Robert A. Magnussen

Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft.

PURPOSE To evaluate whether decreased hamstring autograft size and decreased patient age are predictors of early graft revision. METHODS Of 338 consecutive patients undergoing primary anterior cruciate ligament (ACL) reconstruction with hamstring autograft, 256 (75.7%) were evaluated. Graft size and patient age, gender, and body mass index at the time of ACL reconstruction were recorded, along with whether subsequent ACL revision was performed. RESULTS The 256 patients comprised 136 male and 120 female patients and ranged in age from 11 to 52 years (mean, 25.0 years). The mean follow-up was 14 months (range, 6 to 47 months). Revision ACL reconstruction was performed in 18 of 256 patients (7.0%) at a mean of 12 months after surgery (range, 3 to 31 months). Revision was performed in 1 of 58 patients (1.7%) with grafts greater than 8 mm in diameter, 9 of 139 patients (6.5%) with 7.5- or 8-mm-diameter grafts, and 8 of 59 patients (13.6%) with grafts 7 mm or less in diameter (P = .027). There was 1 revision performed in the 137 patients aged 20 years or older (0.7%), but 17 revisions were performed in the 119 patients aged under 20 years (14.3%) (P < .0001). Most revisions (16 of 18) were noted to occur in patients aged under 20 years with grafts 8 mm in diameter or less, and the revision rate in this population was 16.4% (16 of 97 patients). Age less than 20 years at reconstruction (odds ratio [OR], 18.97; 95% confidence interval [CI], 2.43 to 147.06; P = .005), decreased graft size (OR, 2.20; 95% CI, 1.00 to 4.85; P = .05), and increased follow-up time (OR, 1.07; 95% CI, 1.02 to 1.12) were associated with increased risk of revision. CONCLUSIONS Decreased hamstring autograft size and decreased patient age are predictors of early graft revision. Use of hamstring autografts 8 mm in diameter or less in patients aged under 20 years is associated with higher revision rates. LEVEL OF EVIDENCE Level III, retrospective comparative study.

Ipsilateral Graft and Contralateral ACL Rupture at Five Years or More Following ACL Reconstruction A Systematic Review

BACKGROUND Injury to the ipsilateral graft used for reconstruction of the anterior cruciate ligament (ACL) or a new injury to the contralateral ACL is a devastating outcome following successful ACL reconstruction, rehabilitation, and return to sport. Little evidence exists regarding the intermediate to long-term risk of these events. METHODS The present study is a systematic review of Level-I and II prospective studies that evaluated the rate of rupture of the ACL graft and the ACL in the contralateral knee following a primary ACL reconstruction with use of a mini-open or arthroscopic bone-tendon-bone or hamstring autograft after a minimum duration of follow-up of five years. RESULTS Six studies met the inclusion and exclusion criteria. The ipsilateral ACL graft rupture rate ranged from 1.8% to 10.4%, with a pooled percentage of 5.8%. The contralateral injury rate ranged from 8.2% to 16.0%, with a pooled percentage of 11.8%. CONCLUSIONS This systematic review demonstrates that the risk of ACL tear in the contralateral knee (11.8%) is double the risk of ACL graft rupture in the ipsilateral knee (5.8%). Additional studies must be performed to determine predictors for these injuries and to improve our ability to avoid this devastating outcome.

The Influence of Hamstring Autograft Size on Patient- Reported Outcomes and Risk of Revision After Anterior Cruciate Ligament Reconstruction: A Multicenter Orthopaedic Outcomes Network (MOON) Cohort Study

PURPOSE The purpose of this study was to evaluate the effect of graft size on patient-reported outcomes and revision risk after anterior cruciate ligament (ACL) reconstruction. METHODS A retrospective chart review of prospectively collected cohort data was performed, and 263 of 320 consecutive patients (82.2%) undergoing primary ACL reconstruction with hamstring autograft were evaluated. We recorded graft size; femoral tunnel drilling technique; patient age, sex, and body mass index at the time of ACL reconstruction; Knee Injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee score preoperatively and at 2 years postoperatively; and whether each patient underwent revision ACL reconstruction during the 2-year follow-up period. Revision was used as a marker for graft failure. The relation between graft size and patient-reported outcomes was determined by multiple linear regression. The relation between graft size and risk of revision was determined by dichotomizing graft size at 8 mm and stratifying by age. RESULTS After we controlled for age, sex, operative side, surgeon, body mass index, graft choice, and femoral tunnel drilling technique, a 1-mm increase in graft size was noted to correlate with a 3.3-point increase in the KOOS pain subscale (P = .003), a 2.0-point increase in the KOOS activities of daily living subscale (P = .034), a 5.2-point increase in the KOOS sport/recreation function subscale (P = .004), and a 3.4-point increase in the subjective International Knee Documentation Committee score (P = .026). Revision was required in 0 of 64 patients (0.0%) with grafts greater than 8 mm in diameter and 14 of 199 patients (7.0%) with grafts 8 mm in diameter or smaller (P = .037). Among patients aged 18 years or younger, revision was required in 0 of 14 patients (0.0%) with grafts greater than 8 mm in diameter and 13 of 71 patients (18.3%) with grafts 8 mm in diameter or smaller. CONCLUSIONS Smaller hamstring autograft size is a predictor of poorer KOOS sport/recreation function 2 years after primary ACL reconstruction. A larger sample size is required to confirm the relation between graft size and risk of revision ACL reconstruction. LEVEL OF EVIDENCE Level III, retrospective comparative study.

Autograft Versus Nonirradiated Allograft Tissue for Anterior Cruciate Ligament Reconstruction A Systematic Review

Background: An autograft has traditionally been the gold standard for anterior cruciate ligament reconstruction (ACLR), but the use of allograft tissue has increased in recent years. While numerous studies have demonstrated that irradiated allografts are associated with increased failure rates, some report excellent results after ACLR with nonirradiated allografts. The purpose of this systematic review was to determine whether the use of nonirradiated allograft tissue is associated with poorer outcomes when compared with autografts. Hypothesis: Patients undergoing ACLR with autografts versus nonirradiated allografts will demonstrate no significant differences in graft failure risk, laxity on postoperative physical examination, or differences in patient-oriented outcome scores. Study Design: Systematic review. Methods: A systematic review was performed to identify prospective or retrospective comparative studies (evidence level 1, 2, or 3) of autografts versus nonirradiated allografts for ACLR. Outcome data included graft failure based on clinical findings and instrumented laxity, postoperative laxity on physical examination, and patient-reported outcome scores. Studies were excluded if they did not specify whether the allograft had been irradiated. Quality assessment and data extraction were performed by 2 examiners. Results: Nine studies comparing autografts and nonirradiated allografts were included. Six of the 9 studies compared bone–patellar tendon–bone (BPTB) autografts with BPTB allografts. Two studies compared hamstring tendon autografts to hamstring tendon allografts, and 1 study compared hamstring tendon autografts to tibialis anterior allografts. The mean patient age in 7 of 9 studies ranged from 24.5 to 32 years, with 1 study including only patients older than 40 years and another not reporting patient age. The mean follow-up duration was 24 to 94 months. Six of 9 studies reported clinical graft failure rates, 8 of 9 reported postoperative instrumented laxity measurements, 7 of 9 reported postoperative physical examination findings, and all studies reported patient-reported outcome scores. This review demonstrated no statistically significant difference between autografts and nonirradiated allografts in any outcome measure. Conclusion: No significant differences were found in graft failure rate, postoperative laxity, or patient-reported outcome scores when comparing ACLR with autografts to nonirradiated allografts in this systematic review. These findings apply to patients in their late 20s and early 30s. Caution is advised when considering extrapolation of these findings to younger, more active cohorts.

ACL Reconstruction: Do Outcomes Differ by Sex?

BACKGROUND Anterior cruciate ligament (ACL) reconstruction is frequently performed to restore knee stability and function following ACL injury. Female sex is known to predispose to ACL injury; however, it remains unclear whether female sex predisposes to poor outcomes following ACL reconstruction. We hypothesized that male and female patients exhibit no differences in (1) graft failure risk, (2) contralateral ACL injury risk, (3) knee laxity, and (4) patient-reported outcome scores following ACL reconstruction. METHODS A systematic review of the literature was performed to identify studies in which results of ACL reconstruction were reported by sex at a minimum of two years. Study findings were reviewed, and meta-analysis was performed when data were sufficiently homogenous. RESULTS Thirteen studies were identified from the literature review. Meta-analysis revealed no difference in graft failure risk (eight studies), contralateral ACL rupture risk (three studies), or postoperative knee laxity on physical examination (six studies). There was no evidence of a clinically important difference in patient-reported outcomes according to sex. CONCLUSIONS Results of ACL reconstruction were similar in male and female patients. More high-quality studies are needed to further evaluate these findings.

Does Operative Fixation of an Osteochondritis Dissecans Loose Body Result in Healing and Long-Term Maintenance of Knee Function?:

Background Osteochondritis dissecans (OCD) can progress to loose body formation, resulting in a grade IV defect. The decision to fix versus excise the loose body is controversial. Published operative fixation outcomes are small case series with short follow-up. Hypothesis Operative fixation (ORIF) of the loose body into the grade IV defect will heal and approximate “normal” knee function at long-term follow-up. Study Design Case series; Level of evidence, 4. Methods Twelve patients were identified who underwent ORIF of a knee OCD loose body into the grade IV osteochondral defects ranging in size from 2.0 to 8.0 cm 2 (mean, 3.5 cm2). After 12 weeks, hardware was removed, and healing was assessed. Long-term outcomes were assessed with a Knee injury and Osteoarthritis Outcome Score (KOOS) and a Marx activity score. Results Arthroscopy for screw removal revealed stable healing in 92% (11 of 12) of patients. No patients required subsequent surgery for a loose body. At an average of 9.2 years’ follow-up (range, 3.8-15.8 years), 83% (10 of 12) of patients completed the KOOS. The KOOS subscale scores for pain (mean, 87.8; range, 67-100), other symptoms (mean, 81.8; range, 61-96), function in activities of daily living (mean, 93.1; range, 72-100), and sports and recreation function (mean, 74.0; range, 40-100) were not significantly lower than those of published age-matched controls. However the KOOS subscale score for knee-related quality of life (mean, 61.9; range, 31-88) was significantly lower (P = .003). Conclusion Operative fixation of grade IV OCD loose bodies results in stable fixation. At an average 9 years after surgery, patients did not have symptoms of osteoarthritis pain and had normal function in activities of daily life. However, patients reported significantly lower knee-related quality of life. Operative fixation of OCD loose bodies is a better alternative to lesion excision.

Patellofemoral arthroplasty, where are we today?

PurposePatellofemoral arthroplasty remains controversial, primarily due to the high failure rates reported with early implants. Numerous case series have been published over the years detailing results of various first- and second-generation implants. The purpose of this work is to summarize results published to date and identify common themes regarding implants, surgical techniques, and indications in order to maximize results of future procedures.MethodsA comprehensive review of the MEDLINE database was carried out to identify all clinical studies related to patellofemoral arthroplasty.ResultsFirst-generation resurfacing implants were associated with relatively high failure rates in the medium term. Second-generation implants, with femoral cuts based on TKA designs have yielded more promising medium-term results. Surgical indications are specific and must be carefully followed to minimize poor results. Short-term complications are generally related to patellar maltracking, while long-term complications are generally related to progression of osteoarthritis in the tibiofemoral joint. Implant loosening and polyethylene wear are rarely reported. Short-term results are favourable for new technology including custom implants and computer navigated surgery.ConclusionsOverall, recent improvements in implant design and surgical techniques have resulted in improvements in short- and medium-term results. More work is required to assess the long-term outcomes of modern implant designs.Level of evidenceIV.

Transtibial ACL Femoral Tunnel Preparation Increases Odds of Repeat Ipsilateral Knee Surgery

BACKGROUND Recent efforts to improve the results of anterior cruciate ligament (ACL) reconstruction have focused on placing the femoral tunnel anatomically. Medial portal femoral tunnel techniques facilitate drilling of femoral tunnels that are more anatomic than those made with transtibial techniques. Few studies have compared the clinical outcomes of these two femoral tunnel techniques. We hypothesized that the transtibial technique is associated with decreased Knee injury and Osteoarthritis Outcome Scores (KOOS) and an increased risk of repeat surgery in the ipsilateral knee when compared with the anteromedial portal technique. METHODS Four hundred and thirty-six patients who had undergone primary isolated autograft ACL reconstruction with a transtibial (229 patients) or anteromedial portal (207 patients) technique in 2002 or 2003 were identified in a prospective multicenter cohort. A multiple linear regression model was used to determine whether surgical technique (transtibial or anteromedial portal) was a significant predictor of KOOS at six years postoperatively, after controlling for preoperative KOOS, patient age, sex, activity level, body mass index (BMI), smoking status, graft type, and the presence of meniscal and chondral pathology at the time of reconstruction. A multiple logistic regression model was used to determine whether surgical technique was a significant predictor of repeat ipsilateral knee surgery, after controlling for patient age and activity level, graft type, and meniscal pathology at the time of reconstruction. RESULTS Postoperative KOOS were available for 387 patients (88.8%). Femoral tunnel drilling technique was not a predictor of the KOOS Quality of Life subscore (p = 0.72) or KOOS Function, Sports and Recreational Activities subscore (p = 0.36) at the six-year follow-up evaluation. Data regarding the prevalence of repeat surgery were available for 380 patients. Femoral tunnel technique was a significant predictor of subsequent ipsilateral knee surgery (odds ratio [OR] = 2.49, 95% confidence interval [CI] = 1.30 to 4.78, p = 0.006). CONCLUSIONS Patients who underwent ACL reconstruction with a transtibial technique had significantly higher odds of undergoing repeat ipsilateral knee surgery relative to those who underwent reconstruction with an anteromedial portal technique.

ACL reconstruction and extra-articular tenodesis.

The purpose of this article is to update the orthopedic community on the role of lateral extra-articular tenodesis in the management of anterior cruciate ligament-deficient knees. Information includes historical perspective, current applications and techniques, and a review of published outcomes.

Anterior Cruciate Ligament Reconstruction Rehabilitation MOON Guidelines

Context: Anterior cruciate ligament (ACL) reconstruction rehabilitation has evolved over the past 20 years. This evolution has been driven by a variety of level 1 and level 2 studies. Evidence Acquisition: The MOON Group is a collection of orthopaedic surgeons who have developed a prospective longitudinal cohort of the ACL reconstruction patients. To standardize the management of these patients, we developed, in conjunction with our physical therapy committee, an evidence-based rehabilitation guideline. Study Design: Clinical review. Level of Evidence: Level 2. Results: This review was based on 2 systematic reviews of level 1 and level 2 studies. Recently, the guideline was updated by a new review. Continuous passive motion did not improve ultimate motion. Early weightbearing decreases patellofemoral pain. Postoperative rehabilitative bracing did not improve swelling, pain range of motion, or safety. Open chain quadriceps activity can begin at 6 weeks. Conclusion: High-level evidence exists to determine appropriate ACL rehabilitation guidelines. Utilizing this protocol follows the best available evidence.