilitation, frequency of rehabilitation, patient concerns and attitude, perceived impact on recovery, and changes to employment status. We compared the responses of patients who had surgery in 2019 with those who had surgery in 2020. Statistical analysis was performed using frequency statistics and central tendency measures. RESULTS: A total of 185 patients (97 men, 88 women) completed the survey, for a 73% response rate. Patients had a mean age of 28 years (range, 13-57 years) and had undergone surgery a mean 4.5 months prior (range, 1.5-8 months). Most patients (80%) maintained face-to-face rehabilitation, predominantly with a physical therapist, regardless of whether their surgery took place in 2019 or 2020; rehabilitation with active, supervised exercises was most common. Almost all patients were performing strengthening exercises (164/185), and most were performing range-of-motion (139/185) and aerobic (123/185) activities at their homes. Patients were minimally concerned about access to supervised rehabilitation and knee reinjury, but they were concerned about access to equipment. Because of COVID-19, 30% were working from home; 17% were on reduced hours and 8% on increased hours; 15% were on leave or unemployed; and 30% reported no change in employment status. CONCLUSION: Patients who had undergone ACL reconstruction just before or during the first few months of the COVID-19 pandemic were able to maintain in-person contact with their health professionals during rehabilitation, and they had a positive outlook and managed well despite the restrictions.

Patellar cartilage increase following ACL reconstruction with and without meniscal pathology: a two-year prospective MRI morphological study.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) together with concomitant meniscal injury are risk factors for the development of tibiofemoral (TF) osteoarthritis (OA), but the potential effect on the patellofemoral (PF) joint is unclear. The aim of this study was to: (i) investigate change in patellar cartilage morphology in individuals 2.5 to 4.5 years after ACLR with or without concomitant meniscal pathology and in healthy controls, and (ii) examine the association between baseline patellar cartilage defects and patellar cartilage volume change. METHODS: Thirty two isolated ACLR participants, 25 ACLR participants with combined meniscal pathology and nine healthy controls underwent knee magnetic resonance imaging (MRI) with 2-year intervals (baseline = 2.5 years post-ACLR). Patellar cartilage volume and cartilage defects were assessed from MRI using validated methods. RESULTS: Both ACLR groups showed patellar cartilage volume increased over 2 years (p < 0.05), and isolated ACLR group had greater annual percentage cartilage volume increase compared with controls (mean difference 3.6, 95% confidence interval (CI) 1.0, 6.3%, p = 0.008) and combined ACLR group (mean difference 2.2, 95% CI 0.2, 4.2%, p = 0.028). Patellar cartilage defects regressed in the isolated ACLR group over 2 years (p = 0.02; Z = - 2.33; r = 0.3). Baseline patellar cartilage defect score was positively associated with annual percentage cartilage volume increase (Regression coefficient B = 0.014; 95% CI 0.001, 0.027; p = 0.03) in the pooled ACLR participants. CONCLUSIONS: Hypertrophic response was evident in the patellar cartilage of ACLR participants with and without meniscal pathology. Surprisingly, the increase in patellar cartilage volume was more pronounced in those with isolated ACLR. Although cartilage defects stabilised in the majority of ACLR participants, the severity of patellar cartilage defects at baseline influenced the magnitude of the cartilage hypertrophic response over the subsequent ~ 2 years.

Effect of Time on MRI Appearance of Graft After ACL Reconstruction: A Comparison of Autologous Hamstring and Quadriceps Tendon Grafts.

BACKGROUND: After anterior cruciate ligament (ACL) reconstruction (ACLR), changes in the appearance of the ACL graft can be monitored using magnetic resonance imaging (MRI). PURPOSE: The purpose of this study was to evaluate and compare the MRI signal intensity (SI) of hamstring and quadriceps tendon grafts during the first postoperative year after ACLR. As a secondary aim, the relationship of SI to clinical and anatomic measurements was analyzed. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 78 patients who underwent ACLR with an autologous graft were reviewed; 55 received hamstring grafts and 23 received quadriceps tendon grafts. At 3 and 9 months postoperatively, 3-T MRI was performed using a dedicated knee coil, and the median SI of the intra-articular ACL graft was measured on sagittal-plane images. Postoperative lateral radiographs were analyzed to determine medial and lateral posterior tibial slope (PTS). Side-to-side difference in anterior knee laxity between injured and uninjured limbs was measured at 6 and 12 months postoperatively. RESULTS: The median SI of quadriceps grafts was significantly greater than hamstring grafts at 3 months after ACLR (P = .02). Between 3 and 9 months, the median SI of quadriceps grafts decreased (P < .001), while that of hamstring grafts did not significantly change (P = .55). The lateral PTS was significantly correlated with median SI measurements at 3 and 9 months such that greater lateral PTS values were associated with greater median SI. The side-to-side difference in anterior knee laxity decreased for the quadriceps group (P = .04) between 6 and 12 months but did not change for the hamstring group (P = .88). CONCLUSION: The median SI of quadriceps grafts significantly decreased on MRI between 3 and 9 months after ACLR, while the median SI of hamstring grafts did not significantly change. The change in MRI appearance of the quadriceps grafts was paralleled by a reduction in anterior knee laxity between 6 and 12 months after surgery. In the absence of standardized imaging techniques and imaging analysis methods, the role of MRI in determining graft maturation, and the implications for progression through rehabilitation to return to sport, remain uncertain.