Age, time from injury to surgery and hop performance after primary ACLR affect the risk of contralateral ACLR

Purpose To evaluate factors affecting the risk of contralateral anterior cruciate ligament reconstruction (ACLR) within 5 years of primary ACLR. Methods Primary ACLRs performed at Capio Artro Clinic, Stockholm, Sweden, during the period 2005–2014, were reviewed. The outcome of the study was the occurrence of contralateral ACLR within 5 years of primary ACLR. Univariable and multivariable logistic regression analyses were employed to identify preoperative [age, gender, body mass index (BMI), time from injury to surgery, pre-injury Tegner activity level], intraoperative [graft type, medial meniscus (MM) and lateral meniscus (LM) resection or repair, cartilage injury] and postoperative [limb symmetry index (LSI) for quadriceps and hamstring strength and single-leg-hop test performance at 6 months] risk factors for contralateral ACLR. Results A total of 5393 patients who underwent primary ACLR were included. The incidence of contralateral ACLR within 5 years was 4.7%. Univariable analysis revealed that age ≥ 25 years, BMI ≥ 25 kg/m2, time from injury to surgery ≥ 12 months and the presence of a cartilage injury reduced the odds, whereas female gender, pre-injury Tegner activity level ≥ 6, quadriceps and hamstring strength and a single-leg-hop test LSI of ≥ 90% increased the odds of contralateral ACLR. Multivariable analysis showed that the risk of contralateral ACLR was significantly affected only from age ≥ 25 years (OR 0.40; 95% CI 0.28–0.58; P < 0.001), time from injury to surgery ≥ 12 months (OR 0.48; 95% CI 0.30–0.75; P = 0.001) and a single-leg-hop test LSI of ≥ 90% (OR 1.56; 95% CI 1.04–2.34; P = 0.03). Conclusion Older age (≥ 25 years) and delayed primary ACLR (≥ 12 months) reduced the odds, whereas a symmetrical (LSI ≥ 90%) 6-month single-leg-hop test increased the odds of contralateral ACLR within 5 years of primary ACLR. Knowledge of the factors affecting the risk of contralateral ACLR is important when it comes to the appropriate counselling for primary ACLR. Patients should be advised regarding factors affecting the risk of contralateral ACLR. Level of evidence Level III.

Cell-free osteochondral scaffolds provide a substantial clinical benefit in the treatment of osteochondral defects at a minimum follow-up of 5 years

Purpose The treatment of osteochondral lesions is challenging and no consensus has been established about the best option for restoring both cartilage and subchondral bone. Multilayer collagen-hydroxyapatite scaffolds have shown promising clinical results, but the outcome at a follow-up longer than 5 years still has to be proved. The aim was to evaluate the clinical outcome of patients with a knee isolated osteochondral lesion treated with a biomimetic three-layered scaffold at a minimum 5 years of follow-up. Methods Twenty-nine patients (23 males and 6 females, mean age 31.5 ± 11.4 years) were evaluated retrospectively before surgery, at 1 and 2 years and at last follow-up (FU). Visual Analog Scale (VAS) for pain, International Knee Documentation Committee (IKDC) Subjective Score, Tegner-Lysholm Knee Scoring Scale and Tegner Activity Level Scale were collected. Mean FU was 7.8 ± 2.0 years (min 5.1 - max 11.3). The etiology of the defect was Osteochondritis Dissecans or osteonecrosis (17 vs 12 cases). Results At 12 months FU the IKDC score improved from 51.1 ± 21.7 to 80.1 ± 17.9 (p < 0.01), Tegner Lysholm Score from 59.9 ± 17.3 to 92.5 ± 9.0 (p < 0.01), VAS from 6.1 ± 2.1 to 1.7 ± 2.3 (p < 0.01) and Tegner Activity Level Scale from 1.6 ± 0.5 to 4.9 ± 1.7 (p < 0.01). The results remained stable at 24 months, while at last FU a statistically significant decrease in IKDC, Tegner Lysholm and Tegner Activity Scale was recorded, though not clinically relevant. Patients under 35 achieved statistically better outcomes. Conclusions The use of a cell-free collagen-hydroxyapatite osteochondral scaffold provides substantial clinical benefits in the treatment of knee osteochondral lesions at a minimum follow-up of 5 years, especially in patients younger than 35 years. Level of evidence Level IV.

Comparison of Function- and Activity-Related Outcomes After Anterior Talofibular Ligament Repair With 1 Versus 2 Suture Anchors

Background: Few studies have compared the clinical outcomes of using 1 versus 2 suture anchors for anterior talofibular ligament (ATFL) repair. Purpose: To compare the function and activity-related outcomes of arthroscopic ATFL repair using 1 versus 2 suture anchors. Study Design: Cohort study; Level of evidence, 3. Methods: This retrospective study involved 46 patients (22 patients in the 1-anchor group, 24 patients in the 2-anchor group) who underwent ATFL repair between January 2015 and December 2017. American Orthopaedic Foot & Ankle Society score, Karlsson and Peterson score, and Tegner activity level were evaluated preoperatively and ≥2.5 years postoperatively. At follow-up, patients were also asked about time to return to sport as well as level and intensity of physical fitness. Satisfaction was evaluated with the Sefton grading system. Results: After ≥2.5 years of follow-up (30 months in the 1-anchor group, 33 months in the 2-anchor group), patients in the 2-anchor group had a higher Tegner activity level than those in the 1-anchor group (mean ± SD, 4.75 ± 1.07 vs 4.05 ± 1.17; P = .039). As compared with patients in the 2-anchor group, fewer patients in the 1-anchor group returned to their preoperative activity level (54.2% vs 22.9%; P = .029); the rate of activity at the same or higher intensity as preinjury was also lower in the 1-anchor group (50% vs 79.2%; P = .038). However, there were no differences between the groups in terms of American Orthopaedic Foot & Ankle Society and Karlsson and Peterson scores, time to return to work/sport, duration of activity participation, level of physical fitness, or satisfaction according to Sefton grading. Conclusion: Arthroscopic ATFL repair appears to be an effective treatment regardless of whether 1 or 2 suture anchors are used. The techniques had similar functional outcome scores, but 1-anchor repair produced inferior activity-related outcomes.

Age, time from injury to surgery and quadriceps strength affect the risk of revision surgery after primary ACL reconstruction

Purpose To identify preoperative, intraoperative and postoperative factors associated with revision anterior cruciate ligament reconstruction (ACLR) within 2 years of primary ACLR. Methods Patients who underwent primary ACLR at our institution, from January 2005 to March 2017, were identified. The primary outcome was the occurrence of revision ACLR within 2 years of primary ACLR. Univariate and multivariate logistic regression analyses were used to evaluate preoperative [age, gender, body mass index (BMI), time from injury to surgery, pre-injury Tegner activity level], intraoperative [graft type, graft diameter, medial meniscus (MM) and lateral meniscus (LM) resection or repair, cartilage injury] and postoperative [side-to-side (STS) anterior laxity, limb symmetry index (LSI) for quadriceps and hamstring strength and single-leg-hop test performance at 6 months] risk factors for revision ACLR. Results A total of 6,510 primary ACLRs were included. The overall incidence of revision ACLR within 2 years was 2.5%. Univariate analysis showed that age < 25 years, BMI < 25 kg/m2, time from injury to surgery < 12 months, pre-injury Tegner activity level ≥ 6, LM repair, STS laxity > 5 mm, quadriceps strength and single-leg-hop test LSI of ≥ 90% increased the odds; whereas, MM resection and the presence of a cartilage injury reduced the odds of revision ACLR. Multivariate analysis revealed that revision ACLR was significantly related only to age < 25 years (OR 6.25; 95% CI 3.57–11.11; P < 0.001), time from injury to surgery < 12 months (OR 2.27; 95% CI 1.25–4.17; P = 0.007) and quadriceps strength LSI of ≥ 90% (OR 1.70; 95% CI 1.16–2.49; P = 0.006). Conclusion Age < 25 years, time from injury to surgery < 12 months and 6-month quadriceps strength LSI of ≥ 90% increased the odds of revision ACLR within 2 years of primary ACLR. Understanding the risk factors for revision ACLR has important implications when it comes to the appropriate counseling for primary ACLR. In this study, a large spectrum of potential risk factors for revision ACLR was analyzed in a large cohort. Advising patients regarding the results of an ACLR should also include potential risk factors for revision surgery. Level of evidence III.

Increased Strength following Achilles Tendon Rupture Repair is Associated with Return to Same Level of Play in Patients with Higher Pre-Injury Level of Activity

Category: Hindfoot; Sports; Trauma Introduction/Purpose: Rupture of the Achilles tendon is a common injury that requires a lengthy duration of recovery and rehabilitation. Patients of various levels of physical activity, ranging from professional high-impact sports to low-impact recreational activities, can be affected by this injury. Often, one of the most important outcomes from the patient’s perspective is the ability to return to the same pre-injury level of sporting activity after recovery. The objective of the current study is to examine the relationship between global ankle strength and the ability to return to previous level of play following surgical repair of an Achilles tendon tear. Methods: Patients aged 18-50 years old at a minimum 1-year post-op from surgical repair of an isolated Achilles tendon rupture were recruited to return for a study visit. Patients reported both pre-injury and current activity level using the 10-point Tegner Activity Level Scale. Isokinetic strength testing was performed and the Isokinetic Strength Score (ISS) was calculated using maximal effort dorsiflexion and plantarflexion strength at 30o/s, 90o/s, and 240o/s comparing the operative and uninvolved extremity. The primary outcome was the patients’ ability to return to same level of play or within 1 Tegner activity level. Logitistic regression analysis was used to determine the relationship between ISS and return to play. Subgroup analysis was performed on patients participating in high level athletic activity (pre-injury Tegner >= 7) an those participating in only recreational or low level activity (pre-injury Tegner <7). Results: A total of 36 patients (mean 35 years, 72% male) completed the study protocol at a mean 1.8 years post-op (range 1 year to 3.6 years). Logistic regression revealed no association between ISS and return to play in the complete cohort. Subgroup analysis revealed that for 20 patients who had participated in high level competitive athletics prior to injury (Pre-injury Tegner >= 7), for every 16 point increase in ISS, the odds ratio for return to same level of play was 8.3 (p=0.055) and the OR for return to within 1 Tegner level of play was 6.3 (p=0.043). There was no association between ISS and return to previous activity in the 16 patients with lower pre-injury levels of activity. Conclusion: Improved ankle strength was associated with return to previous level of activity only in patients who participate in high level athletic activity. These results suggest that patients with more strenuous athletic activity prior to injury are more dependent on recovery of ankle strength in the post-operative time period in order to return to their previous high level of play. In contrast, regaining strength may be less important for returning to normal activities for less active patients. [Table: see text]

Activity Measures in Pediatric Athletes: A Comparison of the Hospital for Special Surgery Pediatric Functional Activity Brief Scale and Tegner Activity Level Scale

Background: In young athletes, patient-reported activity level is frequently used to determine return to the same level of sport after treatment. Purpose: To evaluate the validity and score distributions of the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) compared with the Tegner Activity Level Scale (Tegner) in pediatric athletes. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: A retrospective review of 517 consecutive youth athletes who came to a sports medicine specialty clinic for a knee evaluation was performed. Patients completed the HSS Pedi-FABS, Tegner, and a sports participation survey before evaluation. Scores were compared with reported hours, days, and weeks of participation in sports as well as level of competition. Floor or ceiling effects were identified, and finally, the means and distributions of scores in the 8 most common primary sports were analyzed. Results: A total of 398 participants (54.0% female) with an average age of 14.5 years (range, 10.0-18.8 years) were included in the study. The HSS Pedi-FABS demonstrated correlations with hours per week ( r = 0.302; P < .001), days per week ( r = 0.278; P < .001), and weeks per year ( r = 0.136; P = .014) playing a primary sport. The Tegner only demonstrated a correlation with days per week ( r = 0.211; P = .001). Additionally, club/select-level athletes scored higher than junior high/high school–level athletes on the HSS Pedi-FABS (23.8 vs 21.0; P = .004), but no difference was observed with the Tegner. No floor or ceiling effect was observed for the HSS Pedi-FABS, but a ceiling effect was present for the Tegner (32.8%). The HSS Pedi-FABS demonstrated a varied score distribution between the 8 most common primary sports ( P < .001), with soccer players scoring the highest, on average (23.5). Conclusion: The HSS Pedi-FABS, compared with the Tegner, demonstrated more correlations with an athlete’s participation in sport with no floor or ceiling effect and had a wide distribution of scores even among same-sport athletes. The HSS Pedi-FABS may be a more valuable activity measure than the Tegner in pediatric athletes.

Correlation between anthropometric measurements and activity level on length and diameter of semitendinosus tendon autograft in knee ligament surgery: A prospective observational study

Introduction: Preoperative estimation of graft parameters can be useful while using hamstring grafts in knee ligament surgeries. Anthropometric parameters may be an easy way to predict the length and diameter of hamstring tendons. A prospective study was conducted to find the correlation between different anthropometric parameters and activity level of the patient on the length and diameter of the graft. Separate regression equations for males and females were also derived for easy prediction. Methods: Data were obtained from 95 patients who underwent arthroscopic anterior cruciate ligament reconstruction with autologous hamstring tendon graft. Variables studied were age, sex, height, weight, body mass index (BMI), thigh circumference, thigh length, Tegner activity level, diameter (double and quadruple) and length of semitendinosus tendon graft. Results: Height of the patient had strong correlation with graft length (r = 0.41, p < 0.001), double diameter (r = 0.29, p = 0.008) and quadruple diameter (r = 0.3, p = 0.006). Weight of the patients had strong positive correlation with graft length (r = 0.34, p = 0.002) and quadruple diameter (r = 0.34, p = 0.002). Thigh length was found to be positively correlating with graft length (r = 0.43, p < 0.001), double diameter (r = 0.29, p = 0.007) and quadruple diameter of graft (r = 0.34, p = 0.002). BMI and thigh circumference of the patients were not found to correlate with graft size. Male patients were found to have longer semitendinosus graft and larger double and quadruple diameter of the graft. There was no association between the Tegner activity scale and graft size. Regression equations between graft length and quadruple diameter and the anthropometric parameters are also derived. Conclusion: Height, weight and thigh length are useful anthropometric parameters in the prediction of hamstring tendon size. However, the patient’s Tegner activity level was not found to be associated with size of the hamstring tendon.

Therapeutic Response of Extracorporeal Shock Wave Therapy for Insertional Achilles Tendinopathy Between Sports-Active and Nonsports-Active Patients With 5-Year Follow-up

Background: Insertional Achilles tendinopathy (IAT) is a common cause of posterior heel pain. Extracorporeal shock wave therapy (ESWT) has proven to be an effective treatment, but the relationship between therapeutic responses and sports activity levels has not been studied. Purpose: To compare the clinical outcomes of ESWT used to treat IATs between sports-active and nonsports-active patients over 5 years. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective study was conducted on 33 patients with IAT who received ESWT from October 2012 to September 2013. Patients were classified into 2 groups according to their preinjury Tegner activity level: a sports-active group, defined as patients who self-reported to be regular joggers (SA group; Tegner activity level >3; n = 16), and a nonsports-active group (control group; Tegner activity level ≤3; n = 17). The mean age was 31 ± 7 years for the SA group and 37 ± 10 years for the control group. The Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire scores and visual analog scale (VAS) pain scores were used to evaluate the clinical outcomes before treatment, immediately after treatment, and 5 years after treatment. Ultrasonography was also used to assess the insertional Achilles tendon quality. Results: Before treatment, there were no significant differences between the groups with regard to VAS scores, while the VISA-A score in the SA group was higher than that in the control group. After ESWT, both groups had increased VISA-A scores and decreased VAS scores, indicating improvement. At 5-year follow-up, the SA group had a significantly lower mean VAS score (0.3 ± 0.8 vs 1.6 ± 1.3; P = .001) and a significantly higher mean VISA-A score (90 ± 4 vs 78 ± 7; P < .001) compared with the control group. There was no significant difference between the groups regarding the calcification and neovascularization of the Achilles tendon based on ultrasonography. Conclusion: ESWT can improve the symptoms of Achilles tendinopathy, and patients with IAT who had greater sports activity levels had better therapeutic responses than nonsports-active patients after 5-year follow-up.

An electronic patient-reported outcomes measurement system in paediatric orthopaedics

Purpose The purpose of the study was to evaluate the reliability, review differences and assess patient satisfaction of electronic patient-reported outcome measures (PROMs) compared with paper PROMs. Methods Participants between 12 and 19 years of age with a knee-related primary complaint were randomized into two groups. Group 1 completed paper PROMs followed by electronic, while Group 2 received the electronic followed by paper. PROMs included the Pediatric International Knee Documentation Committee (Pedi-IKDC), Hospital for Special Surgery (HSS) Pediatric Functional Activity Brief Scale (HSS Pedi-FABS), Tegner Activity Level Scale, Visual Analogue Scale (VAS), PedsQL Teen and a satisfaction survey. Results In all, 87 participants were enrolled with one excluded due to incomplete PROMs. Of the 86 participants, 54 were female and 32 were male with an average age of 14.3 years (12 to 18). A high degree of reliability was found when comparing the paper and electronic versions of the Pedi-IKDC (0.946; p < 0.001), HSS Pedi-FABS (0.923; p < 0.001), PedsQL Teen (0.894; p < 0.001), Tegner Activity Level Scale before injury (0.848; p < 0.001) and the Tegner Activity Level Scale after (0.930; p < 0.001). Differences were noted between the VAS scores, with paper scores being significantly higher than electronic (5.3 versus 4.6; p < 0.001). While not significant, a trend was noted in which electronic PROMs took, overall, less time than paper (10.0 mins versus 11.2 mins; p = 0.096). Of all participants, 69.8% preferred the electronic PROMs, 67.4% felt they were faster, 93.0% stated they would complete forms at home prior to appointments and 91.8% were not concerned about the safety/privacy of electronic forms. Conclusion PROMs captured electronically were reliable when compared with paper. Electronic PROMs may be quicker, will not require manual scoring and are preferred by patients. Level of Evidence II

Revision Single-Stage Anterior Cruciate Ligament Reconstruction Using an Anterolateral Tibial Tunnel

Revision anterior cruciate ligament (ACL) reconstruction is a technically demanding enterprise. Management of widened or previously malpositioned tunnels is challenging and often requires innovative approaches. The purpose of this study was to evaluate the function and clinical results of revision single-stage ACL surgery using an anterolateral tibial tunnel (ALTT). A consecutive series of knees with arthroscopic ACL revision surgery were analyzed prospectively between April 2012 and September 2015. Among the 93 patients presented with revision ACL reconstruction, 25 patients met the study inclusion criteria for the ALTT technique and were followed up for a minimum of 2 years (range: 24–51 months). The clinical results were evaluated by means of the Lysholm score, International Knee Documentation Committee (IKDC) score, and Tegner activity level scale, and the knee stability was assessed by the Lachman test, pivot shift test, and anterior drawer test. Magnetic resonance imaging (MRI) of the index knee before the surgery and 2 years after revision surgery was assessed. The mean IKDC subjective score, mean Tegner activity level scale, and mean Lysholm score significantly improved in all study participants. This study showed that ACL revision surgery with ALTT can reliably restore stability and provide fair functional outcomes in patients with ACL retear. One could expect acceptable lateral tibial tunnel length compared with medial tibial tunnel in classic ACL revision, intact bony surround, and good graft fixation. This technique is clinically relevant in that making an anterolateral tunnel in one-stage ACL revision surgery had a good subjective result with low complication rate in midterm follow-up.