David Sundemo

A Randomized Controlled Trial With Mean 16-Year Follow-up Comparing Hamstring and Patellar Tendon Autografts in Anterior Cruciate Ligament Reconstruction

Background: There is no consensus in the current literature on which surgical options render the best long-term results after anterior cruciate ligament (ACL) reconstruction in terms of clinical outcomes and the development of radiographic osteoarthritis (OA). Purpose: To investigate the long-term clinical and radiographic results after ACL reconstruction using either a patellar tendon (PT) autograft or a hamstring tendon (HT) autograft. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: This multicenter study was based on 2 previous randomized cohorts consisting of 193 patients who underwent unilateral primary ACL reconstruction using either a PT autograft or an HT autograft. The index surgical procedure was performed between September 1995 and January 2000. Clinical assessments, including knee laxity measurements, functional outcomes, patient-reported outcomes, and bilateral standing radiographs, were performed at the final follow-up examination. Results: At the long-term follow-up, 147 (76%) patients were examined: 61 in the PT group and 86 in the HT group. The mean (±SD) follow-up time was 191.9 ±15.1 months for the HT group and 202.6 ± 10.4 months for the PT group. Knee laxity measurements revealed significantly more patients with a normal pivot-shift test finding in the HT group compared with the PT group (71% vs 51%, respectively; P = .048); however, no significant differences were found in terms of the manual Lachman test or the KT-1000 arthrometer manual maximum test. The patients in the PT group had significantly more difficulty knee walking (P = .049). There were no significant differences between the study groups in terms of patient-reported outcomes or range of motion in the reconstructed knee. In both groups, significantly more signs of radiographic OA were found in the reconstructed knee than in the contralateral healthy knee. However, there were no significant differences between the groups in terms of radiographic OA. Conclusion: Only minor and mostly insignificant differences were found between the PT and HT autograft groups in this long-term randomized controlled trial. In both groups, significantly more signs of radiographic OA were found in the reconstructed knee than in the contralateral knee.

Correlation between quantitative pivot shift and generalized joint laxity: a prospective multicenter study of ACL ruptures

PurposeTo investigate whether an increased magnitude of quantitative rotatory knee laxity is associated with a greater level of generalized joint laxity in ACL-injured and contralateral knees.MethodsA total of 103 patients were enrolled across four international centers to undergo anatomic ACL reconstruction. Rotatory knee laxity was evaluated preoperatively, both in the awake state and under anesthesia, using the standardized pivot shift test. Two devices were used to quantify rotatory knee laxity; an inertial sensor, measuring the joint acceleration, and an image analysis system, measuring the lateral compartment translation of the tibia. The presence of generalized joint laxity was determined using the Beighton Hypermobility Score. The correlation between the level of generalized joint laxity and the magnitude of rotatory knee laxity was calculated for both the involved knee and the non-involved knee. Further, patients were dichotomized into low (0–4) or high (5–9) Beighton Score groups. Alpha was set at < 0.05.ResultsNinety-six patients had complete datasets, 83 and 13 in the low and high Beighton Score groups respectively. In anesthetized patients, there was a significant correlation between the degree of Beighton Score and quantitative pivot shift when analyzing the non-involved knee using the image analysis system (r = 0.235, p < 0.05). When analyzing the same knee, multivariate analysis adjusted for meniscal injury, age and gender revealed an increased odds ratio for patients with increased lateral compartment translation to be part of the high Beighton Score group (OR 1.86, 95% CI 1.10–3.17, p < 0.05). No other correlation was significant. When analyzing the dichotomized subgroups, no significant correlations could be established.ConclusionThe findings in this study suggest that there is a weak correlation between generalized joint laxity and the contralateral healthy knee, indicating increased rotatory knee laxity in these patients. Generalized joint laxity does not appear to correlate with rotatory knee laxity in ACL-injured knees.Level of evidenceProspective cohort study; level of evidence, 2.

How to Predict Injury Risk

Injuries to football players are common and often affect the lower extremities. The number and severity of injuries may affect team performance making injury prevention a high priority for both players and club management. To prevent injuries, the risk factors and injury mechanisms need to be known. This chapter presents an overview of the evidence relating to risk factors in hip/groin, thigh, knee, and ankle injuries. Further, the use of screening tools to aid in the prevention of modifiable risk factors is discussed.

Preoperative knee laxity measurements predict the achievement of a patient-acceptable symptom state after ACL reconstruction: a prospective multicenter study

Objective To determine whether patient-related factors, concomitant injuries and preoperative knee laxity could predict a patient acceptable symptom state (PASS) in the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) at 1 and 2 years follow-up after anterior cruciate ligament (ACL) reconstruction in a multicentre cohort. Methods Patients between 14 and 50 years of age who underwent single-bundle ACL reconstruction with hamstring tendon autograft within 1 year from the index injury were eligible. Additionally, only patients who completed the IKDC-SKF questionnaire at 1 or 2 years of follow-ups were included. Preoperative knee laxity assessment of patients in the awake state was performed using rolimeter, the Lachman and the pivot-shift test. The pivot shift was graded according to the IKDC criteria and also quantified by the use of non-invasive technology for (1) lateral tibial translation and (2) tibial acceleration. The quantitative pivot shift (QPS) was examined in the awake state and under anaesthesia (EUA). Univariable logistic regression models were performed with achieving PASS in the IKDC as the dependent variable. Results A total of 86 patients had complete data on the IKDC-SKF score at 1-year follow-up, of which 67 patients (77.9%) achieved PASS (age 24.8±9.3 years, 43% females). Two-year data were available for 50 patients, of which 39 patients (78.9%) achieved PASS (age 23.9±9.2 years, 42.0% females). A low-grade manual pivot shift according to IKDC grading had increased odds of achieving PASS at 1 year (OR=2.96 (95% CI 1.01 to 8.66), P<0.05) compared with patients who displayed a high-grade pivot shift preoperatively. However, this was not confirmed by the preoperative QPS measures (awake: tibial translation; OR=0.99,(95% CI 0.72 to 1.35), (n.s.), acceleration; OR=1.04,(95% CI 0.68 to 1.59), (n.s.) EUA: tibial translation; OR=1.02 (95% CI 0.78 to 1.31), (n.s.), acceleration; OR=1.14 (95% CI 0.93 to 1.40), (n.s.)). None of the studied variables of patient characteristics, concomitant injuries or knee joint laxity predicted PASS at the 2-year follow-up. Conclusion Almost four in every five patients were able to achieve PASS 1 and 2 years after anatomic single-bundle ACL reconstruction. The presence of preoperative low-grade pivot shift increased the odds of achieving an acceptable level of knee function 1 year after ACL reconstruction compared with high-grade pivot shift; however, QPS did not confirm achievement of PASS in this study. Level of evidence Level III, prospective cohort.

Increased Postoperative Manual Knee Laxity at 2 Years Results in Inferior Long-term Subjective Outcome After Anterior Cruciate Ligament Reconstruction:

Background: Increased postoperative rotatory knee laxity after anterior cruciate ligament (ACL) reconstruction may be associated with an increased risk of osteoarthritis and inferior subjective outcome, although long-term studies are lacking. In terms of anteroposterior knee laxity, this association has not yet been established. Purpose/Hypothesis: The purpose was to investigate whether postoperative knee laxity is associated with inferior long-term outcome in patients who have undergone ACL reconstruction. The hypothesis was that increased laxity would cause an inferior long-term clinical and radiographic outcome. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 193 patients underwent ACL reconstruction and were examined at both 2 and 16 years postoperatively. At the 2-year follow-up, knee laxity was tested by use of the Lachman test, the anterior drawer test, the pivot-shift test, and the KT-1000 arthrometer. Outcome variables examined at the 16-year follow-up involved a radiographic assessment of osteoarthritis, patient-reported outcome measurements, and the single-legged hop test. Results: At the long-term follow-up, 147 (76%) patients were examined. The mean follow-up period for the included patients was 16.4 ± 1.2 years. A negative Lachman test at 2 years resulted in a superior International Knee Documentation Committee (IKDC) score (76.3 ± 19.4 vs 67.8 ± 19.3, P < .05) and Lysholm score (85.2 ± 11.9 vs 76.9 ± 17.8, P < .05) at the 16-year follow-up. Correspondingly, a negative anterior drawer test at 2 years was associated with a superior IKDC score (75.3 ± 18.7 vs 62.9 ± 20.2, P < .05) and Lysholm score (84.1 ± 12.1 vs 72.6 ± 20.2, P < .05) at 16 years. A negative pivot-shift test resulted in a superior IKDC score (74.5 ± 18.8 vs 46.9 ± 17.8, P < .05), a superior Lysholm score (83.3 ± 13.4 vs 58.9 ± 23.0, P < .05), and an increased level of activity (Tegner activity scale, median [range]: 4 [1-10] vs 3 [0-5], P < .05). Osteoarthritis was overrepresented in patients with positive manual knee laxity tests, but the difference was not statistically significant. The KT-1000 arthrometer result was not correlated with any outcome variables assessed in this study. Conclusion: Increased manual anteroposterior and rotatory knee laxity 2 years after ACL reconstruction is associated with an inferior long-term subjective outcome.

Ten-Year Risk Factors for Inferior Knee Injury and Osteoarthritis Outcome Score After Anterior Cruciate Ligament Reconstruction: A Study of 874 Patients From the Swedish National Knee Ligament Register:

Background: Factors relating to the patient and anterior cruciate ligament (ACL) reconstruction may help to identify prognostic factors of long-term outcome after reconstruction. Purpose: To determine 10-year risk factors for inferior knee function after ACL reconstruction. Study Design: Cohort study; Level of evidence, 2. Methods: Prospectively collected data from the Swedish National Knee Ligament Register were extracted for patients who underwent ACL reconstruction between January 2005 and December 2006. Patients who had no data at the 10-year follow-up for the Knee injury and Osteoarthritis Outcome Score (KOOS) were excluded. Multivariable proportional odds regression modeling was used to assess 10-year patient- and surgery-related risk factors across all the KOOS subscales and the KOOS4 (mean score of 4 subscales: pain, knee-related symptoms, function in sport and recreation, and knee-related quality of life). Results: A total of 874 (41%) patients were included (male, 51.5%; median age at the time of ACL reconstruction, 27.5 years [range, 11.2-61.5 years]). An increase in the severity of concomitant articular cartilage injuries resulted in a reduced KOOS on 4 subscales (odds ratio, 0.64-0.80; P < .05). A higher preoperative KOOS pain score increased the odds of a higher score on the pain, symptoms, and sport subscales and the KOOS4. In addition, a higher preoperative body mass index was a significant risk factor for lower scores on 3 KOOS subscales and the KOOS4. No patient- or surgery-related predictor was significant across all KOOS subscales. Conclusion: This 10-year risk factor analysis identified several factors that can affect long-term knee function after ACL reconstruction. Most risk factors were related to preoperative patient-reported outcome and potentially modifiable. On the other hand, most of the surgery-related risk factors were nonmodifiable. Nevertheless, this information may be helpful to physicians and physical therapists counseling patients on their expectations of outcome after ACL reconstruction.