Search

Background: Patient-reported outcome measures (PROMs) are essential clinical instruments used for assessing patient function, assisting in clinical decision making, and quantifying outcomes of surgical and nonsurgical management. However, PROMs are often designed using patients with preexisting pathology and typically assume that a patient without the pathology would have a perfect or near perfect score. This may result in unrealistic expectations or falsely underestimate how well a patient is doing after treatment. The influence of age on PROMs about the hip of healthy individuals has not been studied. Hypothesis: We hypothesize that in asymptomatic individuals hip-specific PROM scores will decrease in an age-dependent manor. Study Design: Cross-sectional study; Level of evidence, 3. Methods: In this multicenter survey study, volunteers who denied preexisting hip pathology and previous hip surgery completed 3 PROMs online or as traditional paper questionnaires. The International Hip Outcome Tool (iHOT), the modified Harris Hip Score (mHHS), and the Hip Outcome Score–Activities of Daily Living (HOS-ADL) and HOS—Sport were completed. Analysis of variance with a Tukey post hoc test was used to analyze differences in PROMs among subgroups. An independent-samples Student t test and a χ2 test were used to analyze differences in continuous and categorical data, respectively. Results: In total 496, 571, 534, and 532 responses were collected for the iHOT, mHHS, HOS-ADL, and HOS–Sport, respectively. Respondents' PROMs were scored and arranged into 3 groups by age: <40 years, 40 to 60 years, and >60 years. The iHOT, mHHS, HOS-ADL, and HOS–Sport of these asymptomatic respondents all decreased in an age-dependent manner: iHOT (<40, 94.1; 40-60, 92.4; >60, 87.0), mHHS (<40, 94.8; 40-60, 91.3; >60, 89.1), HOS-ADL (<40, 98.4; 40-60, 95.0; >60, 90.9), and HOS–Sport (<40, 95.7; 40-60, 82.9; >60, 72.9) (analysis of variance between-group differences, P <.05). Conclusion: This study demonstrated that the iHOT, mHHS, and HOS-ADL and HOS–Sport scores in asymptomatic people decrease in an age-dependent manner. It is important to compare a patient's outcome scores with the age-normalized scores to establish an accurate reference frame with which to interpret outcomes. [ABSTRACT FROM AUTHOR]

Background: Current classification systems for intra-articular pathology intraoperatively have been described for patients with femoroacetabular impingement rather than dysplasia. Purpose: To (1) describe intra-articular findings in dysplastic hips undergoing combined hip arthroscopy and periacetabular osteotomy (PAO); (2) propose a new chondrolabral classification system for dysplastic hips based on these findings; and (3) correlate patient-reported outcome measures (PROM) with the newly proposed classification. Study Design: Case series; Level of evidence, 4. Methods: A total of 46 hips underwent combined hip arthroscopy and PAO at our institution between September 2013 and December 2014, irrespective of symptoms or radiographic findings. PROMs were evaluated preoperatively and at 2 years postoperatively. At the time of hip arthroscopy, the chondrolabral junction was classified as normal without tear (1 hip, type 1); hypertrophic labrum without chondrolabral disruption (19 hips, type 2); chondrolabral disruption on the articular side, not extending into the capsular side (16 hips, type 3A); chondrolabral disruption extending through the capsular side (3 hips, type 3B); and exposed acetabular subchondral bone (7 hips, type 4). Results: There was a significant difference in postoperative modified Harris Hip Score (mHHS) (P =.020), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores (P =.037), and WOMAC total scores (P =.049) between chondrolabral junction types. Post hoc analyses demonstrated significant differences between type 2 (84.9 ± 12.9) and type 3A (67.8 ± 20.7; P =.198), and between type 2 and type 4 (59.3 ± 24.3; P =.011) in postoperative mHHS scores; and between type 2 (83.9 ± 12.9) and type 3A (68.9 ± 23.7; P =.045) in postoperative WOMAC total scores. In multivariate analysis, chondrolabral type 3 or type 4, age >35 years, and previous surgery were significantly correlated with worse mHHS scores at 2 years. Conclusion: This new chondrolabral classification is proposed to describe intra-articular pathology seen during combined hip arthroscopy and PAO, specifically in dysplastic hips. More advanced chondrolabral disease was associated with worse PROMs at 2 years. [ABSTRACT FROM AUTHOR]

Background: Orthopaedic registries have shown value in tracking and surveillance of patients, implants, and outcomes associatedwith procedures. No current anterior cruciate ligament reconstruction registry (ACLRR) exists in the United States.Purpose: To describe the current cohort captured by an institutional ACLRR and describe the outcomes observed in the registeredpatients and how findings from the ACLRR are disseminated.Study Design: Cohort study; Level of evidence, 2.Methods: The anterior cruciate ligament reconstructions (ACLRs) registered between February 2005 and September 2011 by 244surgeons in 48 medical centers were evaluated. The ACLRR collected data intra- and postoperatively using paper forms and electronicmedical records. The ACLRR cohort was longitudinally followed and outcomes were prospectively ascertained. Outcomes(ie, revisions, subsequent operations, venous thromboembolism, and surgical site infections) were adjudicated via chart review.Descriptive statistics are used to describe the cohort and Kaplan-Meier curves to evaluate survival.Results: During the study period, 16,192 ACLRs (15,101 primary and 1091 revisions) with a median follow-up of 1.6 years (interquartilerange, 0.7-2.8 years) were registered. Male patients received 64% of both primary and revision ACLRs. The mean age atsurgery was 29.5 years (SD, 11.4 years) for primary and revision reconstructions. Cartilage injuries were noted in 25.2% of primaryand 37.5% of revision ACLRs, and meniscal injuries were identified in 60.8% and 53.2%, respectively. Autografts were used in57.6% of primary ACLRs and 20.9% of revisions. Allografts were used in 42.4% of primaries and 78.8% of revisions. In primaryACLR, the most common femoral and tibial fixation types were interference screws (42.2% and 79.7%, respectively). Fixationtype distribution was nearly identical in primaries and revisions. Of the primary ACLRs, 3.7% had subsequent operations onthe same knee and 1.7% on the contralateral knee. Deep surgical site infection developed in 0.3% of primaries and 0.8% ofrevisions. Symptomatic deep vein thromboses were seen in 0.2% of both primaries and revisions. The overall revision ratewas 1.7%. Lower rates of graft survival were identified in younger patients and those with allografts.Conclusion: Large, community-based ACLRRs are useful in informing participating surgeons of current treatment practices,prevalence of concurrent injuries, and outcomes associated with the procedures. Information from the ACLRR can be used todevelop interactive patient and surgeon tools that can be used to optimize patient care. [ABSTRACT FROM AUTHOR]

Background: The rerupture or need for revision after anterior cruciate ligament reconstruction (ACLR) is a serious complication. Preventive strategies that target the early identification of risk factors are important to reduce the incidence of additional surgery. Purpose: To perform a systematic review and meta-analysis to investigate risk factors for revision or rerupture after ACLR. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: Literature searches were performed in PubMed, Embase, and Web of Science from database inception to November 2021 and updated in January 2022. Quantitative, original studies reporting potential adjusted risk factors were included. Odds ratios (ORs) were calculated for potential risk factors. Results: A total of 71 studies across 13 countries with a total sample size of 629,120 met the inclusion criteria. Fifteen factors were associated with an increase in the risk of revision or rerupture after ACLR: male sex (OR, 1.27; 95% CI, 1.14-1.41), younger age (OR, 1.07; 95% CI, 1.05-1.08), lower body mass index (BMI) (OR, 1.03; 95% CI, 1.00-1.06), family history (OR, 2.47; 95% CI, 1.50-4.08), White race (OR, 1.32; 95% CI, 1.08-1.60), higher posterolateral tibial slope (OR, 1.15; 95% CI, 1.05-1.26), preoperative high-grade anterior knee laxity (OR, 2.30; 95% CI, 1.46-3.64), higher baseline Marx activity level (OR, 1.07; 95% CI, 1.02-1.13), return to a high activity level/sport (OR, 2.03; 95% CI, 1.15-3.57), an ACLR within less than a year after injury (OR, 2.05; 95% CI, 1.81-2.32), a concomitant medial collateral ligament (MCL) injury (OR, 1.62; 95% CI, 1.31-2.00), an anteromedial portal or transportal technique (OR, 1.36; 95% CI, 1.22-1.51), hamstring tendon (HT) autografts (vs bone–patellar tendon–bone [BPTB] autografts) (OR, 1.60; 95% CI, 1.40-1.82), allografts (OR, 2.63; 95% CI, 1.65-4.19), and smaller graft diameter (OR, 1.21; 95% CI, 1.05-1.38). The other factors failed to show an association with an increased risk of revision or rerupture after ACLR. Conclusion: Male sex, younger age, lower BMI, family history, White race, higher posterolateral tibial slope, preoperative high-grade anterior knee laxity, higher baseline Marx activity level, return to a high activity level/sport, an ACLR within less than a year from injury, a concomitant MCL injury, an anteromedial portal or transportal technique, HT autografts (vs BPTB autografts), allografts, and smaller graft diameter may increase the risk of revision or rerupture after ACLR. Raising awareness and implementing effective preventions/interventions for risk factors are priorities for clinical practitioners to reduce the incidence of revision or rerupture after ACLR. [ABSTRACT FROM AUTHOR]

The author explores the definition and characteristics of pediatric athletes. He talks about the differences that have greater impact on those caring for young athletes, the common sources for pediatric age group classifications, and the factors that distinguish the care of pediatric patients from adult or fully mature patients. He also describes the important driving features of pediatric patients.

Background: Posterior tibial slope (PTS) has recently gained increased attention for its possible role in anterior cruciate ligament and posterior cruciate ligament injury. The possible differences among age, sex, and ethnicity in PTS have not yet been reported. Purpose: To describe demographic variances of proximal tibial anatomy and to detect differences in regard to ethnicity, sex, and age. Study Design: Cross-sectional study; Level of evidence, 3. Methods: In total, 250 cadaveric specimens with full-body computerized tomography scans from the New Mexico Descendant Imaging Database were randomly selected (inclusion/exclusion criteria: older than 18 years, complete imaging of the knee without previous surgery or arthroplasty) and reviewed by 3 independent observers measuring medial posterior tibial slope (MPTS), lateral posterior tibial slope (LPTS), and global posterior tibial slope (PTS), which was calculated as the mean of the MPTS and LPTS. Individuals were evenly divided among male and female and ethnicities/races: African American/Black, Asian American, Hispanic, Native American, and White. Intraclass correlation coefficient was calculated for interobserver reliability and analysis of variance statistical testing to determine statistical significance between groups. Fisher exact test was also used to understand PTS differences among ethnicities when looking at clinically significant values for potential ligamentous injury. Results: Measurements were obtained from 250 specimens with a mean age of 49.4 years (range, 19 to 103 years). The mean PTS was 8.92° (range, –9.4° to 14.95°). Asian Americans had a 1.7° greater mean MPTS than Whites (P =.016), and African Americans/Blacks had a 1.6° greater mean PTS than Whites (P =.022). No difference in mean PTS was seen between age and sex. When looking at clinically significant PTS, 61 (24.4%) individuals had tibial slopes <6° or >12°, 32 (12.8%) and 29 (11.6%), respectively. Statistically significant differences were seen among ethnicities with PTS <6° (P =.017) but not with PTS >12° (P =.106). No sex-based differences were seen in the percentage of specimens with a PTS of >12° or <6°. Conclusion: Among ethnicities, African Americans/Blacks and Asian Americans have increased PTS in comparison with Whites. Nearly 25% of individuals have clinically significant slopes of <6° or >12°, with no difference in tibial slope among sex or age groups. [ABSTRACT FROM AUTHOR]

Background: Anterior cruciate ligament (ACL) reconstruction (ACLR) has higher failure rates in young active patients returning to sports as compared with older, less active individuals. Augmentation of ACLR with an anterolateral procedure has been shown to reduce failure rates; however, indications for this procedure have yet to be clearly defined. Purpose/Hypothesis: The purpose of this study was to identify predictors of ACL graft failure in high-risk patients and determine key indications for when hamstring ACLR should be augmented by a lateral extra-articular tenodesis (LET). We hypothesized that different preoperative characteristics and surgical variables may be associated with graft failure characterized by asymmetric pivot shift and graft rupture. Study Design: Case-control study; Level of evidence, 3. Methods: Data were obtained from the Stability 1 Study, a multicenter randomized controlled trial of young active patients undergoing autologous hamstring ACLR with or without a LET. We performed 2 multivariable logistic regression analyses, with asymmetric pivot shift and graft rupture as the dependent variables. The following were included as predictors: LET, age, sex, graft diameter, tear chronicity, preoperative high-grade knee laxity, preoperative hyperextension on the contralateral side, medial meniscal repair/excision, lateral meniscal repair/excision, posterior tibial slope angle, and return-to-sports exposure time and level. Results: Of the 618 patients in the Stability 1 Study, 568 with a mean age of 18.8 years (292 female; 51.4%) were included in this analysis. Asymmetric pivot shift occurred in 152 (26.8%) and graft rupture in 43 (7.6%). The addition of a LET (odds ratio [OR], 0.56; 95% CI, 0.37-0.83) and increased graft diameter (OR, 0.62; 95% CI, 0.44-0.87) were significantly associated with lower odds of asymmetric pivot shift. The addition of a LET (OR, 0.40; 95% CI, 0.18-0.91) and older age (OR, 0.83; 95% CI, 0.72-0.96) significantly reduced the odds of graft rupture, while greater tibial slope (OR, 1.15; 95% CI, 1.01-1.32), preoperative high-grade knee laxity (OR, 3.27; 95% CI, 1.45-7.41), and greater exposure time to sport (ie, earlier return to sport) (OR, 1.18; 95% CI, 1.08-1.29) were significantly associated with greater odds of rupture. Conclusion: The addition of a LET and larger graft diameter were significantly associated with reduced odds of asymmetric pivot shift. Adding a LET was protective of graft rupture, while younger age, greater posterior tibial slope, high-grade knee laxity, and earlier return to sport were associated with increased odds of graft rupture. Orthopaedic surgeons should consider supplementing hamstring autograft ACLR with a LET in young active patients with morphological characteristics that make them at high risk of reinjury. [ABSTRACT FROM AUTHOR]

Background: Long-term patient-reported outcome measures (PROMs), rates of return to sport, and revision risk after anterior cruciate ligament (ACL) reconstruction (ACLR) are not well understood. Purpose: To provide long-term follow-up of PROMs, return-to-sport rates, and revision rates after ACLR and to identify predictors for poor outcome. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 2042 patients were included in an institutional ACL registry (2009-2013) and longitudinally followed. PROMs were completed preoperatively and at all follow-up time points. Questions regarding return to sport and knee stability were completed at final follow-up. Predictors for poor outcome on the International Knee Documentation Committee (IKDC) score were estimated in a regression model incorporating risk factors such as patient characteristics, graft choice, and concomitant injuries. Revision rates and risk of subsequent non-ACL surgeries were calculated. Results: Autografts were used in 76% of the patients (patellar tendon, 62%; hamstring grafts, 38%). Allografts were used in 24% of patients. The questionnaires were returned by 1045 (51.2%) patients at a mean of 7.2 years (range, 5.0-9.8 years) after surgery. Improvements in IKDC score of >30 points were sustained for all patient categories. The strongest predictor for lesser improvement in IKDC score was a cartilage lesion >2 cm2 identified during surgery. Male sex and college education completion were associated with improved IKDC scores. Meniscal lesions did not predict change) in the IKDC score. A total of 69% of patients had returned to sport after 8.1 years (range, 6.7-9.8 years). The main reason for not returning to sport was fear of reinjury. The revision rate was 7.2% after 9 years (range, 8-11 years), 13% of patients needed subsequent ipsilateral non-ACL surgery, and 6% underwent contralateral ACLR. The absence of a meniscal tear, younger age, and male sex were predictors for revision. Graft choice did not predict PROM results or revision risk. Conclusion: Improvements in IKDC scores were sustained 7 years after ACLR. The strongest predictor for poor outcome was a cartilage lesion >2 cm2. Patients can expect a 70% return-to-sport rate and an 87% chance of their knee feeling stable during daily and athletic activities after 8 years. Young male patients have better PROM scores but a higher risk of revision. There is a 26% chance of subsequent knee surgery within 9 years, including a revision rate of 7%, subsequent non-ACL surgery to the operated knee in 13%, and a 6% chance of contralateral ACLR. [ABSTRACT FROM AUTHOR]

Background: Loss to follow-up in registry studies might affect generalizability and interpretation of results. Purpose: To evaluate the effect of nonresponder bias in our anterior cruciate ligament (ACL) registry. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 2042 patients with ACL reconstruction in the Hospital for Special Surgery ACL Registry between 2009 and 2013 were included in the study. Patients who completed the patient-reported outcome measures at 2 or 5 years were considered responders (n = 808). Baseline data and patient characteristics were compared between responders and nonresponders (n = 1234). Both responders and nonresponders were contacted and invited to complete the International Knee Documentation Committee (IKDC) and Marx scores electronically and respond to questions regarding return to sports and subsequent surgeries. Nonresponders who completed the questionnaires after reminders were considered late responders. The remaining nonresponders were considered never-responders. The late responders (n = 367) completed the questionnaires after a mean follow-up of 7.8 years (range, 6.7-9.6 years), while follow-up for the responders was 6.8 years (range, 5.0-9.7 years). Responders and late responders were then compared in terms of differences in IKDC and Marx scores from baseline to final follow-up. Results: Nonresponders were younger (28.5 vs 31.5 years; P <.001) and more often male (60% vs 53%; P =.003) compared with responders. Responders had a higher level of education and were more likely to be White (79% vs 74%; P =.04). There were no substantial differences in patient characteristics or baseline IKDC and Marx scores between the late responders and never-responders. There were no statistically significant differences in patient-reported outcomes, return to sports, or subsequent surgeries between responders and late responders at a mean follow-up time of 8.8 years (range, 6.7-9.7 years). Repeat email reminders and telephone calls increased response rate by 18% (from 40% to 58%). Conclusion: There was no difference in clinical outcome as evaluated using IKDC and Marx scores between responders and late responders. [ABSTRACT FROM AUTHOR]

Background: Hamstring autograft anterior cruciate ligament reconstructions (ACLRs) have exhibited higher infection rates compared with bone–patellar tendon–bone (BPTB) autograft. The reason for this observed difference is unclear, warranting investigation. Purpose: To evaluate the association between tibial fixation, either with or without a sheath and screw construct, and the risk of deep infection after hamstring autograft ACLR, using BPTB autograft as a reference group for comparison. Study Design: Cohort study; Level of evidence, 3. Methods: Using the Kaiser Permanente ACLR Registry, we identified all primary isolated, unilateral, single-bundle ACLRs with a BPTB or hamstring autograft (January 1, 2008, to September 30, 2016). The exposure groups included the following: (1) BPTB ACLR, (2) hamstring ACLR using a screw and sheath construct for tibial fixation (HS with screw and sheath), and (3) hamstring ACLR using a method other than a screw and sheath construct for tibial fixation (HS without screw and sheath). We used logistic regression to evaluate the likelihood of 90-day postoperative deep infection using BPTB autograft as the reference group and adjusting for age, sex, and body mass index. The number needed to be exposed (NNE) was calculated. Results: Of 15,671 ACLRs, 6745 (43.0%) used a BPTB graft, 2852 (18.2%) used HS with screw and sheath tibial fixation, and 6074 (38.8%) used HS without screw and sheath tibial fixation. There were 38 (0.2%) 90-day deep infections: 11 (0.2%) for BPTB, 14 (0.5%) for HS with screw and sheath, and 13 (0.2%) for HS without screw and sheath. Staphylococcus aureus for the BPTB group and Staphylococcus epidermidis in both hamstring groups were the most common infecting organisms. HS with screw and sheath had a higher likelihood of 90-day deep infection compared with BPTB ACLR (odds ratio [OR], 2.87; 95% CI, 1.29-6.38). We failed to observe a difference for HS without screw and sheath compared with BPTB ACLR (OR, 1.23; 95% CI, 0.54-2.77). The NNE was 330 and 2701 for HS with and HS without screw and sheath, respectively. Conclusion: Although the overall infection rate after ACLR is low, the higher likelihood of infections when sheath and screw combined are used for tibial fixation of a hamstring autograft ACLR should be a consideration when this procedure is performed. [ABSTRACT FROM AUTHOR]

Background: Osteochondral allograft transplantation (OCA) is a successful knee joint preservation technique; however, the effects of defect size and defect size:condyle ratio (DSCR) are poorly understood. Purpose: To quantify clinical outcomes of isolated OCA of the knee based on defect size and DSCR. Study Design: Cohort study; Level of evidence, 3. Methods: Data from patients who underwent OCA of the knee without major concomitant procedures by a single surgeon were analyzed at a minimum follow-up of 2 years. Osteochondral defect size was measured intraoperatively, and femoral condyle size was measured with preoperative imaging. Patient-reported outcomes, reoperations, and survival rates were analyzed per defect size and DSCR, comparing males and females and patients <40 and ≥40 years old. Results: Sixty-eight patients were included, of whom 57% were male (mean ± SD: age, 34.5 ± 10.3 years; follow-up, 5.2 ± 2.6 years). Mean osteochondral defect size and DSCR were 3.48 ± 1.72 cm2 and 0.2 ± 0.1, respectively. Defect size was larger among males as compared with females (3.97 ± 1.71 cm2 vs 2.81 ± 1.16 cm2, P =.005), while DSCRs were not significantly different between sexes (P =.609). The cohort as a whole demonstrated improvements in the following scores: Lysholm, International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index, and 12-Item Short Form Health Survey Physical (P <.05). There were 27 reoperations (39.7%) at a mean of 2.5 ± 1.92 years and 8 failures (11.8%) at a mean of 2.62 ± 1.3 years. Mean DCSR was higher among patients with graft failure (0.26 ± 0.20 vs 0.19 ± 0.07, P =.049). After stratification by age, failures among patients ≥40 years old were associated with a larger defect size (mean 5.37 ± 3.50 cm2 vs 3.22 ± 1.32 cm2, P =.03) and higher DSCR (mean 0.30 ± 0.25 vs 0.19 ± 0.06, P =.05) when compared with nonfailures. Failures among patients <40 years old were not significantly associated with defect size or DSCR (P >.05) as compared with nonfailures. Conclusion: Patients undergoing isolated OCA transplantation demonstrated significant clinical improvements and a graft survival of 88.2% at 5.2 years. Failures overall were associated with a larger DSCR, and failures among patients ≥40 years old with a larger DSCR and larger defect size. Increasing defect size among males was positively correlated with some improved outcomes, although this was not maintained in analysis of the DSCR, suggesting similar prognosis after OCA regardless of sex. Clinical Relevance: Failed osteochondral allografts are associated with larger defect sizes and defect:condyle ratios in this study, providing additional information to surgeons for appropriate patient consultation. [ABSTRACT FROM AUTHOR]

Background: Patients with bilateral anterior cruciate ligament (ACL) injuries tend to report worse results in terms of knee function and quality of life as compared with those with unilateral injury. There are limited data regarding return to preinjury sport in this group. Purpose: To report return-to-sport rates for patients who had bilateral ACL reconstruction and to compare outcomes according to age and sex. Study Design: Case series; Level of evidence, 4. Methods: A total of 107 patients (62 male, 45 female) who underwent primary ACL reconstruction surgery to both knees completed a detailed sports activity survey at a mean 5-year follow-up (range, 2.5-10 years). Follow-up also included the International Knee Documentation Committee subjective form, Marx Activity Scale, and Knee injury and Osteoarthritis Outcome Score–Quality of Life subscale. Rates of return to preinjury levels of sport were calculated for the whole cohort, and for further analysis, the group was divided according to age (<25 vs ≥25 years), sex, and time between the reconstruction procedures (<3 vs ≥3 years). Results: The rate of return to preinjury sport after bilateral ACL reconstruction was 40% (95% CI, 31%-50%), as compared with an 83% (95% CI, 74%-88%) return rate after the first reconstruction procedure. Although not statistically significant, return rates were higher for male versus female patients (47% vs 31%) and older versus younger patients (45% vs 31%). Of those who returned to their preinjury levels of sport after the second reconstruction, 72% thought that they could perform as well as before their ACL injuries. In contrast, only 20% thought that they could perform as well if they returned to a lower level. Fear of reinjury was the most common reason cited for failure to return to sport after the second reconstruction. Patient-reported outcome scores were higher for those who returned to their preinjury levels of sport but did not differ for sex and age. Conclusion: Return-to-sport rates drop markedly after a second (contralateral) ACL reconstruction, with less than half of the investigated cohort returning to its preinjury level of sport. Return-to-sport outcomes are less than ideal for patients who have ACL reconstruction surgery to both knees. [ABSTRACT FROM AUTHOR]

Background: Anterior cruciate ligament (ACL) injury has been a major cause of missed game time among Australian Football League (AFL) players. Return to play after ACL reconstruction is not always achieved, even among elite athletes. The rate of subsequent ACL injury in the AFL from 1990 to 2000 was high as compared with that of other elite sports. Purpose: To determine the rates of return to play and subsequent ACL injury after ACL reconstruction among AFL players from 1999 to 2013 and to explore factors associated with differing rates of return to play and subsequent ACL injury. Study Design: Case series; Level of evidence, 4. Methods: A total of 158 AFL players who underwent ACL reconstruction were identified from a prospectively maintained registry of AFL player injuries. Further data were gathered from official playing statistics, surgical records, and structured phone interviews. Results: The rate of return to play after an initial ACL injury was 77% (121 of 158 players). Greater preinjury playing experience and earlier selection in the AFL draft were associated with higher rates of return to play. The rate of subsequent ACL injury to either knee was 30% (48 of 158 players) and was especially high among players aged <21 years (23 of 46 players, 50%). After subsequent ACL injury, 34 of 48 players (71%) returned to play. In primary ACL reconstruction, the use of Ligament Augmentation and Reconstruction System grafts resulted in a faster return to play (P = .001) but had a higher risk of subsequent revision reconstruction (risk ratio = 2.8, P = .048). Family history of ACL injury was associated with an increased risk of subsequent contralateral ACL injury (risk ratio = 3.8, P = .002). Conclusion: Most AFL players who underwent ACL reconstruction returned to play at least 1 AFL match. The high rate of subsequent ACL injury among AFL players demonstrates the highly demanding nature of Australian football, particularly at the elite level. The risk factors for subsequent ACL injury should be considered carefully when treatment and rehabilitation decisions are made for these high-demand athletes. [ABSTRACT FROM AUTHOR]

Background: There are limited data evaluating the outcomes of revision anterior cruciate ligament (ACL) reconstruction surgery in younger patients despite recent reports that the rates of graft rupture are higher in young cohorts. Purpose: To explore the outcomes of revision ACL reconstruction surgery in younger patients with the specific aims of determining the rates of third ACL injury and whether knee pathology at the time of revision surgery and return to sport were associated with further injury. Study Design: Case-control study; Level of evidence, 3. Methods: The study cohort consisted of 151 consecutive patients who were aged 25 years or younger at the time of their first revision ACL reconstruction. The number of subsequent ACL injuries (graft rerupture or contralateral injury to the native ACL) was determined at a mean follow-up time of 4.5 years (range, 2-9 years). Surgical details were recorded, along with a range of sport participation outcomes. Contingency tables were used to assess the associations between subsequent ACL injury and return to sport, knee pathology, and the drilling of new femoral or tibial tunnels at revision surgery. Results: The follow-up rate was 85% (128/151). Graft reruptures occurred in 20 patients (16%) at a mean time of 2 years after revision surgery. Contralateral ACL injuries occurred in 15 patients (12%) at a mean time of 3.9 years. The total number of patients who had a third ACL injury was 35 (27%). There was a significant association between having medial meniscal pathology and sustaining a graft rerupture (P = .03), but there was no association between graft rerupture and using the same tunnels from the primary procedure at revision surgery. After revision reconstruction, 68% of patients (95% CI, 55%-71%) returned to their preinjury level of sport, compared with 83% (95% CI, 69%-84%) after primary reconstruction in the same patients. Those who had a third ACL injury had a significantly higher rate of return to preinjury sport (83%) after the revision procedure than did the group that did not have further ACL injuries (62%, P = .02). Conclusion: Younger patients are at significant risk of having multiple ACL injuries. The high rate of third ACL injuries presents a significant issue for future knee health in these young athletes. Medial meniscal pathology and returning to high-risk sport are factors that are significantly associated with the high multiple ACL injury rate in the young. [ABSTRACT FROM AUTHOR]

Background: No well-controlled studies have compared the long-term outcome of anterior cruciate ligament (ACL) reconstruction with hamstring tendon autograft between adolescents and adults. Increased posterior tibial slopes (PTSs) have been reported in the ACL-injured versus controls, but the effect of PTS on the outcome after reconstruction is relatively unexplored. Purpose: To compare the prospective longitudinal outcome of “isolated” ACL ruptures treated with anatomic endoscopic ACL reconstruction using hamstring tendon autograft over 20 years in adolescent and adult cohorts and to examine factors for repeat ACL injury. Study Design: Case-control study; Level of evidence, 3. Methods: A single-surgeon series of 200 consecutive patients undergoing isolated primary ACL reconstruction with hamstring tendon autograft were prospectively studied. Subjects were assessed preoperatively and at 2, 7, 15, and 20 years postoperatively. Outcomes included International Knee Documentation Committee (IKDC) Knee Evaluation, IKDC subjective scores, KT-1000 instrumented laxity testing, and radiological evaluation of degenerative change and medial tibial slope. Twenty-year outcomes were compared between those who underwent surgery at the age of 18 years or younger (adolescent group, n = 39) and those who underwent surgery when older than 18 years (adult group, n = 161). Results: At 20 years, 179 of 200 subjects were reviewed (89.5%). ACL graft rupture occurred in 37 subjects and contralateral ACL injury in 22 subjects. Of those with intact ACL grafts at 20 years, outcomes were not statistically different between adolescents and adults for the variables of IKDC subjective score (P = .29), return to preinjury activity level (P = .84), current activity level (P = .69), or degree of radiological degenerative change at 20 years (P = .51). The adolescent group had a higher proportion of grade 1 ligamentous laxity testing compared with the adult group (P = .003). Overall, ACL graft survival at 20 years was 86% for adults and 61% for adolescents (hazard ration, 3.3; P = .001). The hazard for ACL graft rupture was increased by 4.8 in adolescent males and 2.5 in adolescent females compared with adults. At 20 years, the ACL survival for adolescents with a PTS of ≥12° was 22%. The hazard for ACL graft rupture was increased by 11 in adolescents with a PTS of ≥12° (P = .001) compared with adults with a PTS <12°. Conclusion: Repeat ACL injury after isolated ACL reconstruction is common, occurring in 1 in 3 over 20 years. In the absence of further injury, isolated ACL reconstruction using this technique was associated with good long-term outcomes with respect to patient-reported outcomes and return to sports, regardless of age. However, mild ligament laxity and ACL graft rupture after ACL reconstruction are significantly more common in adolescents, especially adolescent males, compared with adults. PTS of 12° or more is the strongest predictor of repeat ACL injury, and its negative effect is most pronounced in adolescents. [ABSTRACT FROM AUTHOR]

Background: Autologous chondrocyte implantation (ACI) is used worldwide in the treatment of cartilage defects in the knee. Several demographic and injury-specific risk factors have been identified that can affect the success of ACI treatment. However, the discovery of predictive biomarkers in this field has thus far been overlooked. Purpose: To identify potential biomarkers in synovial fluid and plasma that can be used in the preoperative setting to help optimize patient selection for cell-based cartilage repair strategies. Study Design: Controlled laboratory study. Methods: Fifty-four ACI-treated patients were included. Cartilage oligomeric matrix protein (COMP), hyaluronan, soluble CD14 levels, and aggrecanase-1 (ADAMTS-4) activity in synovial fluid and COMP and hyaluronan in plasma were measured. Baseline and postoperative functional outcomes were determined using the patient-reported Lysholm score. To find predictors of postoperative function, linear and logistic regression analyses were performed. The dependent variables were the baseline and postoperative Lysholm score; the independent variables were patient age and body mass index, defect location, defect area, having a bone-on-bone defect, type of defect patch (periosteum or collagen), requirement of an extra procedure, and baseline biomarker levels. Results: The mean baseline Lysholm score was 47.4 ± 17.0, which improved to 64.6 ± 21.7 postoperatively. The activity of ADAMTS-4 in synovial fluid was identified as an independent predictor of the postoperative Lysholm score. Indeed, simply the presence or absence of ADAMTS-4 activity in synovial fluid appeared to be the most important predictive factor. As determined by contingency analysis, when ADAMTS-4 activity was detectable, the odds of being a responder were 3 times smaller than when ADAMTS-4 activity was not detectable. Other predictive factors were the baseline Lysholm score, age at ACI, and defect patch type used. Conclusion: The absence of ADAMTS-4 activity in the synovial fluid of joints with cartilage defects may be used in conjunction with known demographic risk factors in the development of an ACI treatment algorithm to help inform the preclinical decision. [ABSTRACT FROM AUTHOR]

Background: A limited number of large multiethnic cohorts of patients undergoing anterior cruciate ligament reconstruction (ACLR) exist; therefore, little is known about racial differences in preoperative and intraoperative characteristics of patients undergoing this procedure. Purpose: To evaluate preoperative patient, surgeon, and hospital characteristics and intraoperative findings associated with various patient races undergoing ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: A cross-sectional study of patients undergoing primary ACLR (performed between January 1, 2008 and September 30, 2012) was conducted. The Kaiser Permanente ACLR Registry was used to identify the cases and variables for the study. The variables of age, sex, time from injury to surgery, body mass index, sport at the time of injury, concomitant injury (menisci, cartilage, other ligament), surgeon training, and surgeon and site volumes were evaluated. Race was categorized into white (reference), Hispanic, Asian, and black. Polychotomous regression models were employed. Odds ratios (ORs) and 95% CIs are provided. Results: A total of 14,278 ACLRs were evaluated; there were 7401 (51.8%) ACLRs performed on white, 3912 (27.4%) on Hispanic, 1894 (13.3%) on Asian, and 1071 (7.5%) on black patients. Men predominated overall as well as in each of the race categories. Compared with white patients, after adjusting for all covariates, Asian (OR, 1.24; 95% CI, 1.10-1.40) and Hispanic (OR, 1.52; 95% CI, 1.39-1.67) patients undergoing ACLR were more likely to be male than female, and black patients were more likely to be female (OR, 0.69; 95% CI, 0.60-0.80). All racial groups tended to undergo ACLR in younger age bands compared with white patients, with black patients having the highest odds of being <17 years (OR, 2.74; 95% CI, 2.23-3.37) and 17 to 24 years of age (OR, 2.28; 95% CI, 1.94-2.68) compared with being ≥25 years. Asian patients were more likely injured playing basketball (OR, 4.31; 95% CI, 3.67-5.06), black patients during football (OR, 3.48; 95% CI, 2.73-4.45) and basketball (OR, 5.52; 95% CI, 4.49-6.78), and Hispanic patients during soccer (OR, 3.09; 95% CI, 2.75-3.48). Hispanic patients had a higher likelihood of having both menisci injured at the time of surgery (OR, 1.31; 95% CI, 1.16-1.49) as well as the lateral meniscus (OR, 1.31; 95% CI, 1.17-1.47). Asian patients had a lower likelihood of cartilage injuries (OR, 0.78; 95% CI, 0.68-0.88). Sports medicine fellowship–trained surgeons were more likely to have operated on black (OR, 1.27; 95% CI, 1.07-1.51) and Hispanic (OR, 1.16; 95% CI, 1.04-1.29) patients. Conclusion: In this large representative sample of patients undergoing ACLR in the United States, 48.2% of the cohort was nonwhite, and racial variations in sex, age, sport at injury, and intraoperative findings at ACLR were identified. Understanding the differences in ACL injury presentation and concomitant injuries by race can be useful in helping tailor the development of an ACL injury prevention program, during the informed consent process, and in the arthroscopic portion of the procedure according to patient race–specific characteristics. [ABSTRACT FROM AUTHOR]

Background: Overuse injuries to the elbow in the throwing athlete are common. Ulnar collateral ligament reconstruction (UCLR), commonly known as Tommy John surgery, is performed on both recreational and high-level athletes. There is no current literature regarding the incidence and demographic distribution of this surgical procedure in relation to patient age, location within the Unites States, and sex. Purpose: To determine the current demographic distribution of UCLR within the US population included in the PearlDiver database. Study Design: Descriptive epidemiology study. Methods: A retrospective analysis of the PearlDiver supercomputer database, a private-payer database, was performed to identify UCLR procedures performed between 2007 and 2011. The Current Procedural Terminology (CPT) code 24346 (reconstruction of the ulnar collateral ligament of the elbow with the use of a tendinous graft) was used. Results: Between 2007 and 2011, a total of 790 patients underwent UCLR. The average (±SD) annual incidence was 3.96 ± 0.38 per 100,000 patients for the overall population but was 22 ± 3.4 for patients aged 15 to 19 years. The overall average annual growth was 4.2%. There were 695 males and 95 females. The 15- to 19-year-old patients accounted for significantly more procedures than any other age group (56.8%; P < .001), followed by 20- to 24-year-olds (22.2%). The incidence of UCLR in the 15- to 19-year-old group increased at an average rate of 9.12% per year (P = .009). Significantly more UCLR procedures were performed in the southern United States than in any other region (P < .001). The number of procedures significantly increased over time (P = .039). Conclusion: According to this database of a privately insured population, UCLR was performed significantly more in patients aged 15 to 19 than any other age group. The average annual incidence of UCLR per 100,000 people for patients aged 15 to 19 was 22 ± 3.4. Further, this database showed that the number of UCLR procedures is increasing over time. Further work should address risk reduction efforts in this at-risk population. [ABSTRACT FROM AUTHOR]

The article focuses on a cohort study measuring disease-specific and overall mortality of French male and female Olympic athletes compared to the general population. It states vital statistics of French elite athletes who participated in summer or winter Olympic Games ranging from 1948 through 2010 was verified by national sources and followed until 2013. It reports the overall mortality of the athletes compared to their compatriots was 49 percent lower in men and 51 percent lower in women.

Background: Patients generally choose to undergo anterior cruciate ligament reconstruction (ACLR) to return to their active lifestyles. However, returning to their previous activity level may result in a retear of their reconstructed knee or an injury to their contralateral anterior cruciate ligament (CACL). Purpose: To determine the risk factors associated with revision ACLR and contralateral ACLR (CACLR), compare the survival of the reconstructed ACL with the CACL, and determine how the risk factors associated with revision ACLR compare with those for CACLR. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective cohort study of prospectively collected data from the Kaiser Permanente ACLR registry between February 1, 2005, and September 30, 2012, was conducted. Primary ACLR cases without history of contralateral knee ACL injury were included. The study endpoints included revision ACLR and CACLR. Graft type (bone–patellar tendon–bone [BPTB] autograft, hamstring autograft, and allograft) was the main exposure of interest, and patient characteristics were evaluated as risk factors for revision ACLR and CACLR. Survival analyses were conducted. Results: A total of 17,436 ACLRs were evaluated. The median age was 27.2 years (interquartile range, 18.7-37.7 years), and 64% were males. The 5-year survival for index ACLR was 95.1% (95% CI, 94.5%-95.6%), and for CACL it was 95.8% (95% CI, 95.2%- 96.3%). Overall, the cohort had a mean of 2.4 ± 1.7 years of follow-up; 18.2% were lost to follow-up. There were fewer CACLRs per 100 years of observation (0.83) than there were revision ACLRs (1.05) during the study period (P<.001). There was a statistically significant difference in the density of revision ACLR and CACL in BPTB autografts (0.74 vs 1.06, respectively; P = .010), hamstring autografts (1.07 vs 0.81; P = .042), and allografts (1.26 vs 0.67; P<.001). The risk factors for revision ACLR and contralateral surgery were different (P<.05). After adjusting for covariates, factors associated with higher risk of revision ACLR were as follows: allografts, hamstring autografts, male sex, younger age, lower body mass index (BMI), and being white as opposed to black. Factors associated with higher risk of CACLR were as follows: younger age, female sex, and lower BMI. Conclusion: The 5-year revision-free and CACLR-free survival rate in this study was 95.1% and 95.8%, respectively. Allografts and hamstring autografts had a higher risk of revision ACLR surgery, and BPTB autografts had a higher risk of CACLR. Males were found to have a higher risk of revision ACLR, and females had a higher risk of CACLR. Increasing age and increasing BMI decreased the risk of both revision and CACLR. [ABSTRACT FROM AUTHOR]

The article presents a study which described the incidence of short-term reoperations for meniscal, cartilage, hardware removal and arthrofibrosis procedures following primary anterior cruciate ligament reconstruction (ACLR), particularly in the U.S. In the study, the Kaiser Permanente Anterior Cruciate Ligament Reconstruction Registry (KPACLRR) was used. Among the factors that were examined are surgical factors, patient factors, and surgeon experience.

The article discusses a study which calculated the incidence density rate (IDR) of primary anterior shoulder dislocation requiring closed reduction in the general population and demographic subgroups in Ontario. Results showed that young male patients have the highest incidence of primary anterior shoulder dislocation requiring CR and the greatest risk of repeat shoulder CR. The study also found that patient, provider, and injury factors all influence repeat shoulder CR risk.

The article discusses a study which explored the prevalence of invalid baseline scores in 502 athletes between the ages of 10 and 18 years who completed preseason baseline neurocognitive tests in large or small groups. The study revealed the tendency of younger athletes to exhibit a greater prevalence of invalid baseline results on neurocognitive computerized tests than older youth athletes. The prevalence also increases when testing is conducted in a large group and nonclinical setting.

The article presents a population study of the injuries sustained in Spanish amateur soccer during the 2010 to 2011 season. It notes that a total of 15,243 injuries were reported during the period, of which 37.2 percent required medical attention. It highlights that the risk of injury among amateur players is lower compared to those reported by professional players. The need for further research into ways of reducing the incidence of injuries in amateur soccer is also emphasized.

The article presents a study that identifies factors associated with the likelihood of meniscus repairs in patients undergoing anterior cruciate ligament reconstruction (ACLR) entered in a community-based registry. The study evaluates the effects of patient age, sex, race, body mass index, and hospital volume on the likelihood of meniscus repairs. It focuses on patients with a meniscus injury and primary ACLR between February 2005 and June 2010.

Background: Anterior cruciate ligament reconstruction (ACLR) is routinely performed for symptomatic instability. Although it isa common procedure, there remain differences in surgical technique. Hospital administrative records in a public health care systemwere used to investigate the effect of patient, provider, and surgical factors on the risk of revision ACLR.Purpose: To define the rate and risk factors for ACL reoperation in Ontario, Canada, including both ipsilateral revision and contralateralprimary procedures.Study Design: Cohort study; Level of evidence, 3.Methods: All primary elective ACLR procedures performed in Ontario (July 2003 to March 2008) in patients aged 15 to 60 yearswere identified via physician billing and hospital databases. Revision and contralateral ACLR were sought until January 2012.Patient factors (age, sex, comorbidity, income quintile, length of index hospital admission), provider factors (surgeon volume, academichospital status), and surgical factors (allograft vs autograft; fixation type [screw, button, staple]; concomitant operative procedures)were used as covariates in a Cox proportional hazards survivorship model to generate hazard ratios (HRs) withconfidence intervals (CIs) (α = .05). Kaplan-Meier survivorship curves with ACL revision as the end point were generated.Results: A total of 12,967 ACLR procedures with a mean follow-up of 5.2 years were eligible for study using preset criteria. The revisionrate was 2.6% (mean ± SD, 2.91 ± 1.71 years to revision). The rate of primary contralateral ACLR was 4.6% (mean, 2.95 ± 1.81years). In the Cox model, younger age (15-19 years) (HR, 2.1; 95% CI, 1.5-2.9; P<.001), ACLR performed at an academic hospital(HR, 1.6; 95% CI, 1.2-2.1; P<.001), and the use of allograft (HR, 1.7; 95% CI, 1.1-2.6; P = .02) significantly increased the risk of revisionACLR. Only younger age (HR, 2.1; 95% CI, 1.6-2.7; P<.001) was associated with an increased risk of contralateral ACLR.Conclusion: Contralateral ACLR was more frequent than revision ACLR in this population, while both surgical procedures weremost common in patients younger than 20 years. Academic hospital status, but not surgeon volume, as well as the use of allograftalso increased the risk for revision ACLR. [ABSTRACT FROM AUTHOR]

Background: Factors contributing to recurrent dislocation, revision stabilization, and complications requiring reoperation after aninitial shoulder stabilization procedure for instability have not been evaluated on a population level.Purpose: (1) To define the rate of ipsilateral revision stabilization, contralateral primary stabilization, postoperative dislocation,and complications after primary shoulder stabilization in a population cohort. (2) To understand which risk factors among patient,surgical, and provider factors influence these outcomes.Study Design: Cohort study; Level of evidence, 3.Methods: All residents of Ontario, Canada, aged 16 to 60 years undergoing primary shoulder stabilization between July 2003 andDecember 2008 were identified from billing and hospital databases. Separate Cox proportional hazards survivorship models werebuilt for the outcomes revision stabilization and postoperative physician-documented shoulder relocation (minimum 2-yearfollow-up). Model covariates included patient demographics (age, sex, preoperative dislocations), provider characteristics (surgeonvolume, hospital academic status), and type of surgery (open, arthroscopic). The frequency and risk factors for contralateralstabilization were identified.Results: A total of 5904 patients (80.6% male; median age, 29 years) were identified. Arthroscopic stabilization was used in ~60% ofcases in 2003, increasing to ~80% in 2008. The rates of postoperative dislocation were 6.9%, revision stabilization 4%, and contralateralprimary stabilization 3.9%. Patients aged younger than 20 years had a 7.7% revision rate (hazard ratio [HR], 2.7; 95% confidenceinterval [CI], 1.7-4.2; P < .0001) and a 12.6% rate of postoperative physician-documented dislocation (HR, 2.4; 95% CI,1.8-3.4; P < .0001), compared with 2.8% and 5.5%, respectively, in patients 29 years old (median cohort age). Patients with 3 ormore preoperative dislocations in Ontario had an increased risk of revision (HR, 2.1; 95% CI, 1.5-3.0; P<.0001) and postoperativedislocation (HR, 10.6; 95% CI, 8.1-14.0; P < .0001). Revision was more common after arthroscopic (4.3%) compared with open(3.5%) stabilization (HR, 1.4; 95% CI, 1.02-1.98; P = .04). No provider factor was predictive, including surgeon volume. Reoperationrate for complications not related to recurrent instability was 0.23% (infection, 0.07%; manipulation under anesthesia, 0.15%).Conclusion: The risks of revision stabilization and postoperative (either shoulder) dislocation were most influenced by young age(<20 years) and having had 3 or more preoperative dislocations. Complications requiring surgery are rare. [ABSTRACT FROM AUTHOR]

Background: Treatment of the anterior cruciate ligament (ACL)–deficient knee in older patients remains a core debate.Purpose: To perform a systematic review of studies that assessed outcomes in patients aged 40 years and older treated withACL reconstruction and to provide a new methodological scoring system that is directed at critical assessment of studies evaluatingACL surgical outcomes: the ACL Methodology Score (AMS).Study Design: Systematic review.Methods: A comprehensive literature search was performed from 1995 to 2012 using MEDLINE, EMBASE, and Scopus. Inclusioncriteria for studies were primary ACL injury, patient age of 40 years and older, and mean follow-up of at least 21 months afterreconstruction. Nineteen studies met the inclusion criteria from the 371 abstracts from MEDLINE and 880 abstracts from Scopus.Clinical outcomes (International Knee Documentation Committee [IKDC], Lysholm, and Tegner activity scores), joint stabilitymeasures (Lachman test, pivot-shift test, and instrumented knee arthrometer assessment), graft type, complications, andreported chondral or meniscal injury were evaluated in this review. A new methodology scoring system was developed to be specificat critically analyzing ACL outcome studies and used to examine each study design.Results: Nineteen studies describing 627 patients (632 knees; mean age, 49.0 years; range, 42.6-60.0 years) were included in thereview. The mean time to surgery was 32.0 months (range, 2.9-88.0 months), with a mean follow-up of 40.2 months (range, 21.0-114.0 months). The IKDC, Lysholm, and Tegner scores and knee laxity assessment indicated favorable results in the studies thatreported these outcomes. Patients did not demonstrate a significant difference between graft types and functional outcomescores or stability assessment. The mean AMS was 43.9 ± 7.2 (range, 33.5-57.5). The level of evidence rating did not positivelycorrelate with the AMS, which suggests that the new AMS system may be able to detect errors in methodology or reporting thatmay not be taken into account by the classic level of evidence rating.Conclusion: Patients aged 40 years and older with an ACL injury can have satisfactory outcomes after reconstruction. However,the quality of currently available data is still limited, such that further well-designed studies are needed to determine long-termefficacy and to better inform our patients with regard to expected outcomes. [ABSTRACT FROM AUTHOR]

Ligament reconstruction is the current standard of care for active patients with an anterior cruciate ligament (ACL) rupture. Although the majority of ACL reconstruction (ACLR) surgeries successfully restore the mechanical stability of the injured knee, postsurgical outcomes remain widely varied. Less than half of athletes who undergo ACLR return to sport within the first year after surgery, and it is estimated that approximately 1 in 4 to 1 in 5 young, active athletes who undergo ACLR will go on to a second knee injury. The outcomes after a second knee injury and surgery are significantly less favorable than outcomes after primary injuries. As advances in graft reconstruction and fixation techniques have improved to consistently restore passive joint stability to the preinjury level, successful return to sport after ACLR appears to be predicated on numerous postsurgical factors. Importantly, a secondary ACL injury is most strongly related to modifiable postsurgical risk factors. Biomechanical abnormalities and movement asymmetries, which are more prevalent in this cohort than previously hypothesized, can persist despite high levels of functional performance, and also represent biomechanical and neuromuscular control deficits and imbalances that are strongly associated with secondary injury incidence. Decreased neuromuscular control and high-risk movement biomechanics, which appear to be heavily influenced by abnormal trunk and lower extremity movement patterns, not only predict first knee injury risk but also reinjury risk. These seminal findings indicate that abnormal movement biomechanics and neuromuscular control profiles are likely both residual to, and exacerbated by, the initial injury. Evidence-based medicine (EBM) strategies should be used to develop effective, efficacious interventions targeted to these impairments to optimize the safe return to high-risk activity.In this Current Concepts article, the authors present the latest evidence related to risk factors associated with ligament failure or a secondary (contralateral) injury in athletes who return to sport after ACLR. From these data, they propose an EBM paradigm shift in postoperative rehabilitation and return-to-sport training after ACLR that is focused on the resolution of neuromuscular deficits that commonly persist after surgical reconstruction and standard rehabilitation of athletes. [ABSTRACT FROM PUBLISHER]

The article reports a study which systematically reviewed and synthesized the scientific literature regarding the influence of age of neuromuscular training (NMT) implementation on the effectiveness for reduction of anterior cruciate ligament (ACL) injury incidence. The findings of this meta-analysis revealed an age-related association between NMT implementation and reduction of ACL incidence. This supports initiating integrative NMT programs during early adolescence.

The article discusses a study that was conducted for examining the factor structure exhibited by the 22-item Post-Concussion Symptom Scale (PCSS) as observed in high school and college athletes. The results demonstrate higher baseline levels of the cognitive-sensory and vestibular-somatic symptom factors in high school athletes. The study thus concludes by proving significant age and sex differences in baseline and postconcussion symptom factor scores.

Background: It has been suggested that a surgeon’s experience and training are the most important factors associated with graft selection, but no studies have qualified this association. Graft usage prevalence has not been described for large anterior cruciate ligament reconstruction (ACLR) populations in the United States.Purpose: To describe the prevalence of graft usage in a large community-based practice and evaluate the association of patient, surgeon, and site characteristics with choice of primary ACLR graft.Study Design: Cross-sectional study; Level of evidence, 3.Methods: Primary ACLRs performed between February 2005 and June 2010 were selected for the study. A community-based ligament registry was used to identify cases and variables used for analysis. Graft choice (any allograft, hamstring autograft, and bone–patellar tendon–bone [BPTB] autograft) was compared by patient characteristics and surgeon and site characteristics. Associations between independent variables and graft choice were evaluated using a polychotomous regression model.Results: Of the 9849 patients included in the study, 64% were male, and overall median age was 28 years. Of these, 2796 (28.4%) received BPTB autografts, 3013 (30.6%) received hamstring autografts, and 4040 (41.0%) received allografts. The prevalence of graft source by patients’ gender, race, age, body mass index (BMI), as well as surgeons’ fellowship training status, average volume, and site volume were significantly different (all P < .001). Adjusted models showed that patients’ gender (P < .001), race (P = .018), age (P < .001), BMI (P < .001), as well as surgeons’ fellowship training status (P < .001), average volume (P < .001), and site volume (P < .001) are associated with graft selection. Older and female patients with lower BMI were more likely to receive allografts and hamstring autografts than BPTB autografts. Cases performed by non–fellowship-trained surgeons, lower volume sites, and/or lower volume surgeons were also more likely to be performed with allografts or hamstring autografts than BPTB autografts.Conclusion: Gender, age, race, as well as facility and surgeon characteristics such as volume and location are associated with ACL graft choices. [ABSTRACT FROM PUBLISHER]

Background: There has been much controversy regarding the effects of sterilization techniques and graft history on the structural integrity of allograft ligaments used in reconstruction of the anterior cruciate ligament. The purpose of this review was to comprehensively examine anterior cruciate ligament allograft studies published in the last decade to evaluate the extent to which tissue source, tissue processing techniques, and donor age are reported.Methods: The authors reviewed 202 articles published from 1999 through November 2009, of which 68 retrospective, prospective, biomechanical, and histology studies evaluating 4689 allografts were included.Results: The majority of studies do not accurately report key elements of graft history including tissue bank, processing or sterilization technique, or donor age. Underreporting was particularly prominent in clinical studies as compared with basic science studies. Limited reporting of allograft processing, allograft source, and donor age raises serious questions regarding the generalizability of published studies of allograft tissue for anterior cruciate ligament reconstruction.Conclusion/Clinical Relevance: Orthopaedic surgeons who use allograft tissue must understand the tissue treatments being used (ie, preservation methods, chemical and sterilization processes) to best inform their patients regarding the risks, benefits, and long-term outcomes when such tissues are used. A complete understanding of the implanted tissue, as well as surgeon and recipient demographics, is necessary to ensure appropriate and predictable long-term outcomes. [ABSTRACT FROM AUTHOR]

Background: Allograft tissue remains a valuable alternative for anterior cruciate ligament reconstruction. No study to date has correlated the effect of donor age to bone mineral density (BMD) in a large series of irradiated bone—patellar tendon—bone (BPTB) allograft tissue.Hypothesis/Purpose: The authors attempted to correlate donor age with BMD in a large group of BPTB allograft specimens treated with low-dose gamma irradiation (1.0-1.3 Mrad) collected over a 4-year period. They hypothesized there would be no effect of donor age on the BMD of irradiated BPTB allografts.Study Design: Descriptive laboratory study.Methods: A total of 110 BPTB allograft specimens from 44 male and 66 female donors with a mean age of 46 years (range, 21-58 years) were analyzed. Bone mineral density data were obtained from both the patellar and tibial bone plugs of the BPTB complex. Statistical analyses were conducted using linear regression for correlations and 2-tailed Student t tests for comparisons between groups.Results: The mean BMD of the patellar bone plug (0.471 g/cm2) was significantly greater than the mean BMD of the tibial bone plug (0.328 g/cm2) (P < .001). No correlation was identified between donor age and BMD for either the patella or tibial bone plugs (R2 = .014 and .011, respectively). Both patellar and tibial BMD was significantly greater for the male grafts than the female ones.Conclusion: No correlation was found between donor age and BMD for irradiated BPTB allograft tissue. The patellar bone plugs were noted to have a greater BMD than the tibial bone plugs. Allograft tissue from male donors had higher BMD values than that harvested from female donors. [ABSTRACT FROM AUTHOR]

Background: Autologous chondrocyte implantation (ACI) is an accepted surgical treatment in patients with isolated cartilage defects of the knee. Age has been considered as a limiting factor and the technique has not been recommended in patients older than 40 to 50 years. Nevertheless, some more recent studies report satisfying clinical results in middle-aged patients.Hypothesis: Analogous to the microfracture technique, age over 40 years is associated with inferior clinical outcome after ACI.Study Design: Cohort study; Level of evidence, 2.Methods: Thirty-seven patients with an average age of 47.8 years (group 1) were matched with 37 patients with an average age of 31 years (group 2). Both groups underwent ACI for treatment of isolated cartilage defects of the knee. All patients were enrolled prospectively and followed for a period of 24 months using International Knee Documentation Committee (IKDC), Lysholm scale, Cincinnati sports scale, and Tegner activity evaluation instruments.Results: Statistical analysis revealed a significant increase in function after ACI in both groups as early as 6 months after surgery until the end of the study period. There was only a slight tendency for better clinical outcome in younger patients (IKDC at 24 months: group 1, 72.2 ± 15.8 [standard deviation]; group 2: 76.1 ± 14.1; P = .261; Lysholm at 24 months: group 1: 80.42 ± 15.37; group 2: 80.65 ± 12.01), no statistical significant differences were found between patients of group 1 and group 2 at any of the time points investigated.Conclusion: In contrast to other cartilage repair techniques, patients 40 years and older do not have an inferior outcome up to 24 months after ACI for isolated cartilage defects when compared with younger patients. [ABSTRACT FROM AUTHOR]

The authors convey their response to a feedback about multiplicity in their report on delayed anterior cruciate ligament (ACL) reconstruction in patients over 40 years of age and the orthopaedic literature as a whole. Topics mentioned include the authors' decision to dichotomize the time variable to three months in the initial study design, trial of non-operative management after an ACL tear, and a debate on whether to correct for multiplicity.