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Purpose: To develop and validate a standardized patient satisfaction measurement tool for adult patients undergoing primary anterior cruciate ligament reconstruction (ACLR)., Methods: A 4-phase iterative process that included item generation and pilot survey development, item reduction, survey readability, and survey validation was used. To develop and validate the Hospital for Special Surgery ACL Satisfaction Survey (HSS ACL-SS), 70 patients were included in the survey development phase and 77 patients were included in the validation phase. The HSS ACL-SS was compared with other currently used ACLR outcome measures including the International Knee Documentation Committee score, Tegner-Lysholm score, Short Form 12 (SF-12) Mental Component Score, and SF-12 Physical Component Score. Test-retest reliability, internal consistency, convergent and discriminant validity, and floor and ceiling effects were assessed., Results: The HSS ACL-SS consists of 10 items identified by patients as being important for satisfaction after ACLR. In the validation phase, the mean score on the HSS ACL-SS (of 50) among all patients was 37.9 ± 9.9 (range, 10-50). Statistically significant positive correlations were seen between the HSS ACL-SS score and the International Knee Documentation Committee score (r = 0.351, P = .002) and Tegner-Lysholm score (r = 0.333, P = .003). No statistically significant correlation was found between the satisfaction score and the SF-12 Mental or Physical Component Score. The lowest possible score (10 of 50 points) was achieved in 1 patient (1.3%) and the highest possible score (50 of 50 points) was achieved in 7 patients (9.1%), indicating no significant floor or ceiling effects of the instrument. Internal consistency for all 10 items was strong (Cronbach α, 0.995). The mean intraclass correlation coefficient between test and retest responses was 0.701, indicating moderate agreement., Conclusions: The HSS ACL-SS is a validated and reliable patient-derived satisfaction measure with excellent psychometric properties for active adults undergoing ACLR. The results of this study show that the HSS ACL-SS may be a useful tool to measure postoperative patient satisfaction., Level of Evidence: Level II, development of diagnostic or monitoring criteria in consecutive patients., (Copyright © 2020 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: There is increased interest in understanding the preoperative determinants of postoperative outcomes. Return to play (RTP) and the patient-reported minimal clinically important difference (MCID) are useful measures of postoperative outcomes after anterior cruciate ligament reconstruction (ACLR)., Purpose: To define the MCID after ACLR and to investigate the role of preoperative outcome scores for predicting the MCID and RTP after ACLR., Study Design: Case-control study; Level of evidence, 3., Methods: There were 294 active athletes enrolled as part of an institutional ACL registry with a minimum 2-year follow-up who were eligible for inclusion. A questionnaire was administered to elicit factors associated with RTP. Patient demographic and clinical data as well as patient-reported outcome measures were captured as part of the registry. Outcome measures included the International Knee Documentation Committee (IKDC) subjective knee evaluation form, Lysholm scale, and 12-Item Short Form Health Survey (SF-12) physical component summary (PCS) and mental component summary (MCS). Preoperative outcome score thresholds predictive of RTP were determined using a receiver operating characteristic (ROC) with area under the curve (AUC) analysis. The MCID was calculated using a distribution-based method. Multivariable logistic models were fitted to identify predictors for achieving the MCID and RTP., Results: At a mean (±SD) follow-up of 3.7 ± 0.7 years, 231 patients were included from a total 294 eligible patients. The mean age and body mass index were 26.7 ± 12.5 years and 23.7 ± 3.2 kg/m 2 , respectively. Of the 231 patients, 201 (87.0%) returned to play at a mean time of 10.1 months. Two-year postoperative scores on all measures were significantly increased from preoperative scores (IKDC: 50.1 ± 15.6 to 87.4 ± 10.7; Lysholm: 61.2 ± 18.1 to 89.5 ± 10.4; SF-12 PCS: 41.5 ± 9.0 to 54.7 ± 4.6; SF-12 MCS: 53.6 ± 8.1 to 55.7 ± 5.7; P < .001 for all). The corresponding MCID values were 9.0 (IKDC), 10.0 (Lysholm), 5.1 (SF-12 PCS), and 4.3 (SF-12 MCS). Preoperative score thresholds predictive of RTP were the following: IKDC, 60.9; Lysholm, 57.0; SF-12 PCS, 42.3; and SF-12 MCS, 48.3. These thresholds were not independently predictive but achieved significance as part of the multivariable analysis. In the multivariable analysis for RTP, preoperative SF-12 PCS scores above 42.3 (odds ratio [OR], 2.73; 95% CI, 1.09-7.62) and SF-12 MCS scores above 48.3 (OR, 4.41; 95% CI, 1.80-10.98) were predictive for achieving RTP; an ACL allograft (OR, 0.26; 95% CI, 0.06-1.00) was negatively predictive of RTP. In the multivariable analysis for the MCID, patients with higher preoperative scores were less likely to achieve the MCID ( P < .0001); however, a higher preoperative SF-12 MCS score was predictive of achieving the MCID on the IKDC form (OR, 1.27; 95% CI, 1.11-1.52) and Lysholm scale (OR, 1.08; 95% CI, 1.00-1.16). Medial meniscal injuries, older age, and white race were also associated with a decreased likelihood for achieving the MCID., Conclusion: Preoperative SF-12 MCS and PCS scores were predictive of RTP after ACLR; patients scoring above 42.3 on the SF-12 PCS and 48.3 on the SF-12 MCS were more likely to achieve RTP. Additionally, we defined the MCID after ACLR and found that higher SF-12 MCS scores were predictive of achieving the MCID on knee-specific questionnaires.

Anterior cruciate ligament (ACL) tears are common in athletes. Techniques and methods of treatment for these injuries continue to vary among surgeons. Thirty National Basketball Association (NBA) team physicians were surveyed during the NBA Pre-Draft Combine. Survey questions involved current and previous practice methods of primary and revision ACL reconstruction, including technique, graft choice, rehabilitation, and treatment of combined ACL and medial collateral ligament injuries. Descriptive parametric statistics, Fisher exact test, and logistic regression were used, and significance was set at α = 0.05. All 30 team physicians completed the survey. Eighty-seven percent indicated they use autograft (81% bone-patellar tendon-bone) for primary ACL reconstruction in NBA athletes, and 43% indicated they use autograft for revision cases. Fourteen surgeons (47%) indicated they use an anteromedial portal (AMP) for femoral tunnel drilling, whereas 5 years earlier only 4 (13%) used this technique. There was a significant (P = .009) positive correlation between fewer years in practice and AMP use. NBA team physicians' use of an AMP for femoral tunnel drilling has increased over the past 5 years.

Purpose: The purpose of this study was to objectively evaluate the anatomic and biomechanical outcomes of anterior cruciate ligament (ACL) reconstruction with transtibial versus anteromedial portal drilling of the femoral tunnel., Methods: Ten human cadaveric knees (5 matched pairs) without ligament injury or pre-existing arthritis underwent ACL reconstruction by either a transtibial or anteromedial portal technique. A medial arthrotomy was created in all cases before reconstruction to determine the center of the native ACL tibial and femoral footprints. A 10-mm tibial tunnel directed toward the center of the tibial footprint was prepared in an identical fashion, starting at the anterior border of the medial collateral ligament in all cases. For transtibial femoral socket preparation (n = 5), a guidewire was placed as close to the center of the femoral footprint as possible. With anteromedial portal reconstruction (n = 5), the guidewire was positioned centrally in the femoral footprint and the tunnel drilled through the medial portal in hyperflexion. An identical graft was fixed and tensioned, and knee stability was assessed with the following standardized examinations: (1) anterior drawer, (2) Lachman, (3) maximal internal rotation at 30°, (4) manual pivot shift, and (5) instrumented pivot shift. Distance from the femoral guidewire to the center of the femoral footprint and dimensions of the tibial tunnel intra-articular aperture were measured for all specimens. Statistical analysis was completed with a repeated-measures analysis of variance and Tukey multiple comparisons test with P ≤ .05 defined as significant., Results: The anteromedial portal ACL reconstruction controlled tibial translation significantly more than the transtibial reconstruction with anterior drawer, Lachman, and pivot-shift examinations of knee stability (P ≤ .05). Anteromedial portal ACL reconstruction restored the Lachman and anterior drawer examinations to those of the intact condition and constrained translation with the manual and instrumented pivot-shift examinations more than the native ACL (P ≤ .05). Despite optimal guidewire positioning, the transtibial technique resulted in a mean position 1.94 mm anterior and 3.26 mm superior to the center of the femoral footprint. The guidewire was positioned at the center of the femoral footprint through the anteromedial portal in all cases. The tibial tunnel intra-articular aperture was 38% larger in the anteroposterior dimension with the transtibial versus anteromedial portal technique (mean, 14.9 mm v 10.8 mm; P ≤ .05)., Conclusions: The anteromedial portal drilling technique allows for accurate positioning of the femoral socket in the center of the native footprint, resulting in secondary improvement in time-zero control of tibial translation with Lachman and pivot-shift testing compared with conventional transtibial ACL reconstruction. This technique respects the native ACL anatomy but cannot restore it with a single-bundle ACL reconstruction. Eccentric, posterolateral positioning of the guidewire in the tibial tunnel with the transtibial technique results in iatrogenic re-reaming of the tibial tunnel and significant intra-articular aperture expansion., Clinical Relevance: Anteromedial portal drilling of the femoral socket may allow for improved restoration of anatomy and stability with ACL reconstruction compared with conventional transtibial drilling techniques., (Copyright © 2011 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Knee joint infection is a potentially devastating complication of anterior cruciate ligament (ACL) reconstruction. There is a theoretical increased risk of infection with the use of allograft material., Hypothesis: An allograft ACL reconstruction predisposes patients to a higher risk of bacterial infection., Study Design: Cohort Study; Level of evidence, 3., Methods: All primary ACL reconstructions performed at our institution between January 2002 and December 2006 were reviewed; 3126 total procedures were identified. A retrospective medical record review was performed to determine the incidence of infection, offending organism, time after surgery until presentation, infection treatment, and graft salvage as an outcome of graft choice., Results: Of the 3126 ACL reconstructions, 1777 autografts and 1349 allografts were performed. Eighteen infections were identified (0.58%). Infections occurred in 6 of the 1349 allografts (0.44%), 7 of the 1430 bone-patellar tendon-bone (BPTB) autografts (0.49%), and 5 of the 347 hamstring autografts (1.44%). Five grafts were removed because of graft incompetence or loosening: 3 hamstring tendon, 1 BPTB, and 1 allograft. The most common organism isolated was Staphylococcus aureus. Hamstring tendon autograft had an increased incidence of infection compared with both BPTB autograft and allograft (P <.05), with a trend toward a more common need for graft removal (P = .09). Allograft reconstructions were equally likely to have graft salvage as autograft reconstructions., Conclusion: Hamstring tendon autografts have a higher incidence of infection than BPTB autografts or allografts. The use of allograft material in ACL reconstructions does not increase the risk of infection or the need for graft removal with infection.

The shoe-surface interface has been implicated as a possible risk factor for anterior cruciate ligament (ACL) injuries. The purpose of this study is to develop a biomechanical, cadaveric model to evaluate the effect of various shoe-surface interfaces on ACL strain. There will be a significant difference in ACL strain between different shoe-surface combinations when a standardized rotational moment (a simulated cutting movement) is applied to an axially loaded lower extremity. The study design was a controlled laboratory study. Eight fresh-frozen cadaveric lower extremities were thawed and the femurs were potted with the knee in 30 deg of flexion. Each specimen was placed in a custom-made testing apparatus, which allowed axial loading and tibial rotation but prevented femoral rotation. For each specimen, a 500 N axial load and a 1.5 Nm internal rotation moment were placed for four different shoe-surface combinations: group I (AstroTurf-turf shoes), group II (modern playing turf-turf shoes), group III (modern playing turf-cleats), and group IV (natural grass-cleats). Maximum strain, initial axial force and moment, and maximum axial force and moment were calculated by a strain gauge and a six component force plate. The preliminary trials confirmed a linear relationship between strain and both the moment and the axial force for our testing configuration. In the experimental trials, the average maximum strain was 3.90, 3.19, 3.14, and 2.16 for groups I-IV, respectively. Group IV had significantly less maximum strain (p<0.05) than each of the other groups. This model can reproducibly create a detectable strain in the anteromedial bundle of the ACL in response to a given axial load and internal rotation moment. Within the elastic range of the stress-strain curve, the natural grass and cleat combination produced less strain in the ACL than the other combinations. The favorable biomechanical properties of the cleat-grass interface may result in fewer noncontact ACL injuries.

Objective: To evaluate magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) in detecting soft tissue, neurovascular, and bony injury after multiple ligament knee injury, including knee dislocation., Materials and Methods: A retrospective search was performed for patients presenting with reported knee dislocation from May 1993 through May 2000 who underwent both MRI and surgical reconstruction. Twenty-one patients met these criteria (15 men and six women; age range 14 to 75 years; mean 32.6 years). Magnetic resonance diagnoses of soft tissue and bony injury were compared with the patients' operative findings. MRA of the popliteal vessels was performed in seventeen of our twenty-one patients, and the results of these studies are described., Results: Multiple ligamentous, tendinous, meniscal, chondral, osseous, and neural injuries were seen. There was excellent correlation (kappa > 0.8) between the magnetic resonance and operative findings with regard to the size and location of tears. Regarding meniscal tears, the type (e.g., bucket, radial split, meniscocapsular separation) and location correlated well with surgery. All ten nerve injuries noted on magnetic resonance were confirmed at surgery. Six of our patients had both conventional angiograms and MRAs with 100 percent agreement between the studies. In one patient an intimal flap in the popliteal artery was seen on MRA and confirmed on conventional angiographic images., Conclusion: MRI is an accurate method of assessing soft tissue, osseous, and neural damage after knee dislocation. Our early experience with popliteal fossa MRA is encouraging with complete agreement between the MRA and conventional angiography in patients who had both studies.

The effect of iliotibial band "lateral sling" augmentation on long-term outcome in ACL reconstruction using free autogenous central-third patellar tendon was evaluated retrospectively. Eighty reconstructions were reviewed; the minimum followup was 2 years and the average was 4 years. Sixty percent of the procedures involved supplementation with a lateral sling. By both clinical evaluation and KT-1000 measurement, there were no differences in the results of patients with lateral sling augmentation and those without it. In addition, 40% of patients had chronic pain and/or swelling related to the lateral sling. We do not currently recommend the routine use of a lateral sling augmentation for ACL reconstruction using central-third patellar tendon.