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Background: Patients undergoing anterior cruciate ligament reconstruction (ACLR) are at an increased risk for posttraumatic osteoarthritis (PTOA). While we have previously shown that meniscal treatment with ACLR predicts more radiographic PTOA at 2 to 3 years postoperatively, there are a limited number of similar studies that have assessed cartilage directly with magnetic resonance imaging (MRI). Hypothesis: Meniscal repair or partial meniscectomy at the time of ACLR independently predicts more articular cartilage damage on 2- to 3-year postoperative MRI compared with a healthy meniscus or a stable untreated tear. Study Design: Cohort study; Level of evidence, 2. Methods: A consecutive series of patients undergoing ACLR from 1 site within the prospective, nested Multicenter Orthopaedic Outcomes Network (MOON) cohort underwent bilateral knee MRI at 2 to 3 years postoperatively. Patients were aged Results: The cohort included 60 patients (32 female; median age, 18.7 years). Concomitant meniscal treatment at the time of index ACLR was performed in 17 medial menisci (13 meniscal repair and 4 partial meniscectomy) and 27 lateral menisci (3 meniscal repair and 24 partial meniscectomy). Articular cartilage damage was worse in the ipsilateral reconstructed knee ( P < .001). A meniscal injury requiring surgical treatment with ACLR predicted a worse CDS for medial meniscal treatment (medial compartment CDS: P = .005; whole joint CDS: P < .001) and lateral meniscal treatment (lateral compartment CDS: P = .038; whole joint CDS: P = .863). Other predictors of a worse relative CDS included age for the medial compartment ( P < .001), surgically observed articular cartilage damage for the patellofemoral compartment ( P = .048), and body mass index ( P = .007) and age ( P = .020) for the whole joint. Conclusion: A meniscal injury requiring surgical treatment with partial meniscectomy or meniscal repair at the time of ACLR predicted worse articular cartilage damage on MRI at 2 to 3 years after surgery. Further research is required to differentiate between the effects of partial meniscectomy and meniscal repair.

The management of anterior cruciate ligament (ACL) injuries in the skeletally immature and adolescent patient remains an area of controversy in sports medicine. This study, therefore, summarizes and discusses the current evidence related to treating pediatric and adolescent patients who sustain an ACL injury. The current literature identifies a trend towards ACL reconstruction as the preferred treatment option for ACL injuries in the young, largely justified by the risk of further structural damage to the knee joint. Worryingly, a second ACL injury is all too common in the younger population, where almost one in every three to four young patients who sustain an ACL injury and return to high-risk pivoting sport will go on to sustain another ACL injury. The clinical experience of these patients emphasizes the rarity of an athlete who makes it to elite level after a pediatric or adolescent ACL injury, with or without reconstruction. If these patients are unable to make it to an elite level of sport, treatment should possibly be modified to take account of the risks associated with returning to pivoting and strenuous sport. The surveillance of young athletes may be beneficial when it comes to reducing injuries. Further research is crucial to better understand specific risk factors in the young and to establish independent structures to allow for unbiased decision-making for a safe return to sport after ACL injury.

Supplemental material, sj-pdf-1-ajs-10.1177_03635465231160726 for External Validation of the KOOS-ACL in the MOON Group Cohort of Young Athletes Followed for 10 Postoperative Years by Hana Marmura, Paul F. Tremblay, Dianne M. Bryant, Kurt P. Spindler, Laura J. Huston and Alan M.J. Getgood in The American Journal of Sports Medicine

Supplemental material, sj-docx-1-ajs-10.1177_03635465231151389 for Meniscal and Articular Cartilage Predictors of Outcome After Revision ACL Reconstruction: A 6-Year Follow-up Cohort Study by Rick W. Wright, Laura J. Huston, Amanda K. Haas, Jacquelyn S. Pennings, Christina R. Allen, Daniel E. Cooper, Thomas M. DeBerardino, Warren R. Dunn, Brett (Brick) A. Lantz, Kurt P. Spindler, Michael J. Stuart, John P. Albright, Annunziato (Ned) Amendola, Jack T. Andrish, Christopher C. Annunziata, Robert A. Arciero, Bernard R. Bach, Champ L. Baker, Arthur R. Bartolozzi, Keith M. Baumgarten, Jeffery R. Bechler, Jeffrey H. Berg, Geoffrey A. Bernas, Stephen F. Brockmeier, Robert H. Brophy, Charles A. Bush-Joseph, J. Brad Butler, John D. Campbell, James L. Carey, James E. Carpenter, Brian J. Cole, Jonathan M. Cooper, Charles L. Cox, R. Alexander Creighton, Diane L. Dahm, Tal S. David, David C. Flanigan, Robert W. Frederick, Theodore J. Ganley, Elizabeth A. Garofoli, Charles J. Gatt, Steven R. Gecha, James Robert Giffin, Sharon L. Hame, Jo A. Hannafin, Christopher D. Harner, Norman Lindsay Harris, Keith S. Hechtman, Elliott B. Hershman, Rudolf G. Hoellrich, David C. Johnson, Timothy S. Johnson, Morgan H. Jones, Christopher C. Kaeding, Ganesh V. Kamath, Thomas E. Klootwyk, Bruce A. Levy, C. Benjamin Ma, G. Peter Maiers, Robert G. Marx, Matthew J. Matava, Gregory M. Mathien, David R. McAllister, Eric C. McCarty, Robert G. McCormack, Bruce S. Miller, Carl W. Nissen, Daniel F. O’Neill, Brett D. Owens, Richard D. Parker, Mark L. Purnell, Arun J. Ramappa, Michael A. Rauh, Arthur C. Rettig, Jon K. Sekiya, Kevin G. Shea, Orrin H. Sherman, James R. Slauterbeck, Matthew V. Smith, Jeffrey T. Spang, LTC Steven J. Svoboda, Timothy N. Taft, Joachim J. Tenuta, Edwin M. Tingstad, Armando F. Vidal, Darius G. Viskontas, Richard A. White, James S. Williams, Michelle L. Wolcott, Brian R. Wolf and James J. York in The American Journal of Sports Medicine

Supplemental material, sj-pdf-1-ajs-10.1177_03635465231172769 for Predictors of Return to Activity at 2 Years After Anterior Cruciate Ligament Reconstruction Among Patients With High Preinjury Marx Activity Scores: A MOON Prospective Cohort Study by Andrew J. Sheean, Yuxuan Jin, Laura J. Huston, Robert H. Brophy, Charles L. Cox, David C. Flanigan, Morgan H. Jones, Christopher C. Kaeding, Robert A. Magnussen, Robert G. Marx, Matthew J. Matava, Eric C. McCarty, Richard D. Parker, Michelle L. Wolcott, Brian R. Wolf, Rick W. Wright and Kurt P. Spindler in The American Journal of Sports Medicine

Virtual encounters have experienced an exponential rise amid the current COVID-19 crisis. This abrupt change, seen in response to unprecedented medical and environmental challenges, has been forced upon the orthopaedic community. However, such changes to adopting virtual care and technology were already in the evolution forecast, albeit in an unpredictable timetable impeded by regulatory and financial barriers. This adoption is not meant to replace, but rather augment established, traditional models of care while ensuring patient/provider safety, especially during the pandemic. While our department, like those of other institutions, has performed virtual care for several years, it represented a small fraction of daily care. The pandemic required an accelerated and comprehensive approach to the new reality. Contemporary literature has already shown equivalent safety and patient satisfaction, as well as superior efficiency and reduced expenses with musculoskeletal virtual care (MSKVC) versus traditional models. Nevertheless, current literature detailing operational models of MSKVC is scarce. The current review describes our pre-pandemic MSKVC model and the shift to a MSKVC pandemic workflow that enumerates the conceptual workflow organization (patient triage, from timely care provision based on symptom acuity/severity to a continuum that includes future follow-up). Furthermore, specific setup requirements (both resource/personnel requirements such as hardware, software, and network connectivity requirements, and patient/provider characteristics respectively), and professional expectations are outlined. MSKVC has already become a pivotal element of musculoskeletal care, due to COVID-19, and these changes are confidently here to stay. Readiness to adapt and evolve will be required of individual musculoskeletal clinical teams as well as organizations, as established paradigms evolve. Cite this article: Bone Joint Open 2020;1-6:272–280.

Additional file 1. Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) Checklist.

Supplemental Material, sj-pdf-1-ojs-10.1177_23259671211065447 for Design Features and Rationale of the BEAR-MOON (Bridge-Enhanced ACL Restoration Multicenter Orthopaedic Outcomes Network) Randomized Clinical Trial by BEAR-MOON Design Group, Kurt P. Spindler, Peter B. Imrey, Sercan Yalcin, Gerald J. Beck, Gary Calbrese, Charles L. Cox, Paul D. Fadale, Lutul Farrow, Robert Fitch, David Flanigan, Braden C. Fleming, Michael J. Hulstyn, Morgan H. Jones, Christopher Kaeding, Jeffrey N. Katz, Peter Kriz, Robert Magnussen, Ellen McErlean, Carrie Melgaard, Brett D. Owens, Paul Saluan, Greg Strnad, Carl S. Winalski and Rick Wright in Orthopaedic Journal of Sports Medicine

Supplemental material, sj-docx-1-ajs-10.1177_03635465221104470 for Descriptive Characteristics and Outcomes of Patients Undergoing Revision Anterior Cruciate Ligament Reconstruction With and Without Tunnel Bone Grafting by Steven F. DeFroda, Brett D. Owens, Rick W. Wright, Laura J. Huston, Jacquelyn S. Pennings, Amanda K. Haas, Christina R. Allen, Daniel E. Cooper, Thomas M. DeBerardino, Warren R. Dunn, Brett Brick A. Lantz, Kurt P. Spindler, Michael J. Stuart, John P. Albright, Annunziato (Ned) Amendola, Christopher C. Annunziata, Robert A. Arciero, Bernard R. Bach, Champ L. Baker, Arthur R. Bartolozzi, Keith M. Baumgarten, Jeffery R. Bechler, Jeffrey H. Berg, Geoffrey A. Bernas, Stephen F. Brockmeier, Robert H. Brophy, Charles A. Bush-Joseph, J. Brad Butler, James L. Carey, James E. Carpenter, Brian J. Cole, Jonathan M. Cooper, Charles L. Cox, R. Alexander Creighton, Tal S. David, David C. Flanigan, Robert W. Frederick, Theodore J. Ganley, Elizabeth A. Garofoli, Charles J. Gatt, Steven R. Gecha, James Robert Giffin, Sharon L. Hame, Jo A. Hannafin, Christopher D. Harner, Norman Lindsay Harris, Keith S. Hechtman, Elliott B. Hershman, Rudolf G. Hoellrich, David C. Johnson, Timothy S. Johnson, Morgan H. Jones, Christopher C. Kaeding, Ganesh V. Kamath, Thomas E. Klootwyk, Bruce A. Levy, C. Benjamin Ma, G. Peter Maiers, Robert G. Marx, Matthew J. Matava, Gregory M. Mathien, David R. McAllister, Eric C. McCarty, Robert G. McCormack, Bruce S. Miller, Carl W. Nissen, Daniel F. O’Neill, Richard D. Parker, Mark L. Purnell, Arun J. Ramappa, Michael A. Rauh, Arthur C. Rettig, Jon K. Sekiya, Kevin G. Shea, Orrin H. Sherman, James R. Slauterbeck, Matthew V. Smith, Jeffrey T. Spang, Steven J. Svoboda, Timothy N. Taft, Joachim J. Tenuta, Edwin M. Tingstad, Armando F. Vidal, Darius G. Viskontas, Richard A. White, James S. Williams, Michelle L. Wolcott, Brian R. Wolf and James J. York in The American Journal of Sports Medicine

BackgroundAlthough graft choice may be limited in the revision setting based on previously used grafts, most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome.HypothesisIn the ACL revision setting, there would be no difference between autograft and allograft in rerupture rate and patient-reported outcomes (PROs) at 6-year follow-up.Study designCohort study; Level of evidence, 2.MethodsPatients who had revision surgery were identified and prospectively enrolled in this cohort study by 83 surgeons over 52 sites. Data collected included baseline characteristics, surgical technique and pathology, and a series of validated PRO measures. Patients were followed up at 6 years and asked to complete the identical set of PRO instruments. Incidence of additional surgery and reoperation because of graft failure were also recorded. Multivariable regression models were used to determine the predictors (risk factors) of PROs, graft rerupture, and reoperation at 6 years after revision surgery.ResultsA total of 1234 patients including 716 (58%) men were enrolled. A total of 325 (26%) underwent revision using a bone-patellar tendon-bone (BTB) autograft; 251 (20%), soft tissue autograft; 289 (23%), BTB allograft; 302 (25%), soft tissue allograft; and 67 (5%), other graft. Questionnaires and telephone follow-up for subsequent surgery information were obtained for 809 (66%) patients, while telephone follow-up was only obtained for an additional 128 patients for the total follow-up on 949 (77%) patients. Graft choice was a significant predictor of 6-year Marx Activity Rating Scale scores (P = .024). Specifically, patients who received a BTB autograft for revision reconstruction had higher activity levels than did patients who received a BTB allograft (odds ratio [OR], 1.92; 95% CI, 1.25-2.94). Graft rerupture was reported in 5.8% (55/949) of patients by their 6-year follow-up: 3.5% (16/455) of patients with autografts and 8.4% (37/441) of patients with allografts. Use of a BTB autograft for revision resulted in patients being 4.2 times less likely to sustain a subsequent graft rupture than if a BTB allograft were utilized (P = .011; 95% CI, 1.56-11.27). No significant differences were found in graft rerupture rates between BTB autograft and soft tissue autografts (P = .87) or between BTB autografts and soft tissue allografts (P = .36). Use of an autograft was found to be a significant predictor of having fewer reoperations within 6 years compared with using an allograft (P = .010; OR, 0.56; 95% CI, 0.36-0.87).ConclusionBTB and soft tissue autografts had a decreased risk in graft rerupture compared with BTB allografts. BTB autografts were associated with higher activity level than were BTB allografts at 6 years after revision reconstruction. Surgeons and patients should consider this information when choosing a graft for revision ACL reconstruction.

Supplemental material, sj-pdf-1-ajs-10.1177_03635465211015435 for Validity of Research Based on Public Data in Sports Medicine: A Quantitative Assessment of Anterior Cruciate Ligament Injuries in the National Football League by Paul M. Inclan, Peter S. Chang, Christina D. Mack, Gary S. Solomon, Robert H. Brophy, Richard Y. Hinton, Kurt P. Spindler, Allen K. Sills and Matthew J. Matava in The American Journal of Sports Medicine

Supplemental Material, sj-pdf-1-ojs-10.1177_23259671211015667 for Biologic Association Annual Summit: 2020 Report by Rachel M. Frank, Seth L. Sherman, Jorge Chahla, Jason L. Dragoo, Bert Mandelbaum, Members of the Biologic Association, Adam W. Anz, James P. Bradley, Constance R. Chu, Brian J. Cole, Jack Farr, David C. Flanigan, Andreas H. Gomoll, Joanne Halbrecht, Kay Horsch, Christian Lattermann, Philipp Leucht, William J. Maloney, Louis F. McIntyre, Iain Murray, George F. Muschler, Norimasa Nakamura, Nicolas S. Piuzzi, Scott A. Rodeo, Daniel B.F. Saris, William O. Shaffer, Shane A. Shapiro, Kurt P. Spindler, Matthias Steinwachs, John M. Tokish, C. Thomas Vangsness, John Tracy Watson, Adam B. Yanke and Kenneth R. Zaslav in Orthopaedic Journal of Sports Medicine

Supplemental material, sj-pdf-1-ajs-10.1177_03635465211025003 for Neither Residual Anterior Knee Laxity Up to 6 mm nor a Pivot Glide Predict Patient-Reported Outcome Scores or Subsequent Knee Surgery Between 2 and 6 Years After ACL Reconstruction by Robert A. Magnussen, Emily K. Reinke, Laura J. Huston, Isaac Briskin, Charles L. Cox, Warren R. Dunn, David C. Flanigan, Morgan H. Jones, Christopher C. Kaeding, Matthew J. Matava, Richard D. Parker, Matthew V. Smith, Rick W. Wright and Kurt P. Spindler in The American Journal of Sports Medicine

Supplemental material, sj-pdf-1-ajs-10.1177_03635465211010798 for Validation of a Risk Calculator to Personalize Graft Choice and Reduce Rupture Rates for Anterior Cruciate Ligament Reconstruction by Hana Marmura, Alan M.J. Getgood, Kurt P. Spindler, Michael W. Kattan, Isaac Briskin and Dianne M. Bryant in The American Journal of Sports Medicine

Supplemental material, sj-pdf-1-ajs-10.1177_0363546521995182 for The Clinical Radiographic Incidence of Posttraumatic Osteoarthritis 10 Years After Anterior Cruciate Ligament Reconstruction: Data From the MOON Nested Cohort by The MOON Group in The American Journal of Sports Medicine

PurposeA stringent outcome assessment is a key aspect for establishing evidence-based clinical guidelines for anterior cruciate ligament (ACL) injury treatment. The aim of this consensus statement was to establish what data should be reported when conducting an ACL outcome study, what specific outcome measurements should be used and at what follow-up time those outcomes should be assessed.MethodsTo establish a standardized approach to assessment of clinical outcome after ACL treatment, a consensus meeting including a multidisciplinary group of ACL experts was held at the ACL Consensus Meeting Panther Symposium, Pittsburgh, PA; USA, in June 2019. The group reached consensus on nine statements by using a modified Delphi method.ResultsIn general, outcomes after ACL treatment can be divided into four robust categories-early adverse events, patient-reported outcomes, ACL graft failure/recurrent ligament disruption and clinical measures of knee function and structure. A comprehensive assessment following ACL treatment should aim to provide a complete overview of the treatment result, optimally including the various aspects of outcome categories. For most research questions, a minimum follow-up of 2 years with an optimal follow-up rate of 80% is necessary to achieve a comprehensive assessment. This should include clinical examination, any sustained re-injuries, validated knee-specific PROs and Health-Related Quality of Life questionnaires. In the mid- to long-term follow-up, the presence of osteoarthritis should be evaluated.ConclusionThis consensus paper provides practical guidelines for how the aforementioned entities of outcomes should be reported and suggests the preferred tools for a reliable and valid assessment of outcome after ACL treatment.Level of evidenceV.

The cause of subsequent surgery after anterior cruciate ligament (ACL) reconstruction varies, but if risk factors for specific subsequent surgical procedures can be identified, we can better understand which patients are at greatest risk.To report the incidence and types of subsequent surgery that occurred in a cohort of patients 6 years after their index ACL reconstruction and to identify which variables were associated with the incidence of patients undergoing subsequent surgery after their index ACL reconstruction.Cohort study; Level of evidence, 2.Patients completed a questionnaire before their index ACL surgery and were followed up at 2 and 6 years. Patients were contacted to determine whether any underwent additional surgery since baseline. Operative reports were obtained, and all surgical procedures were categorized and recorded. Logistic regression models were constructed to predict which patient demographic and surgical variables were associated with the incidence of undergoing subsequent surgery after their index ACL reconstruction.The cohort consisted of 3276 patients (56.3% male) with a median age of 23 years. A 6-year follow-up was obtained on 91.5% (2999/3276) with regard to information on the incidence and frequency of subsequent surgery. Overall, 20.4% (612/2999) of the cohort was documented to have undergone at least 1 subsequent surgery on the ipsilateral knee 6 years after their index ACL reconstruction. The most common subsequent surgical procedures were related to the meniscus (11.9%), revision ACL reconstruction (7.5%), loss of motion (7.8%), and articular cartilage (6.7%). Significant risk factors for incurring subsequent meniscus-related surgery were having a medial meniscal repair at the time of index surgery, reconstruction with a hamstring autograft or allograft, higher baseline Marx activity level, younger age, and cessation of smoking. Significant predictors of undergoing subsequent surgery involving articular cartilage were higher body mass index, higher Marx activity level, reconstruction with a hamstring autograft or allograft, meniscal repair at the time of index surgery, or a grade 3/4 articular cartilage abnormality classified at the time of index ACL reconstruction. Risk factors for incurring subsequent surgery for loss of motion were younger age, female sex, low baseline Knee injury and Osteoarthritis Outcome Score symptom subscore, and reconstruction with a soft tissue allograft.These findings can be used to identify patients who are at the greatest risk of incurring subsequent surgery after ACL reconstruction.

BackgroundPatient-reported outcomes (PROs) are a valid measure of results after revision anterior cruciate ligament (ACL) reconstruction. Revision ACL reconstruction has been documented to have worse outcomes when compared with primary ACL reconstruction. Understanding positive and negative predictors of PROs will allow surgeons to modify and potentially improve outcome for patients.Purpose/hypothesisThe purpose was to describe PROs after revision ACL reconstruction and test the hypothesis that patient- and technique-specific variables are associated with these outcomes.Study designCohort study; Level of evidence, 2.MethodsPatients undergoing revision ACL reconstruction were identified and prospectively enrolled by 83 surgeons over 52 sites. Data included baseline demographics, surgical technique and pathology, and a series of validated PRO instruments: International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index, and Marx Activity Rating Scale. Patients were followed up at 2 years and asked to complete the identical set of outcome instruments. Multivariate regression models were used to control for a variety of demographic and surgical factors to determine the positive and negative predictors of PRO scores at 2 years after revision surgery.ResultsA total of 1205 patients met the inclusion criteria and were successfully enrolled: 697 (58%) were male, with a median cohort age of 26 years. The median time since their most recent previous ACL reconstruction was 3.4 years. Two-year questionnaire follow-up was obtained from 989 patients (82%). The most significant positive predictors of 2-year IKDC scores were a high baseline IKDC score, high baseline Marx activity level, male sex, and having a longer time since the most recent previous ACL reconstruction, while negative predictors included having a lateral meniscectomy before the revision ACL reconstruction or having grade 3/4 chondrosis in either the trochlear groove or the medial tibial plateau at the time of the revision surgery. For KOOS, having a high baseline score and having a longer time between the most recent previous ACL reconstruction and revision surgery were significant positive predictors for having a better (ie, higher) 2-year KOOS, while having a lateral meniscectomy before the revision ACL reconstruction was a consistent predictor for having a significantly worse (ie, lower) 2-year KOOS. Statistically significant positive predictors for 2-year Marx activity levels included higher baseline Marx activity levels, younger age, male sex, and being a nonsmoker. Negative 2-year activity level predictors included having an allograft or a biologic enhancement at the time of revision surgery.ConclusionPROs after revision ACL reconstruction are associated with a variety of patient- and surgeon-related variables. Understanding positive and negative predictors of PROs will allow surgeons to guide patient expectations as well as potentially improve outcomes.

BACKGROUND: Patient reported outcomes (PROs) are a valid measure of results following revision anterior cruciate ligament (ACL) reconstruction. Revision ACL reconstruction has been documented to have worse outcomes compared with primary ACL reconstructions. Understanding positive and negative predictors of PROs will allow surgeons to modify and potentially improve outcome for these patients. HYPOTHESIS/PURPOSE: The purpose of this study was to describe PROs following revision ACL reconstruction and test the hypothesis that patient and technique specific variables are associated with these outcomes. STUDY DESIGN: Cohort study METHODS: Revision ACL reconstruction patients were identified and prospectively enrolled by 83 surgeons over 52 sites. Data collected included baseline demographics, surgical technique and pathology, and a series of validated PRO instruments (IKDC, KOOS, WOMAC and Marx activity rating score). Patients were followed up at 2 years, and asked to complete the identical set of outcome instruments. Multivariate regression models were used to control for a variety of demographic and surgical factors, in order to determine both the positive and negative predictors of PRO scores at 2 years following revision surgery. RESULTS: 1205 patients met the inclusion criteria and were successfully enrolled. 697 (58%) were males, with a median cohort age of 26 years. The median time since their last ACL reconstruction was 3.4 years. Two-year questionnaire follow-up was obtained on 989 subjects (82%). The most significant positive predictors of 2-year IKDC scores were a high baseline IKDC score, high baseline Marx activity level, male gender, and having a longer time between a patient’s last ACL reconstruction, while negative predictors included having a previous lateral meniscectomy prior to the revision ACL reconstruction or having Grades 3/4 chondrosis in either the trochlear groove or medial tibial plateau at the time of the revision surgery. For KOOS, having a high baseline score and having a longer time between their last ACL reconstruction and revision surgery were significant positive predictors for having better (i.e. higher) 2-year KOOS scores, while having a previous lateral meniscectomy prior to the revision ACL reconstruction was a consistent predictor for having significantly worse (i.e. lower) 2-year KOOS scores. Statistically significant positive predictors for 2-year Marx activity levels included higher baseline Marx activity levels, younger age, male gender, and being a non-smoker. Negative 2-year activity level predictors included having an allograft or a biologic enhancement at the time of revision surgery. CONCLUSIONS: PROs following revision ACL reconstruction are associated with a variety of patient and surgeon related variables. Understanding positive and negative predictors of PROs will allow surgeons to guide patient expectation as well as potentially improve outcome for these patients.

BackgroundAnterior cruciate ligament (ACL) revision cohorts continually report lower outcome scores on validated knee questionnaires than primary ACL cohorts at similar time points after surgery. It is unclear how these outcomes are associated with physical activity after physician clearance for return to recreational or competitive sports after ACL revision surgery.HypothesesParticipants who return to either multiple sports or a singular sport after revision ACL surgery will report decreased knee symptoms, increased activity level, and improved knee function as measured by validated patient-reported outcome measures (PROMs) and compared with no sports participation. Multisport participation as compared with singular sport participation will result in similar increased PROMs and activity level.Study designCross-sectional study; Level of evidence, 3.MethodsA total of 1205 patients who underwent revision ACL reconstruction were enrolled by 83 surgeons at 52 clinical sites. At the time of revision, baseline data collected included the following: demographics, surgical characteristics, previous knee treatment and PROMs, the International Knee Documentation Committee (IKDC) questionnaire, Marx activity score, Knee injury and Osteoarthritis Outcome Score (KOOS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A series of multivariate regression models were used to evaluate the association of IKDC, KOOS, WOMAC, and Marx Activity Rating Scale scores at 2 years after revision surgery by sports participation category, controlling for known significant covariates.ResultsTwo-year follow-up was obtained on 82% (986 of 1205) of the original cohort. Patients who reported not participating in sports after revision surgery had lower median PROMs both at baseline and at 2 years as compared with patients who participated in either a single sport or multiple sports. Significant differences were found in the change of scores among groups on the IKDC (P < .0001), KOOS-Symptoms (P = .01), KOOS-Sports and Recreation (P = .04), and KOOS-Quality of Life (P < .0001). Patients with no sports participation were 2.0 to 5.7 times more likely than multiple-sport participants to report significantly lower PROMs, depending on the specific outcome measure assessed, and 1.8 to 3.8 times more likely than single-sport participants (except for WOMAC-Stiffness, P = .18), after controlling for known covariates.ConclusionParticipation in either a single sport or multiple sports in the 2 years after ACL revision surgery was found to be significantly associated with higher PROMs across multiple validated self-reported assessment tools. During follow-up appointments, surgeons should continue to expect that patients who report returning to physical activity after surgery will self-report better functional outcomes, regardless of baseline activity levels.

Supplemental material, DS_10.1177_0363546518819444 for Influence of Baseline Magnetic Resonance Imaging Features on Outcome of Arthroscopic Meniscectomy and Physical Therapy Treatment of Meniscal Tears in Osteoarthritis by Lindsey A. MacFarlane, Heidi Yang, Jamie E. Collins, Ali Guermazi, Morgan H. Jones, Kurt P. Spindler, Amelia R. Winter, Elena Losina and Jeffrey N. Katz in The American Journal of Sports Medicine

Supplemental material, DS_10.1177_0363546519856348 for Relationship Between Sports Participation After Revision Anterior Cruciate Ligament Reconstruction and 2-Year Patient-Reported Outcome Measures in The American Journal of Sports Medicine

Supplemental material, DS_10.1177_0363546519829770 for Comparison of Standard and Right/Left International Knee Documentation Committee Subjective Knee Form Scores by Justin A. Magnuson, Greg Strnad, Clair Smith, Morgan H. Jones, Paul Saluan, James J. Irrgang and Kurt P. Spindler in The American Journal of Sports Medicine

Supplemental material, DS_10.1177_0363546519892570 for Associations of Preoperative Patient Mental Health and Sociodemographic and Clinical Characteristics With Baseline Pain, Function, and Satisfaction in Patients Undergoing Rotator Cuff Repairs by Sambit Sahoo, Eric T. Ricchetti and Alexander Zajichek in The American Journal of Sports Medicine

Background: Prospectively-collected patient-reported outcomes (PROs) following shoulder instability surgery are limited. Attention has been drawn to standardizing these outcome measures in the adolescent literature. Hypothesis/Purpose: The purpose of this study was to evaluate which factors predict unfavorable PROs following shoulder instability surgery, including a “No” response to the Patient Acceptable Symptom State (PASS) question. We hypothesized that poor outcomes are associated with adolescent males, bone loss, larger labral tears, and articular cartilage injury. Methods: A cohort of patients age 13 years and older undergoing shoulder instability surgery were prospectively enrolled in point-of-care data collection at a single institution across 12 surgeons from 2015-2017. Demographics, ASES and SANE responses, and surgical findings were obtained at baseline. ASES, SANE, and PASS responses as well as revision surgery were queried at least one year post-operatively. Patients with isolated posterior labral tears and prior ipsilateral shoulder surgery were excluded. Regression analyses were performed. Results: A total 268 patients met inclusion criteria of which 201 completed follow-up responses (75%). Non-responders had a greater BMI, smaller proportion of glenoid bone loss, fewer Hill-Sachs lesions, and lower baseline ASES scores by 7.5 points (p < 0.05). Responders’ mean age was 25.5 years and 23% were female. Revision surgery occurred in 2.5% of these patients, and 81% responded “Yes” to PASS. A “Yes” response correlated to mean 31-point improvement in ASES and 34-point improvement in SANE scores. On univariate analysis, “No” responders were more likely to have a smoking history, a larger proportion of glenoid bone loss, and revision surgery (p < 0.05). However, on multivariate analysis, only combined labral tears (anterior/inferior plus superior or posterior tears) and injured capsules were associated with greater odds of responding “No” to PASS and with lower ASES and SANE scores (p ≤ 0.05) (Table 1). Age, sex, Hill-Sachs lesions, and grade III/IV articular cartilage injuries were not associated with variation in any PROs. Conclusion: In this prospective cohort, patients largely approve of their symptom state at one year or greater following shoulder instability surgery. A PASS “Yes” response occurred in 81% of patients and correlated to a clinically and statistically significant improvement in ASES and SANE scores. Combined labral tears and injured capsules were negative prognosticators across PROs, whereas age, sex, and Hill-Sachs lesions were not. Table: Table 1. Significant variables predicting PASS "No" responses, poorer ASES/SANE scores, and revision surgery. P values less than or equal to 0.05 are listed. VARIABLE CATEGORY PASS ASES SANE REVISION SURGERY Sex Male (vs Female) Age - BMI - Years of Education - Smoking Status Quit (vs Never) Current (vs Never) 0.033 Baseline VR12 MCS - Glenoid Bone Loss 20% (vs None) 0.004 Anchor Quantity - Labral Tear Location Superior(vs Anterior/Inferior) Combined(vs Anterior/Inferior) 0.050 0.023 0.009 Laterality Right (vs Left) Hill-Sachs Lesion Yes, Engaging (vs No) Yes, Non-engaging (vs No) Capsule Status Injured (vs Normal) 0.033 0.003 0.001 0.019 Humeral and/or Glenoid Articular Cartilage Injury Grade III/IV Lesion(vs Normal to grade II)

BackgroundThe occurrence of physiologic knee hyperextension (HE) in the revision anterior cruciate ligament reconstruction (ACLR) population and its effect on outcomes have yet to be reported. Hypothesis/Purpose: The prevalence of knee HE in revision ACLR and its effect on 2-year outcome were studied with the hypothesis that preoperative physiologic knee HE ≥5° is a risk factor for anterior cruciate ligament (ACL) graft rupture.Study designCohort study; Level of evidence, 2.MethodsPatients undergoing revision ACLR were identified and prospectively enrolled between 2006 and 2011. Study inclusion criteria were patients undergoing single-bundle graft reconstructions. Patients were followed up at 2 years and asked to complete an identical set of outcome instruments (International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, WOMAC, and Marx Activity Rating Scale) as well as provide information regarding revision ACL graft failure. A regression model with graft failure as the dependent variable included age, sex, graft type at the time of the revision ACL surgery, and physiologic preoperative passive HE ≥5° (yes/no) to assess these as potential risk factors for clinical outcomes 2 years after revision ACLR.ResultsAnalyses included 1145 patients, for whom 2-year follow-up was attained for 91%. The median age was 26 years, with age being a continuous variable. Those below the median were grouped as "younger" and those above as "older" (age: interquartile range = 20, 35 years), and 42% of patients were female. There were 50% autografts, 48% allografts, and 2% that had a combination of autograft plus allograft. Passive knee HE ≥5° was present in 374 (33%) patients in the revision cohort, with 52% being female. Graft rupture at 2-year follow-up occurred in 34 cases in the entire cohort, of which 12 were in the HE ≥5° group (3.2% failure rate) and 22 in the non-HE group (2.9% failure rate). The median age of patients who failed was 19 years, as opposed to 26 years for those with intact grafts. Three variables in the regression model were significant predictors of graft failure: younger age (odds ratio [OR] = 3.6; 95% CI, 1.6-7.9; P = .002), use of allograft (OR = 3.3; 95% CI, 1.5-7.4; P = .003), and HE ≥5° (OR = 2.12; 95% CI, 1.1-4.7; P = .03).ConclusionThis study revealed that preoperative physiologic passive knee HE ≥5° is present in one-third of patients who undergo revision ACLR. HE ≥5° was an independent significant predictor of graft failure after revision ACLR with a >2-fold OR of subsequent graft rupture in revision ACL surgery. Registration: NCT00625885 ( ClinicalTrials.gov identifier).

BACKGROUND: The Knee Injury and Osteoarthritis Outcome Score (KOOS) has demonstrated inferior psychometric properties when compared to the International Knee Documentation Committee Subjective Knee Form (IKDC). The KOOS, Joint Replacement (KOOS,JR) is a validated short-form instrument to assess patient-reported outcome measures (PROs) after knee arthroplasty, and the purpose of this study was to determine if augmenting the KOOS,JR with additional KOOS items would allow for the creation of a short-form KOOS-based global knee score for patients undergoing anterior cruciate ligament (ACL) reconstruction with psychometric properties similar to that of the IKDC. HYPOTHESIS: We hypothesized that an augmented version of the KOOS,JR could be created that would demonstrate convergent validity with the IKDC but avoid the ceiling effects and limitations previously noted with several of the KOOS subscales. STUDY DESIGN: Cohort study. Level of Evidence: Diagnostic, Level II. METHODS: Using pre- and 2-year postoperative responses to the KOOS questionnaires from a sample of 1,904 primary ACL reconstruction patients, an aggregate score combining the KOOS,JR and the 4 KOOS Quality of Life questions, termed the KOOS(global), was developed. Again using the pre- and postoperative responses from the 1,904 ACL reconstruction patients, psychometric properties of the KOOS(global) were compared to the IKDC Subjective Score. Convergent validity between the KOOS(global) and IKDC was assessed with a Spearman correlation (rho). Responsiveness of the 2 instruments was assessed by calculating the pre- to effect size (ES) and relative efficiency (RE). Finally, the presence of a preoperative floor or postoperative ceiling effect was defined using the threshold of 15% of patients reporting either the worst possible (0 for both KOOS(global) and IKDC) or best possible scores (100 for both KOOS(global) and IKDC), respectively. RESULTS: The newly developed KOOS(global) was responsive after ACL reconstruction and demonstrated convergent validity with the IKDC. The KOOS(global) significantly correlated with IKDC scores (rho=.91, p

BackgroundArticular cartilage health is an important issue following anterior cruciate ligament (ACL) injury and primary ACL reconstruction. Factors present at the time of primary ACL reconstruction may influence the subsequent progression of articular cartilage damage.HypothesisLarger meniscus resection at primary ACL reconstruction, increased patient age, and increased body mass index (BMI) are associated with increased odds of worsened articular cartilage damage at the time of revision ACL reconstruction.Study designCase-control study; Level of evidence, 3.MethodsSubjects who had primary and revision data in the databases of the Multicenter Orthopaedics Outcomes Network (MOON) and Multicenter ACL Revision Study (MARS) were included. Reviewed data included chondral surface status at the time of primary and revision surgery, meniscus status at the time of primary reconstruction, primary reconstruction graft type, time from primary to revision ACL surgery, as well as demographics and Marx activity score at the time of revision. Significant progression of articular cartilage damage was defined in each compartment according to progression on the modified Outerbridge scale (increase ≥1 grade) or >25% enlargement in any area of damage. Logistic regression identified predictors of significant chondral surface change in each compartment from primary to revision surgery.ResultsA total of 134 patients were included, with a median age of 19.5 years at revision surgery. Progression of articular cartilage damage was noted in 34 patients (25.4%) in the lateral compartment, 32 (23.9%) in the medial compartment, and 31 (23.1%) in the patellofemoral compartment. For the lateral compartment, patients who had >33% of the lateral meniscus excised at primary reconstruction had 16.9-times greater odds of progression of articular cartilage injury than those with an intact lateral meniscus ( P < .001). For the medial compartment, patients who had

Supplemental material, DS_10.1177_0363546517749850 for Ten-Year Outcomes and Risk Factors After Anterior Cruciate Ligament Reconstruction: A MOON Longitudinal Prospective Cohort Study by The MOON Knee Group in The American Journal of Sports Medicine

Supplemental material, DS_10.1177_0363546518788325 for 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 by Eric Hamrin Senorski, Eleonor Svantesson, Kurt P. Spindler, Eduard Alentorn-Geli, David Sundemo, Olaf Westin, Jon Karlsson and Kristian Samuelsson in The American Journal of Sports Medicine

BACKGROUND: Articular cartilage health is an important issue following anterior cruciate ligament (ACL) injury and primary ACL reconstruction. Factors present at the time of primary ACL reconstruction may influence the subsequent progression of articular cartilage damage. HYPOTHESIS: We hypothesized that larger meniscus resection at primary ACL reconstruction, increased patient age, and increased body mass index (BMI) are associated with increased odds of worsened articular cartilage damage at the time of revision ACL reconstruction. STUDY DESIGN: Prospective cohort study METHODS: Subjects who had both primary and revision data contained in the Multicenter Orthopaedics Outcomes Network (MOON) and Multicenter ACL Revision Study (MARS) databases were included. Data reviewed included chondral surface status at the time of primary and revision surgery, meniscal status at the time of primary reconstruction, primary reconstruction graft type, time from primary to revision ACL surgery, as well as demographics and Marx activity score at the time of revision. Significant progression of articular cartilage damage was defined in each compartments according to progression on the modified Outerbridge scale (increase of ≥1 grade) or a greater than 25% enlargement in any area of damage. Logistic regression was used to identify predictors of significant chondral surface change in each compartment from primary to revision surgery. RESULTS: A total of 134 patients were included with a median age19.5 years at revision surgery. Progression of articular cartilage damage was noted in 34 patients (25.4%) in the lateral compartment, 32 patients (23.9%) in the medial compartment, and 31 patients (23.1%) in the patellofemoral compartment. In the lateral compartment, patients who had greater than 33% of their lateral meniscus excised at primary reconstruction had 16.9 times greater odds of progression of articular cartilage injury than those with an intact lateral meniscus (p < 0.001). In the medial compartment, patients who had less than 33% of their medial meniscus excised at the time of the primary reconstruction had 4.8 times greater odds of progression of articular cartilage injury than those with an intact medial meniscus (p = 0.02). Odds of significant chondral surface change increased by 5% in the lateral compartment and 6% in the medial compartment for each increased year of age (p ≤0.02). In the patellofemoral compartment, the use of allograft was associated with a 15-fold increased odds of progression of articular cartilage damage relative to a patellar tendon autograft (p < 0.001). Each one unit increase in BMI at the time of revision surgery was associated with a 10% increase in the odds of progression of articular cartilage damage (p = 0.046) in the patellofemoral compartment. CONCLUSION: Excision of the medial and lateral meniscus at primary ACL reconstruction increases the odds of articular cartilage damage in the corresponding compartment at the time of revision ACL reconstruction. Increased age is a risk factor for deterioration of articular cartilage in both tibiofemoral compartments, while increased BMI and the use of allograft for primary ACL reconstruction are associated with an increased risk of progression in the patellofemoral compartment.

BackgroundRevision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstruction.HypothesisCertain factors under the control of the surgeon at the time of revision surgery can both negatively and positively affect outcomes.Study designCase-control study; Level of evidence, 3.MethodsPatients undergoing revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, intraoperative surgical technique and joint disorders, and a series of validated patient-reported outcome instruments (International Knee Documentation Committee [IKDC] subjective form, Knee Injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating scale) completed before surgery. Patients were followed up for 2 years and asked to complete an identical set of outcome instruments. Regression analysis was used to control for age, sex, body mass index (BMI), activity level, baseline outcome scores, revision number, time since last ACL reconstruction, and a variety of previous and current surgical variables to assess the surgical risk factors for clinical outcomes 2 years after revision ACL reconstruction.ResultsA total of 1205 patients (697 male [58%]) met the inclusion criteria and were successfully enrolled. The median age was 26 years, and the median time since their last ACL reconstruction was 3.4 years. Two-year follow-up was obtained on 82% (989/1205). Both previous and current surgical factors were found to be significant contributors toward poorer clinical outcomes at 2 years. Having undergone previous arthrotomy (nonarthroscopic open approach) for ACL reconstruction compared with the 1-incision technique resulted in significantly poorer outcomes for the 2-year IKDC ( P = .037; odds ratio [OR], 2.43; 95% CI, 1.05-5.88) and KOOS pain, sports/recreation, and quality of life (QOL) subscales ( P ≤ .05; OR range, 2.38-4.35; 95% CI, 1.03-10.00). The use of a metal interference screw for current femoral fixation resulted in significantly better outcomes for the 2-year KOOS symptoms, pain, and QOL subscales ( P ≤ .05; OR range, 1.70-1.96; 95% CI, 1.00-3.33) as well as WOMAC stiffness subscale ( P = .041; OR, 1.75; 95% CI, 1.02-3.03). Not performing notchplasty at revision significantly improved 2-year outcomes for the IKDC ( P = .013; OR, 1.47; 95% CI, 1.08-1.99), KOOS activities of daily living (ADL) and QOL subscales ( P ≤ .04; OR range, 1.40-1.41; 95% CI, 1.03-1.93), and WOMAC stiffness and ADL subscales ( P ≤ .04; OR range, 1.41-1.49; 95% CI, 1.03-2.05). Factors before revision ACL reconstruction that increased the risk of poorer clinical outcomes at 2 years included lower baseline outcome scores, a lower Marx activity score at the time of revision, a higher BMI, female sex, and a shorter time since the patient's last ACL reconstruction. Prior femoral fixation, prior femoral tunnel aperture position, and knee flexion angle at the time of revision graft fixation were not found to affect 2-year outcomes in this revision cohort.ConclusionThere are certain surgical variables that the physician can control at the time of revision ACL reconstruction that can modify clinical outcomes at 2 years. Whenever possible, opting for an anteromedial portal or transtibial surgical exposure, choosing a metal interference screw for femoral fixation, and not performing notchplasty are associated with significantly better 2-year clinical outcomes.

BackgroundWhile revision anterior cruciate ligament reconstruction (ACLR) can be performed to restore knee stability and improve patient activity levels, outcomes after this surgery are reported to be inferior to those after primary ACLR. Further reoperations after revision ACLR can have an even more profound effect on patient satisfaction and outcomes. However, there is a current lack of information regarding the rate and risk factors for subsequent surgery after revision ACLR.PurposeTo report the rate of reoperations, procedures performed, and risk factors for a reoperation 2 years after revision ACLR.Study designCase-control study; Level of evidence, 3.MethodsA total of 1205 patients who underwent revision ACLR were enrolled in the Multicenter ACL Revision Study (MARS) between 2006 and 2011, composing the prospective cohort. Two-year questionnaire follow-up was obtained for 989 patients (82%), while telephone follow-up was obtained for 1112 patients (92%). If a patient reported having undergone subsequent surgery, operative reports detailing the subsequent procedure(s) were obtained and categorized. Multivariate regression analysis was performed to determine independent risk factors for a reoperation.ResultsOf the 1112 patients included in the analysis, 122 patients (11%) underwent a total of 172 subsequent procedures on the ipsilateral knee at 2-year follow-up. Of the reoperations, 27% were meniscal procedures (69% meniscectomy, 26% repair), 19% were subsequent revision ACLR, 17% were cartilage procedures (61% chondroplasty, 17% microfracture, 13% mosaicplasty), 11% were hardware removal, and 9% were procedures for arthrofibrosis. Multivariate analysis revealed that patients aged

The Multicenter Orthopaedic Outcomes Network (MOON) is an NIH-funded prospective, longitudinal cohort of over 3,500 patients who have undergone anterior cruciate ligament reconstruction (ACLR) by 14 sports medicine surgeons at 7 academic medical centers. Patient reported outcome questionnaires (PRO's) are completed at baseline and multiple timepoints after surgery, and a nested cohort of patients return for radiographs to assess the development of joint space changes. We review the risk factors for worse patient reported outcomes, the predictors of clinically significant symptoms of post-traumatic osteoarthritis (PTOA), and the factors associated with more radiographic joint space narrowing. Baseline PRO's were highly predictive of follow-up scores. Factors associated with worse PRO's at 2 and 6 years included female sex, higher BMI, smoking, less education, allograft, medial meniscectomy, or repair, and chondral injury. Partial lateral meniscectomy was unexpectedly associated with better PRO's. Factors associated with clinically significant symptoms of PTOA at 2 and 6 years included subsequent surgery, meniscal pathology, and chondral injury. Factors associated with narrower medial compartment joint space width included medial meniscectomy, medial meniscus repair, and increased age. Medial joint space width was slightly wider overall for the ACLR knees compared to the contralateral normal knees. Future studies will evaluate PRO's and radiographs at 10-year follow-up. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1366-1374, 2017.

Objectives: Complete disruptions of the medial collateral ligament (MCL) are rare, but do occur with anterior cruciate ligament (ACL) tears. Complete ACL/MCL injuries may be managed with ACL reconstruction and either conservative or operative treatment of the MCL. MCL tear location has also been associated with outcome. We hypothesized that outcomes would be best with acute surgery and worse with proximal MCL tears.We also hypothesized that operative management of MCL injuries would not influence outcome. Methods: Patients enrolled in a multicenter prospective longitudinal cohort who underwent unilateral primary ACL reconstruction between 2002-2008 and who had 2-year follow-up were evaluated. Patients with concomitant grade III MCL injuries treated either operatively or non-operatively were identified. Concurrent injuries (to meniscus or articular cartilage) and subsequent surgeries were documented. Comparisons of surgical chronicity (before and after 30 days from injury) and MCL tear location (femoral or tibial) were performed. Patient reported outcomes (KOOS, IKDC and Marx activity scores) were measured at the time of ACL reconstruction and at 2-year follow-up. Results: Initially, 3028 patients were identified to have undergone primary ACL reconstruction in the cohort during the identified time frame, with 2586 patients completing 2-year follow-up (85%). Complete MCL tears were documented in 1.1% (27/2586) of the cohort: 16 operatively managed patients and 11 conservatively treated MCLs during ACL reconstruction. Concurrent articular pathology was similar between groups. Clinically important differences were seen in baseline KOOS (all subscales) and IKDC scores, with lower scores seen in patients who underwent operative MCL treatment. Reoperation for arthrofibrosis was higher after operative repair of the MCL (19%) versus nonoperative treatment (9%). At 2 years the non-operative MCL cohort maintained significantly better KOOS Sports Rec (88.2 versus 74.4), KOOS QOL (81.3 versus 68.4), and IKDC (87.6 versus 76.0) scores compared to the MCL surgery group. Marx activity scores were equal between groups at the time of study enrollment, however patients who underwent operative MCL management had lower activity scores at 2 years (6.5 versus 10.7). Tibial-sided MCL injuries were associated with worse baseline outcomes compared with femoral-sided MCL injuries in terms of KOOS ADL, Sports Rec, and QOL subscales, but these differences were resolved by 2 years. Surgical chronicity did not influence 2-year outcome. Conclusion: Complete and combined ACL/MCL injuries are rare. Both operative and nonoperative management of MCL tears in our cohort demonstrated clinical improvements between study enrollment and 2-year follow-up. MCL surgery during ACL reconstruction was associated with more frequent stiffness, worse patient-reported outcomes and lower activity at 2 years. There may be a subset of patients with severe combined ACL and medial knee injuries that may benefit from operative management, however, that patient population has yet to be defined.

Objectives: ACL reconstruction effectively restores knee stability and allows a return to athletic activities after ACL injury, but patients are still at higher risk of developing post-traumatic OA. Patient reported outcomes from the Multicenter Orthopaedic Outcomes Network (MOON) prospective longitudinal cohort of over 1500 patients undergoing ACL reconstruction showed no increase in OA symptoms (KOOS subscale) at 2 or 6 years after surgery. Therefore, identification of structural changes of OA that may precede the onset of symptoms is of critical importance for determining risk factors for the initiation and progression of post-traumatic OA in addition to measuring the effectiveness of potential disease-modifying treatments. One structural measure of OA is radiographic joint space width (JSW). We previously demonstrated that meniscus treatment and age predict narrower medial compartment JSW. Methods: 335 patients from the MOON cohort (154 males, 181 females, median age 18 years at the time of surgery) were recruited at a minimum of 2 years following surgery for on-site evaluations including bilateral metatarsophalangeal joint (MTP) radiographs to assess JSW. To minimize bias related to pre-existing knee injury or OA, subjects were 35 years or younger, were injured playing a sport, had primary ACL reconstruction without prior meniscus or articular cartilage surgery, did not undergo subsequent ACL revision, and had a surgically normal contralateral knee. Radiographic JSW was measured in the lateral compartment of both knees using a validated semiautomated method. The association of age, sex, BMI, meniscus treatment, and articular cartilage treatment with lateral compartment JSW differences (JSD) between the reconstructed and normal knees was examined using multivariable generalized linear models. The Holm-Bonferroni method was used to account for multiple comparisons. Results: The mean lateral compartment JSW was 7.73 mm and (95% CI 7.61-7.85 mm) for ACL reconstructed knees and 7.82 mm (95% CI 7.71-7.94 mm) for contralateral normal knees, with a mean JSD of 0.10 mm (p

To determine which patient and injury factors are associated with the detection of high-grade laxity on examination under anesthesia before anterior cruciate ligament (ACL) reconstruction.We identified 2,318 patients who underwent primary ACL reconstruction without associated ligament injuries. Demographic data and information regarding meniscal tears were collected. Patients with high-grade Lachman (difference from contralateral side10 mm), pivot-shift (International Knee Documentation Committee grade 3+), or anterior drawer (difference from contralateral side10 mm) tests were identified by physical examination under anesthesia before ACL reconstruction. Logistic regression modeling was used to evaluate whether chronicity of the ACL injury, patient age, sex, body mass index, generalized ligamentous laxity, and presence of meniscal tears were associated with increased odds of high-grade laxity, while we controlled for examining surgeon.Patients with chronic tears (6 months from injury) had greater than twice the odds of having high-grade Lachman, pivot-shift, and anterior drawer tests (all P.001) relative to patients with acute tears (3 months from injury). Generalized ligamentous laxity (odds ratio [OR], 2.33; P.001) and the presence of medial (OR, 1.63; P.001) or lateral (OR, 1.41; P = .013) meniscus tears were associated with increased odds of a high-grade Lachman test. Age younger than 20 years (OR, 1.34; P = .023), female sex (OR, 1.49; P = .001), generalized ligamentous laxity (OR, 3.46; P.001), and the presence of a medial (OR, 1.53; P.001) or lateral (OR, 1.27; P = .041) meniscus tear were associated with increased odds of a high-grade pivot-shift test. Generalized ligamentous laxity (OR, 2.27; P.001) and the presence of a medial (OR, 1.73; P = .001) or lateral (OR, 1.50; P = .010) meniscus tear were associated with increased odds of a high-grade anterior drawer test.Chronic ACL tears, generalized ligamentous laxity, and meniscus tears are associated with increased odds of high-grade laxity with all 3 tests. Female patients and age younger than 20 years are associated with increased odds of a high-grade pivot-shift test.Level II, lesser-quality prospective study.

Objectives: Meniscus tears frequently accompany acute anterior cruciate ligament ruptures. Management of meniscus tears is highly variable and includes repair, meniscectomy, and non-treatment of tears identified at the time of ACL reconstruction. The purpose of this study is to determine the rate of subsequent reoperation and clinical outcome of meniscal tears left in situ without treatment at the time of ACL reconstruction with a minimum follow-up of 6 years. Methods: Patients with meniscus tears left untreated at the time of primary ACL reconstruction were identified from a multicenter study group between 2002 and 2004 with minimum 6-year follow-up. Patient demographic variables, comorbidities, meniscus tear characteristics, and information on subsequent surgery were obtained. The primary endpoint of the study was need for reoperation for meniscal pathology. Univariate and multivariate analyses were used in order to determine patient demographic variables and meniscus tear characteristics that served as risk factors for reoperation. Results: There were 1440 primary ACL reconstructions performed during the timeframe of the study. There were 955 patients (66.3%) with concomitant meniscal tears identified. Of these, 143 (15.3%) had meniscal tears left in situ at the time of surgery. There were 11 patients (7.9%) who underwent reoperation for meniscal pathology within the same compartment as the meniscal tear left in situ (Table 1). Reoperation was performed more frequently for medial meniscus tears as compared to lateral meniscus tears (17.6% vs. 4.3%, p = 0.048). Medial meniscus tears and tears ≥10 mm in length were identified as risk factors for reoperation. Conclusion: Lateral and medial meniscus tears left in situ at the time of ACL reconstruction did not require reoperation at minimum 6-year follow-up in 95.7% and 82.4% of patients, respectively. Our results suggest that surgeons should consider alternative treatment for medial meniscus tears and tears ≥ 10 mm in length at the time of ACL reconstruction.

There is sparse literature regarding the prognosis and predictors of anterior cruciate ligament (ACL) reconstruction outcomes at six years as measured by validated patient-based outcome instruments and assessed by multivariable analysis. Knowing prognostic information would be valuable in physician counseling of patients considering ACL reconstruction. Large sample sizes with adequate follow-up are necessary for such analysis. A previously published randomized controlled trial had an enrollment of 225 patients1, which limits risk factor analysis. A previous cohort study utilizing multivariable analysis was limited by 69% follow-up and the lack of baseline measurements of the outcomes2, which are important to adjust for, as they are often the strongest predictor of follow-up scores. The Short Form-36 (SF-36) is a widely used measure of general quality of life. It allows for comparison across different disease categories; therefore, normative-based scoring converts the scores such that they have direct interpretation related to the general United States population, with a mean score (and standard deviation) of 50 ± 10 points. Hence, a 1-point change in a score is one-tenth of a standard deviation or an effect size of 0.103. The Short Form-6 dimension (SF-6D), a preference-based utility measure, can be calculated from the SF-36, allowing the calculation of quality-adjusted life years (QALYs)4. Previous studies utilizing the SF-36 in athletic populations have compared domain scores, ranging from 0 to 100 points, to normative values, which do not as easily lend themselves to interpretation, but have not reported normative-based scores5,6. The eight subscales of the SF-36 can be collapsed into two components, the Physical Component Summary (PCS) score and the Mental Component Summary (MCS) score. The use of the PCS and MCS has been advocated for large studies, particularly when there is a focus on the general effect on health7. The aim of the current study was to determine the prognosis and predictors of health-related quality of life as measured by the SF-36 at two and six years after surgery as well as the utility gained following ACL reconstruction as measured by the SF-6D. These results should aid evidence-based decision-making as related to a patient’s prognosis following ACL reconstruction, should provide a high level of evidence for surgeon decision-making, and should have the potential to identify future modifiable risk factors that could be altered to improve outcomes of ACL reconstruction. Furthermore, the improvements in health-related quality of life and utility according to the SF-6D should provide justification for expenditures related to patients with ACL injuries.

Background: Long-term results after anterior cruciate ligament (ACL) reconstruction are being reported with greater frequency, allowing a detailed analysis of long-term patient-reported outcomes and predictors. Purpose: To summarize expected patient-reported outcomes at a minimum 10 years following ACL reconstruction and to explore patient and surgical factors that affect these results. Study Design: Systematic review; Level of evidence, 4. Methods: Prospective studies detailing patient-reported outcomes with a minimum follow-up of 10 years were identified. Average scores for each outcome measure were calculated. Factors identified in each paper as predictors of patient-reported outcomes were identified and described. Results: Thirteen studies met inclusion and exclusion criteria. Lysholm scores were reported in 317 of 406 patients (78.1%) in 6 studies, with a mean score of 91.7 ± 11.2. Subjective International Knee Documentation Committee scores were reported in 1726 of 2611 patients (66.1%) in 5 studies, with a mean score of 84.2 ± 15.5. Cincinnati knee scores were reported in 1323 of 1801 patients (73.5%) in 3 studies, with a mean score of 87.4 ± 14.4. Tegner activity scores were reported in 728 of 914 patients (79.6%) in 8 studies, with a mean score of 5.1. There was mixed evidence that meniscectomy and articular cartilage damage were associated with poorer patient-reported outcomes. Patient sex and graft choice did not affect patient-reported outcomes. Conclusion: Patient-reported outcomes are generally good at a minimum of 10 tears following ACL reconstruction. Further large prospective studies with regression modeling and consistent outcome reporting will clarify predictors of outcomes.

Objectives: It is not clear if there is an additional value to assess the Knee injury and Osteoarthritis Outcome Score (KOOS) at both 1 and 2-years after primary Anterior Cruciate Ligament (ACL) reconstruction. The purpose was to investigate within individual patient if there is an equivalence between KOOS at 1 and 2-years after primary ACL reconstruction in The Swedish National Knee Ligament Register. Methods: This cohort study was based on data from the Swedish National Knee Ligament Register during the period of January 1, 2005, through December 31, 2013. The longitudinal KOOS scores for each individual at 1-year and 2-year follow-up were assessed through the Two One-Sided Test procedure with an acceptance criterion of 4. Subset analysis was also performed with patients classified by sex, age, graft type and by patients with meniscus and/or cartilage injury. Results: A total of 23 952 patients were eligible for analysis after applied exclusion criteria’s (women, n=10,116; 42.2% and men, n=13,836; 57.8%). The largest age group was between 16 and 20 years of age (n=6,599; 27.6%). The most common ACL graft was hamstring tendon (n=22,504; 94.0%) of which the combination semitendinosus and gracilis was the most common. A total of 7,119 patients reported on the KOOS Pain domain at both 1 and 2-year follow-up with a mean difference of 0.21 (13.1 SD, 0.16 SE, [90% CI, -0.05 - 0.46], p

Most surgeons believe that graft choice for ACL reconstruction is an important factor related to outcome. Although graft choice may be limited in the revision setting based on previously used grafts, it is still felt to be important.

This paper presents the rationale and design features of the MeTeOR Trial (Meniscal Tear in Osteoarthritis Research; Clinical Trials.gov NCT00597012). MeTeOR is an NIH-funded seven-center prospective randomized controlled trial (RCT) designed to establish the efficacy of arthroscopic partial meniscectomy combined with a standardized physical therapy program as compared with a standardized physical therapy program alone in patients with a symptomatic meniscal tear in the setting of mild to moderate knee osteoarthritic change (OA). The design and execution of a trial that compares surgery with a nonoperative treatment strategy presents distinctive challenges. The goal of this paper is to provide the clinical rationale for MeTeOR and to highlight salient design features, with particular attention to those that present clinical and methodologic challenges.

The predictors of anterior cruciate ligament reconstruction (ACLR) outcome at 6 years as measured by validated patient-based outcome instruments are unknown.Certain variables evaluated at the time of ACLR will predict return to sports function (as measured by the International Knee Documentation Committee [IKDC] questionnaire and the Knee injury and Osteoarthritis Outcome Score [KOOS] Sports and Recreation subscale), knee-related quality of life (KOOS Knee Related Quality of Life subscale), and activity level (Marx Activity Scale). Potential predictor variables include demographic factors, surgical technique and graft choice for ACLR, and intra-articular injuries and treatment.Cohort study; Level of evidence, 2.All patients with unilateral ACLRs from 2002 currently enrolled in the MOON (Multicenter Orthopaedic Outcomes Network) cohort were evaluated. Patients completed the validated outcome instruments preoperatively. Physicians documented intra-articular pathologic abnormalities, treatment, and surgical techniques used at the time of surgery. At 2 and 6 years postoperatively, patients completed the same validated outcome instruments.Follow-up was obtained at 2 years (88%) and at 6 years (84%). The cohort was 57% male with a median age of 23 years at enrollment. The ability to perform sports function was maintained at 6 years, but the Marx activity level continued to decline from baseline. Revision ACLR and use of allograft predicted worse outcomes on the IKDC and both KOOS subscales. Lateral meniscus treatment, smoking status, and body mass index at baseline were each predictors on 2 of 3 scales. The predictors of lower activity level were revision ACLR and female sex.Six years after ACLR, patients could perform sports-related functions and maintain a high knee-related quality of life similar to their 2-year level, although their physical activity level (Marx) dropped over time. Choosing autograft rather than allograft, not smoking, and having normal body mass index are advised to improve long-term outcomes.

Increased knee pain at the time of anterior cruciate ligament reconstruction may potentially predict more difficult rehabilitation, prolonged recovery, and/or be predictive of increased knee pain at 2 years.A bone bruise and/or other preoperative factors are associated with more knee pain/symptoms at the time of index anterior cruciate ligament reconstruction, and the presence of a bone bruise would be associated with specific demographic and injury-related factors.Cohort study (prevalence); Level of evidence, 2.In 2007, the Multicenter Orthopaedic Outcomes Network (MOON) database began to prospectively collect surgeon-reported magnetic resonance imaging bone bruise status. A multivariable analysis was performed to (1) determine if a bone bruise, among other preoperative factors, is associated with more knee symptoms/pain and (2) examine the association of factors related to bone bruise. To evaluate the association of a bone bruise with knee pain/symptoms, linear multiple regression models were fit using the continuous scores of the Knee injury and Osteoarthritis Outcome Score (KOOS) symptoms and pain subscales and the Short Form 36 (SF-36) bodily pain subscale as dependent variables. To examine the association between a bone bruise and risk factors, a logistic regression model was used, in which the dependent variable was the presence or absence of a bone bruise.Baseline data for 525 patients were used for analysis, and a bone bruise was present in 419 (80%). The cohort comprises 58% male patients, with a median age of 23 years. The median Marx activity level was 13. Factors associated with more pain were higher body mass index (P.0001), female sex (P = .001), lateral collateral ligament injury (P = .012), and older age (P = .038). Factors associated with more symptoms were a concomitant lateral collateral ligament injury (P = .014), higher body mass index (P.0001), and female sex (P.0001). Bone bruise is not associated with symptoms/pain at the time of index anterior cruciate ligament reconstruction. None of the factors included in the SF-36 bodily pain model were found to be significant. After controlling for other baseline factors, the following factors were associated with a bone bruise: younger age (P = .034) and not jumping at the time of injury (P = .006).After anterior cruciate ligament injury, risk factors associated with a bone bruise are younger age and not jumping at the time of injury. Bone bruise is not associated with symptoms/pain at the time of index anterior cruciate ligament reconstruction.

The CALAXO osteoconductive interference screw was recalled in August 2007 due to reports of increased numbers of postoperative complications associated with screw swelling and prominence leading to the need for surgical debridement. This study reviews complications associated with CALAXO screw use in a consecutive cohort of patients undergoing anterior cruciate ligament reconstruction surgery by the senior author at the authors' institution. Over a 12-month period, 226 CALAXO interference screws, either of 20 mm length or 25 mm length, were implanted in 112 patients, and postoperative complications were noted. The 25-mm tibial screw was over 5 times (RR 5.2, 95% CI 1.8 to 15.3) more likely to be prominent than the 20-mm screw (p value=.002). Four surgical debridements were required in the 25-mm tibial screw group; none were required in the 20-mm group. The authors hypothesize that the inability to bury the longer screw length into the bone tunnel is associated with postoperative complications associated with the CALAXO screw.

Meniscal repair is performed in an attempt to prevent posttraumatic arthritis resulting from meniscal dysfunction after meniscal tears. The socioeconomic implications of premature arthritis are significant in the young patient population. Investigations and techniques focusing on meniscus preservation and healing are now at the forefront of orthopaedic sports medicine.Concomitant meniscal repair with anterior cruciate ligament reconstruction is a durable and successful procedure at 2-year follow-up.Case series; Level of evidence, 4.All unilateral primary anterior cruciate ligament reconstructions entered in 2002 in a cohort who had meniscal repair at the time of anterior cruciate ligament reconstruction were evaluated. Validated patient-oriented outcome instruments were completed preoperatively and then again at the 2-year postoperative time point. Reoperation after the index procedure was also documented and confirmed by operative reports.A total of 437 unilateral primary anterior cruciate ligament reconstructions were performed with 82 concomitant meniscal repairs (54 medial, 28 lateral) in 80 patients during the study period. Patient follow-up was obtained on 94% (77 of 82) of the meniscal repairs, allowing confirmation of meniscal repair success (defined as no repeat arthroscopic procedure) or failure. The overall success rate for meniscal repairs was 96% (74 of 77 patients) at 2-year follow-up.Meniscal repair is a successful procedure in conjunction with anterior cruciate ligament reconstruction. When confronted with a "repairable" meniscal tear at the time of anterior cruciate ligament reconstruction, orthopaedic surgeons can expect an estimated90% clinical success rate at 2-year follow-up using a variety of methods as shown in our study.