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Objective: This study aimed to identify risk factors contributing to the early onset of patellofemoral osteoarthritis (PFOA) within the first two years following anterior cruciate ligament reconstruction (ACLR) using a hamstring tendon autograft., Methods: Participants aged 18 to 40 who had undergone ACLR within the past two years were included in this study, along with a control group of healthy volunteers. Magnetic resonance imaging (MRI) data were obtained preoperatively, at two years postoperatively, and from the control group. T-tests were used to assess differences in patellofemoral alignment (PA) and trochlear morphology (TM) between the pre- and post-ACLR patients and healthy controls. The incidence of PFOA was recorded, and associations between PA, TM, and clinical parameters were evaluated in patients with and without PFOA. Logistic regression analysis was conducted to identify potential risk factors for PFOA development., Results: A total of 177 patients, with a mean follow-up period of 22.17 ± 5.09 months and a mean age of 26.4 ± 5.6 years, were included in the study. Following ACL injury, significant alterations in patellar tilt angle (PTA), tuberositas tibae-trochlear groove distance (TT-TG), Insall-Salvati ratio (ISR), and static anterior tibial translation (SATT) were observed compared to the control group. Postoperatively, deviations in PTA and SATT remained significant when compared to healthy controls. Of the 177 patients, 68 (38.42%) developed early-onset PFOA. Factors associated with the early onset of PFOA included age at the time of surgery, the interval between injury and surgery, PTA, bisect offset (BO), sulcus angle (SA), thigh circumference, SATT, and partial meniscectomy., Conclusion: Significant differences in PTA, TT-TG, ISR, and SATT were identified between patients who underwent ACLR and healthy controls. Postoperatively, there was no correction in PTA or SATT, which remained significantly altered. Factors such as age at the time of surgery, PTA, BO, SA, ISR, SATT, thigh circumference, partial meniscectomy, and the time interval between injury and surgery were associated with the early onset of PFOA within two years post-ACLR. These findings may aid in the prevention of PFOA by identifying individuals at higher risk for early development., (© 2024. The Author(s).)

Muscle weakness following anterior cruciate ligament reconstruction (ACLR) increases the risk of posttraumatic osteoarthritis (OA). However, focusing solely on muscle weakness overlooks other aspects like muscle composition, which could hinder strength recovery. Intramuscular fat is a non-contractile element linked to joint degeneration in idiopathic OA, but its role post-ACLR has not been thoroughly investigated. To bridge this gap, we aimed to characterize quadriceps volume and intramuscular fat in participants with ACLR (male/female = 15/9, age = 22.8 ± 3.6 years, body mass index [BMI] = 23.2 ± 1.9, time since surgery = 3.3 ± 0.9 years) and in controls (male/female = 14/10, age = 22.0 ± 3.1 years, BMI = 23.3 ± 2.6) while also exploring the associations between intramuscular fat and muscle volume with isometric strength. Linear mixed effects models assessed (I) muscle volume, (II) intramuscular fat, and (III) strength between limbs (ACLR vs. contralateral vs. control). Regression analyses were run to determine if intramuscular fat or volume were associated with quadriceps strength. The ACLR limb was 8%-11% smaller than the contralateral limb (p < 0.05). No between-limb differences in intramuscular fat were observed (p = 0.091-0.997). Muscle volume but not intramuscular fat was associated with strength in the ACLR and control limbs (p < 0.001-0.002). We demonstrate that intramuscular fat does not appear to be an additional source of quadriceps dysfunction following ACLR and that muscle size only explains some of the variance in muscle strength., (© 2024 Orthopaedic Research Society.)

We report a case of a 12-years-old boy that underwent anterior cruciate ligament (ACL) reconstruction and lateral meniscus repair. The all-epiphyseal, all-inside technique, with quadriceps tendon autograft and adjustable suspensory button fixation was utilized due to the open physes. Intraoperative fluoroscopy confirmed optimal position of the buttons, while arthroscopic evaluation of the graft showed proper tension, with full range of motion and knee stability. Nevertheless, routine radiographic evaluation of the knee, 6 ​h postoperatively, revealed tibial button migration through the tunnel into the knee joint, while the knee was unstable in clinical examination. The graft was removed and reloaded with extended buttons. The femoral socket was retained in the revision surgery while a new tibial socket was drilled with the transphyseal technique (all-inside technique). The postoperative course was uneventful. The patient returned to unrestricted activities at twelve months after revision surgery and remains fully active two years postoperatively. This is the first case of tibial button migration reported in the literature, with immediate migration after surgery, intra-articular position of the button and negative impact on graft tension. Failure to recognize and treat this detrimental complication could be catastrophic for the knee. The technique of the surgical treatment is also described. Surgeons should be aware of this rare complication, that could adversely affect the clinical outcome., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Nikolaos Koukoulias reports a relationship with Smith and Nephew Inc that includes: consulting or advisory. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: To compare the anterior and posterior trans-septal (TS) portal approaches in anterior cruciate ligament reconstruction (ACLR) by evaluating femoral tunnel positioning and passive anterior tibial subluxation (PATS)., Methods: A total of 205 patients who underwent primary ACLR using the outside-in technique between March 2018 and December 2021 were retrospectively enrolled. Patients were classified into two groups based on the viewing techniques: the anterior group was treated using anteromedial or anterolateral portals (n = 155), and the TS group was treated using posterior TS portal (n = 55). The relative locations of the femoral tunnel were evaluated using the deep-shallow planes (X-axis) and superior-inferior planes (Y-axis) with the quadrant method in the lateral femoral condyle on a 3-dimensional computed tomography image. Anterior tibial subluxation for the lateral and medial compartments relative to the femoral condyles was evaluated as measured on magnetic resonance imaging. Knee laxity was assessed using the pivot-shift test and stress radiography., Results: In the posterior TS group, the femoral tunnel was usually located deeper on the X-axis and more superior on the Y-axis, which corresponds to a more proximal position, than in the anterior group (deeper on the X-axis and superior on the Y-axis). Moreover, the femoral tunnel locations in this group were more compactly distributed than those in the anterior group. The TS group showed significantly better reduction of postoperative PATS in the lateral compartments than the anterior group (anterior group vs. TS group: lateral compartment, 3.2 ± 3.1 vs. 4.5 ± 3.2 mm; p = .016). Significantly better results were found in the TS group for knee stability as assessed by the pivot-shift grade (p = .044); however, there were no significant differences between the two groups with respect to patient-reported outcome measures (p > .05) and other complications (p = .090)., Conclusion: Our results suggest that positioning the femoral tunnel using the posterior TS portal approach may lead to better outcomes in terms of PATS and rotational stability compared to the anterior portal approach in ACLR., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

Infection after anterior cruciate ligament reconstruction (ACLR) is a rare and catastrophic postoperative complication. The aims of this study were to investigate the diagnostic, treatment and rehabilitation measures for postoperative infection following after ACLR. A retrospective study was conducted on 1500 patients who underwent ACLR between January 2011 and January 2022. Twenty patients who met the criteria for summarizing the incidence patterns and treatment experiences were selected for a complete investigation of their diagnostic, therapeutic, and rehabilitation processes, as well as outpatient follow-up results. Among the 20 patients who developed postoperative infections, Staphylococcus aureus was the main pathogen (80%). The clinical manifestations mainly included fever (80%) and knee joint pain (100%). Laboratory tests demonstrated that C-reactive protein (CRP) levels were greater than 50 mmol/L in fifteen patients (75%). All of the patients received intravenous antibiotic therapy. Five patients (25%) of tendon socket infection were treated with continuous negative pressure suction irrigation, whereas the other fifteen patients with intra-articular infection were treated with arthroscopic debridement and continuous flushing. The Lysholm score of the affected knee was compared before treatment and 6 months after treatment, and the difference was statistically significant (t = 20.78, P < 0.001). The success rate of treatment was 100%, and there were no significant differences between patients who received secondary treatment and functional exercise and those who underwent ACLR in terms of knee joint function or range of motion during the same time period. Infection was rare after ACLR, however it was fatal, and the main pathogen was Staphylococcus aureus. Early diagnosis and a comprehensive treatment approach are pivotal for the successful management of postoperative infections following ACLR. The results of this study contribute valuable clinical insights for further refining surgical procedures, enhancing infection prevention measures, and optimizing rehabilitation protocols., (© 2024. The Author(s).)

The purpose of this study was to systematically review and meta-analyze randomized controlled trials (RCTs) reporting the comparative clinical and functional outcomes, postoperative complications, and radiological outcomes of single-bundle anterior cruciate ligament reconstruction (ACLR) performed using the transtibial (TT) approach or anteromedial (AM) technique. A systematic review of the literature was performed according to Cochrane and PRISMA guidelines. RCTs comparing TT and AM techniques were considered only. The quality of the studies was defined using the GRADE system, and the risk of bias was assessed with the RoB 2 tool. The primary endpoint was to systematically review and meta-analyze the clinical outcomes, residual laxity and failure rate of both AM and TT techniques. In the current meta-analysis 13 RCTs involving 989 patients who underwent arthroscopic single-bundle ACLR (486 TT and 503 AM) were included. Patients undergoing AM technique resulted in higher objective-IKDC (p < 0.001) and Lysholm scores (p = 0.002), despite a lower incidence of pathological anterior tibial translation (p < 0.001) and positive pivot-shift test (p < 0.001). No differences were detected in IKDC subjective score (p = 0.26), Tegner activity scale (p = 0.18) and graft failure (p = 0.07). ACL reconstruction through AM portal technique provides better clinical outcomes and lower incidence of residual rotational and anteroposterior laxity in comparison with the TT technique. No statistically significant difference in subjective outcomes and graft failure was reported., (© 2024. The Author(s), under exclusive licence to Istituto Ortopedico Rizzoli.)

Many studies have reported the risk factors associated with primary anterior cruciate ligament (ACL) injury. However, few studies have focused on the bony morphology of secondary ipsilateral injury after ACL reconstruction. This study aimed to investigate the morphological risk factors of the proximal tibia contributing to secondary ipsilateral injury after ACL reconstruction. Twenty patients who were selected from secondary ipsilateral injury after ACL reconstruction between January 2015 and May 2020 were included in the secondary injury group. They were matched in a 1:2 ratio to the control group, which underwent primary ACL reconstruction during the same period and did not experience reinjury at the minimum 2-year follow-up, based on age, gender, and body mass index. All parameters, including medial tibial posterior slope, lateral tibial posterior slope (LTPS), medial tibial plateau depth, and lateral tibial plateau height, were recorded by using magnetic resonance imaging. Binary logistic regression analysis and receiver operator characteristic curves were conducted to explore the risk factors for reinjury and determine the cutoff value for the significant parameter. The LTPS was significantly larger in the secondary injury group than in the control group (9.6 ± 1.5° to 7.0 ± 1.4°, P < .001), and there was no significant difference in the medial tibial posterior slope, medial tibial posterior slope, and lateral tibial plateau height between the 2 groups (P > .05). The LTPS was found to be an independent risk factor for secondary ipsilateral injury after ACL reconstruction (odds ratio = 3.220, 95% confidence interval = 1.904-5.446, P < .001). The cutoff value of the LTPS was 8.8°, with a sensitivity of 91.7% and a specificity of 81.2%. The LTPS could be a unique predictor of secondary ipsilateral injury after ACL reconstruction. Orthopedists should implement effective measurements during primary reconstruction when the LTPS is >8.8°., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Anterior cruciate ligament (ACL) graft failure is influenced by factors such as meniscal tears and tibial plateau slope. Combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction has reduced failure rates; however, its efficacy in high-risk patients remains unclear. This study hypothesized that combined ACL and ALL reconstruction would yield similar clinical outcomes in patients with varying risks of ACL failure., Patients and Methods: A total of 76 patients who underwent primary single-bundle ACL reconstruction combined with ALL reconstruction between June 2018 and June 2021 were included. The medial tibial slope (MTS), lateral tibial slope (LTS), and anterior tibial translation (ATT) were measured using magnetic resonance imaging and plain radiography of the knee joint. The meniscal lesions were assessed during surgery. Preoperative clinical assessments and final follow-up were conducted using patient-reported outcome measurements (PROMs), including the International Knee Documentation Committee (IKDC) evaluation, Lysholm knee scoring scale, and Tegner Activity scale. PROMs were collected at least two years postoperatively., Results: The average follow-up was 32.5 ± 7.4 months. There were no significant differences in postoperative IKDC score, Lysholm score, or Tegner activity score between patients with or without medial meniscus injury (p = 0.155, 0.914, and 0.042, respectively), with or without lateral meniscus injury (p = 0.737, 0.569, and 0.942, respectively), medial tibial slope > 12° or ≤ 12° (p = 0.290, 0.496, and 0.988, respectively), or lateral tibial slope > 7.4° or ≤ 7.4° (p = 0.213, 0.625, and 0.922, respectively). No significant correlations were found between anterior tibial translation and postoperative IKDC (R = -0.058, p = 0.365), Lysholm (R = -0.017, p = 0.459), or Tegner activity scores (R = -0.147, p = 0.189)., Conclusion: Our study demonstrates that single-bundle ACL reconstruction combined with ALL reconstruction provides reliable and comparable clinical outcomes in patients with high-risk factors for ACL graft failure, such as increased tibial slope or meniscal injury. Our results suggest that the indications for ALL reconstruction may be expanded to include patients with a high tibial slope or meniscal injury, because these factors have been shown to contribute to increased rotational instability and high rates of ACL graft failure. Future prospective randomized controlled trials with large patient cohorts and long follow-up periods are needed to validate these findings and establish clear guidelines for patient selection and surgical decision-making., Level of Evidence: Level 3., (© 2024. The Author(s).)

Background: The reported incidence of posttraumatic knee osteoarthritis (PTOA) after primary anterior cruciate ligament reconstruction (ACLR) varies considerably. Further, there are gaps in identifying which patients are at risk for PTOA after ACLR and whether there are modifiable factors., Purpose: To (1) determine the incidence of PTOA in a primary ACLR cohort and (2) identify patient and perioperative factors associated with the development of PTOA after primary ACLR., Study Design: Cohort study; Level of evidence, 3., Methods: Data from the Kaiser Permanente ACLR Registry were used to conduct a cohort study. Patients who had undergone primary ACLR without a previous diagnosis of osteoarthritis were identified (2009-2020). The crude incidence of PTOA was calculated using the Aalen-Johansen estimator with a multistate model. The association of patient and operative factors with the development of PTOA after primary ACLR was modeled as a time to event using multistate Cox proportional hazards regression. Models stratified by age (<22 and ≥22 years) were also conducted because of the effect modification of age., Results: The study sample included 41,976 cases of primary ACLR. The incidence of PTOA was 1.7%, 5.1%, and 13.6% at 2, 5, and 10 year follow-ups, respectively. Risk factors for PTOA that were consistently identified in the overall cohort and age-stratified groups included a body mass index ≥30 versus <30 and an allograft or quadriceps tendon autograft versus a hamstring tendon autograft. Patients presenting with knee pain after ACLR were further identified when considering postoperative factors. Other risk factors for PTOA in the overall cohort included age ≥22 versus <22 years, bone-patellar tendon-bone autograft versus hamstring tendon autograft, hypertension, cartilage injury, meniscal injury, revision after primary ACLR with concomitant meniscal/cartilage surgery, multiligament injury, other activity at the time of injury compared with sport, and tibial tunnel drilling technique rather than the anteromedial portal., Conclusion: Knee pain after ACLR may be an early sign of PTOA. Surgeons should consider the adverse associations of a higher body mass index and an allograft or quadriceps tendon autograft with the development of PTOA, as these were factors identified with a higher risk, regardless of a patient's age at the time of primary ACLR., Competing Interests: The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Introduction: Peroneus longus has proved to be a promising graft for ACL reconstruction due to its high tensile strength, and ease of harvesting. While multiple studies have assessed the functional outcomes of the knee after ACL reconstruction using peroneus longus autograft, we aimed to evaluated donor site morbidity among the Indian population., Matreials and Methods: This was a prospective, longitudinal, descriptive study conducted at a tertiary care hospital. Preoperative AOFAS and Karlsson-Peterson scores were obtained, and patients were followed up after surgery for a period of 6-months using the same scoring systems and strength testing with a hand-held Chatillon MSE-100-M dynamometer. Pedobarographs were done using Diers Pedoscan Plantar Pressure Measurement System on a subset of seven patients., Results: 20 patients participated in the study. Mean AOFAS and Karlsson-Peterson scores pre-operatively were 99.7 ± 1.34 and 98.5 ± 4.62 respectively. On completing 6- months of follow-up these scores were found to be 95.6 ± 9.43 and 88.75 ± 18.42 respectively. Deterioration of mean evertor strength was noted at all follow-ups compared to the opposite side. Static pedobarographs showed significant decreased in total surface area of contact and pressure over the posterior aspect of the operated side by 3-months which improved later at 6-months. Dynamic pedobarographs showed decreased mean average plantar pressure while walking on the operated side and significant increase in mean surface area of contact of the operated side (191.886±22.678 cm 2 ) at 6-months of follow-up compared to the opposite side (184.471 ± 22.218 cm 2 ). Five patients showed deviation of the point of maximum pressure while walking on the operated foot making it lateral to the COP with increased lateral plantar/ medial plantar pressure ratio., Conclusion: While the use of peroneus longus tendon autografts in arthroscopic ACL reconstruction does not seem problematic on short-term subjective assessment, there is objective evidence in keeping with evertor weakness, weakness of first ray plantar flexion and possible ankle instability., Level of Evidence: Level lll., (© 2024. Crown.)

Background and Objectives : Although previous reports have shown that early anterior cruciate ligament (ACL) reconstruction is associated with an increased risk of stiffness, recommendations for delayed surgery are based on outdated literature. The advent of arthroscopic surgery and accelerated rehabilitation protocols warrants a reexamination of the optimal surgical timing. The purpose of this study was to investigate complications during early ACL reconstruction after injury in young athletes. Materials and Methods : A total of 87 patients (27 males and 60 females) were included in this study. Patients who underwent anatomic ACL reconstruction using hamstring autografts were evaluated. Patients under 25 years of age with a Tegner activity score greater than 6 were included and classified into three groups according to the time from injury to surgical treatment: one week from injury to surgery (early group), three to six weeks from injury to surgery (normal group), and three to six months from injury to surgery (delayed group). We evaluated the rates of various complications such as graft rupture, contralateral injury, the need for manipulation for loss of ROM, infection, and fracture around the knee up to 2 years postoperatively. In addition, we investigated postoperative muscle strength, Lysholm score, Tegner activity score, and period of the return to sport from injury. Results: Patients in the delayed group were younger than those in the other groups ( p = 0.009). Patients in the early group had a lower range of motion than those in the other groups preoperationly. However, the 1-month postoperative range of motion was comparable between groups. Patients in the early group had greater postoperative Tegner activity scores than those in the other groups. The period of return to sport from injury in the delayed group was longer than in the other groups. There were no statistically significant differences in the postoperative complication rate, muscle strength, or Lysholm score. Conclusions : ACL reconstruction performed 1 week from injury to surgery in young athletic patients indicated the rate of complications were not significantly different among the groups. Early ACL reconstruction with no postoperative complications may be related to early return to sports and a high level of sports.

Background: We investigated whether double-bundle (DB) anterior cruciate ligament (ACL) reconstruction (ACLR) combined with anterolateral ligament reconstruction (ALLR) improved clinical and radiological outcomes in patients at high risk of ACL failure. The primary outcome was graft failure, and secondary outcomes included knee stability and patient-reported outcome measures (PROMs)., Patients and Methods: Fifty-two patients who underwent DB ACLR combined with ALLR were included in this retrospective cohort study. Preoperative risk factors, including femorotibial angle (FTA), lateral tibial slope (LTS), medial tibial slope (MTS), and meniscal tears, were assessed using X-ray and magnetic resonance imaging (MRI). The grade of post-operative pivot shift, Lysholm score, and Tegner activity score were used to assess clinical outcomes. The minimum follow up duration was 2 years., Results: The cohort (mean age, 26.1 ± 9.4 years; 51.9% male) had a mean follow-up duration of 28.9 ± 3.4 months. Preoperatively, 57.8% had lateral meniscus (LM) tears, and 61.0% had a grade 2-3 pivot shift. Postoperatively, no graft failures or revision cases occurred during follow-up. Approximately 90.4% of the patients exhibited a negative pivot shift (p < 0.001), with Lysholm and Tegner activity scores of 92.5 ± 6.1 and 5.1 ± 2.0. The medial meniscus (MM) tear group had a significantly smaller FTA than the intact group (p = 0.043). No significant differences in PROMs were found between the LM tear and intact LM groups or between the high and low MTS or LTS groups (p = n.s.)., Conclusion: DB ACLR combined with ALLR had satisfactory clinical outcomes in patients at high risk of ACL failure, with no graft failures observed during a mean follow-up duration of 2.4 years. The technique effectively reduced the postoperative pivot shift, regardless of preoperative risk factors., Study Design: Level IV, retrospective therapeutic case-series., Trail Registration: ethical approval number, 202300134B0; ethical committee, the Institutional Review Board of Chang Gung Medical Foundation., (© 2024. The Author(s).)

Purpose: This study aims to evaluate the long-term outcomes of saphenous nerve (SN) injuries from hamstring tendon harvesting during ACL reconstruction, focusing on clinical results and patient satisfaction after at least two years. Additionally, it investigates the incidence, recovery patterns, and impact of these injuries on functional outcomes, daily activities, and ACL re-rupture rates immediately post-surgery and at final follow-up., Materials and Methods: A retrospective review was conducted on patients who had undergone ACL reconstruction with hamstring tendon grafts at a single institution between January 2015 and January 2020. The incidence of SN injuries was assessed immediately after surgery and at final follow-up. Additionally, the recovery rate and time were evaluated, and the impact of these injuries on functional outcomes was measured using the Lysholm Knee Score (LKS) and patient-reported effects on daily activities., Results: Of the 159 patients analyzed, iatrogenic SN injuries were initially observed in 87 (54.7%) patients post-ACLR. By the final follow-up, paresthesia had resolved in 36 (22.6%) patients within an average of 11.1 months. Persistent SN injuries were recorded in 51 (32.1%) patients, affecting various extents of the infrapatellar branch (IPBSN) and the sartorial branch (SBSN) of the saphenous nerve. Patients with persistent SN injuries experienced a significant impact on daily activities and had lower LKS scores compared to those without injuries or with recovered injuries. Furthermore, a higher re-rupture rate was associated with persistent SN injuries., Conclusions: The study finds that SN injuries during hamstring graft harvesting for ACL reconstruction are common, with a significant portion of patients experiencing persistent sensory deficits for at least two years postoperatively. These injuries are observed to adversely affect patient satisfaction and functional outcomes and to increase the re-rupture rate., (© 2024. The Author(s).)

Background: Anterior cruciate ligament (ACL) injuries are common among physically active individuals, and obesity may increase the risk of such injuries due to factors like biomechanical stress on the knee. We aimed to determine if obesity affects postoperative outcomes after ACL reconstruction., Methods: Data from adults aged 20 years and older with ACL injuries who underwent inpatient reconstruction from 2005 to 2018 were extracted from the United States (US) Nationwide Inpatient Sample (NIS) database. Patients were divided into two groups based on the presence of co-existing obesity, defined as a body mass index (BMI) ≥ 30 kg/m 2 . Propensity-score matching (PSM) was employed to balance between-group differences. Associations between obesity and concomitant meniscus injury, length of stay (LOS), post-procedural complications, and non-routine discharge were examined using univariate and multivariable logistic and linear regressions., Results: After PSM, data from 1323 patients (representing 6396 individuals in the US) were analyzed. Of these, 441 (33%) were classified as obese, while 882 (67%) were not obese. After adjustment, obesity was significantly associated with a longer LOS (adjusted beta (aBeta) = 0.32, 95% confidence interval (CI) 0.31-0.321) and an increased likelihood of non-routine discharge (adjusted OR (aOR) = 2.18, 95% CI 1.47-3.22). There were no significant associations between obesity and concomitant meniscus injury (aOR = 1.04, 95% CI 0.81-1.32) or post-procedural complications (aOR = 0.97, 95% CI 0.74-1.27)., Conclusions: In patients undergoing ACL reconstruction in the US, obesity is independently associated with a longer LOS and a higher risk of non-routine discharge. Nevertheless, obesity does not appear to be associated with concomitant meniscus injury or post-procedural complications., (© 2024. The Author(s).)

Case: A 14-year-old adolescent girl and 18-year-old man underwent right anterior cruciate ligament (ACL) reconstruction using quadriceps tendon (QT) autografts via partial-thickness harvest. While both patients initially recovered well, later they experienced a painful snapping in their knee localized to the lateral QT, just proximal to the patella. Surgical completion of the previous partial-thickness defect with imbrication provided resolution of symptoms at 4 and 9 months postoperatively, respectively., Conclusion: We present a snapping QT as a rare complication of partial-thickness QT harvest for ACL reconstruction. Surgical completion of the partial-thickness defect with imbrication resolved the snapping sensation in these two cases., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C394)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Objective: To report opioid prescription patterns after pediatric anterior cruciate ligament reconstruction (ACLR) and identify if the implementation of the opioid prescribing guidelines (OPGs) modified these patterns., Design: A retrospective chart review., Setting: Level 1 Pediatric Trauma Center., Patients: Pediatric patients who underwent primary ACLR at a single pediatric hospital system between the years 2016 and 2018 were included. Patients were excluded if they did not receive an opioid prescription from an orthopedic provider at the time of discharge or if they underwent an additional operative procedure within 90 days of the index surgery. Eighty-six patients met the criteria for a retrospective review., Interventions: Opioid prescriptions were converted into morphine equivalent doses (MEDs) for standardization., Main Outcome Measure: The average MED prescribed at the time of discharge and during follow-up visits for pediatric patients undergoing ACLR., Results: Patient's age was the only independent variable that had a significant relationship with discharge MED (p = 0.002) and predicted that MED at discharge increases by 20.7 units [confidence interval = 12.3-29.1] for each increasing year in patient age. Discharge MED prescribed after implementation of the OPG was found to be significantly less than discharge MED prescribed prior to the OPG through Wilcoxon rank-sum test (p < 0.001)., Conclusions: Implementation of the OPG in Ohio led to a significant reduction in opioid doses prescribed to patients at all time points within 90 days of ACLR. However, these guidelines also led to a significant increase in the likelihood that post-OPG patients would receive an additional opioid prescription during follow-up within 90 days of surgery.

Background: Arthrofibrosis is a fibrotic joint disorder resulting in restricted joint motion and pain. Risk factors associated with the development of postoperative arthrofibrosis include female sex, type of graft, and quicker time to reconstruction. These patients have typically benefitted from manipulation under anesthesia or arthroscopic lysis of adhesions. The purpose of this study was to retrospectively review the rate of arthrofibrosis in children and adolescents who previously underwent anterior cruciate ligament (ACL) reconstruction., Materials and Methods: This was a retrospective chart review examining patients 18 years or younger who underwent ACL reconstruction between 2013 and 2023. Data collected included age, body mass index, reconstruction technique, concomitant meniscal or ligamentous pathology, and need for revision surgery for arthroscopic lysis of adhesions vs manipulation under anesthesia., Results: A total of 461 patients 18 years or younger who underwent ACL reconstruction were included in this study. Eighteen (3.90%) patients required reoperation for the development of arthrofibrosis. Skeletally immature patients were found to have a statistically significant lower rate of arthrofibrosis compared with skeletally mature patients (0% vs 4.80%; P =.0184). Patients with a higher weight and body mass index had an increased rate of arthrofibrosis ( P =.0485 and P =.0410, respectively). Graft type did not have a significant impact on arthrofibrosis rates. There were no significant findings in terms of concomitant injuries and rate of arthrofibrosis., Conclusion: Arthrofibrosis developed in 3.90% of patients after ACL reconstruction. Skeletal immaturity may be protective against the development of arthrofibrosis. No association was found between graft type or concomitant knee pathology and arthrofibrosis. [ Orthopedics . 2024;47(4):e161-e166.].

The hamstring tendon (HT) autograft is currently the most widely utilised autograft option for anterior cruciate ligament (ACL) reconstruction. However, recent studies endorse the peroneus longus tendon (PLT) autograft as a viable alternative. To evaluate this, we systematically reviewed randomised controlled trials (RCTs) to compare the efficacy of PLT against HT autografts. Our search encompassed Cochrane, Embase, OVID, PubMed, and Scopus databases for RCTs comparing outcomes of PLT and HT autografts in ACL reconstruction. Primary outcomes included Lysholm and International Knee Documentation Committee (IKDC) scores, while secondary outcomes involved American Orthopaedic Foot and Ankle Society (AOFAS) scores, graft diameters and donor-site complications. Statistical analysis was performed using Review Manager 5.4 (Cochrane Collaboration) and heterogeneity was assessed with I 2 statistics. 683 patients from 6 RCTs were included, with 338 (49.5%) patients treated with PLT autografts. Follow-up ranged from 12 to 30 months. Despite lower preoperative Lysholm scores in the PLT group, no significant differences were observed at 6 and 12 months. Although preoperative and 6-month IKDC scores were lower in the PLT group, no significant differences were found at 12 and 24 months. AOFAS scores showed no significant preoperative difference, but slightly lower scores were noted in the PLT group at 12 or 24 months. There was no significant difference in graft diameter, while donor-site complications were fewer in the PLT group. In summary, the PLT autograft is a promising and non-inferior alternative to the HT autograft, demonstrating equivalent outcomes in patient-reported knee and ankle metrics, comparable graft diameters and fewer donor-site complications., (© 2024. The Author(s).)

Purpose: The early complications of isolated anterior cruciate ligament reconstruction surgery (ACLR) have not been well characterized using large databases. This study aims to characterize incidence, impact, and risk factors for short-term operative complications following elective, isolated ACLR surgery. We hypothesize that demographic and perioperative factors may predict 30-day complications after isolated ACLR., Methods: This case-control analysis of the American College of Surgeons National Surgical Quality Improvement Program Database (2005-2017) used Current Procedural Terminology codes to identify elective, isolated ACLR patients. Patients undergoing concomitant procedures were excluded. Complications were analyzed using bivariate analysis against demographic variables. Multiple stepwise logistic regression was used to identify independent risk factors for morbidity after ACLR., Results: A total 12,790 patients (37.0% female, p = 0.674) were included with a mean age of 32.2 years old (SD 10.7 years, p < 0.001). Mean BMI was 27.8 kg/m 2 (6.5) where 28.9% of patients had a BMI > 30 (p = 0.064). The most common complications were wound-related (0.57%). In cases with complications, there were higher rates of (1.3% vs 0.8%, p = 0.004) prolonged operation (> 1.5 h), higher rate (2.9% vs 1.8%, p = 0.004) of extended length of stay (≥ 1 day), unplanned reoperation (15.8% vs 0.3%, p < 0.001), and unplanned readmission (17.5% vs 0.3%, p < 0.001). Multivariate analysis showed prolonged operative time (p = 0.001), dyspnea (p = 0.008), and non-ambulatory surgery (p = 0.034) to be predictive of any complication. Dependent functional status (p = 0.091), mFI-5 > 0.2 (= 0.173), female sex (p = 0.191), obesity (p = 0.101), and smoking (p = 0.113) were not risk factors for complications., Conclusion: ACLR is associated with low rates of morbidity and readmissions. The most common comorbidities, complications, and predictors of morbidities were identified to aid surgeons in further reducing adverse outcomes of ACLR. Operative time > 1.5 h, dyspnea, and non-ambulatory surgery are predictive of complications., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Complications following anterior cruciate ligament (ACL) reconstruction can be detrimental to a patient's recovery and limit their ability to successfully return to sport. Arthrofibrosis, graft failure, and infection are a few examples of complications that can arise. Therefore, it is important for surgeons to recognize that each step during perioperative surgical decision making can impact patients' risk for such complications. The purpose of this paper is to discuss common complications following ACL reconstruction and how surgeons can avoid or reduce the risk of complications., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To determine if global, central, or peripheral adiposity is associated with prevalent and worsening cartilage lesions following anterior cruciate ligament reconstruction (ACLR)., Methods: In 107 individuals one-year post-ACLR, adiposity was assessed globally (body mass index), centrally (waist circumference), and peripherally (knee subcutaneous adipose tissue thickness) from magnetic resonance imaging (MRI). Tibiofemoral and patellofemoral cartilage lesions were assessed from knee MRIs at 1- and 5-years post-ACLR. Poisson regression evaluated the relation of adiposity with prevalent and worsening tibiofemoral and patellofemoral cartilage lesions adjusting for age, sex, and activity level., Results: The prevalence ratios of adiposity with tibiofemoral (presence in 49%) and patellofemoral (44%) cartilage lesions ranged from 0.99 to 1.03. Adiposity was more strongly associated with longitudinal changes in tibiofemoral (worsening in 21%) and patellofemoral (44%) cartilage lesions. One-unit increase in global (kg/m 2 ), central (cm), and peripheral (mm) adiposity was associated with a higher risk of worsening tibiofemoral cartilage lesions by 17% (risk ratios [95% confidence interval (CI)]: 1.17 [1.09 to 1.23]), 5% (1.05 [1.02 to 1.08]), and 9% (1.09 [1.03 to 1.16]), and patellofemoral cartilage lesions by 5% (1.05 [1.00 to 1.12]), 2% (1.02 [1.00 to 1.04]) and 2% (1.02 [1.00 to 1.04]), respectively., Conclusion: Greater adiposity was a risk factor for worsening cartilage lesions up to 5 years post-ACLR. Clinical interventions aimed at mitigating excess adiposity may be beneficial in preventive approaches for early post-traumatic osteoarthritis., Competing Interests: Conflicts of interest Ali Guermazi is a shareholder of Boston Imaging Core Lab, LLC, and a consultant to Merck Serono, Pfizer, GE Healthcare, Galapagos, Roche and TissueGene; Adam Culvenor is an associate editor of Osteoarthritis and Cartilage. Kay M. Crossley holds a research grant from Levin Health. The team has no other conflicts of interest to declare., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Case: A 35-year-old man sustained a proximal tibia fracture from a low-energy mechanism 1 year after anterior cruciate and medial collateral ligament repairs with suture augmentation (SA). The fracture propagated through both tibial SA anchor sites. Following intramedullary tibial nailing, he returned to his prior level of function., Conclusion: While complications of SA for ligamentous procedures are rare, these techniques are being implemented more frequently and the full complication profile is yet to be determined. Our report documents a new complication and potential risk factors that surgeons should consider when performing SA for multiligament knee surgery in active individuals., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C376)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

A female underwent arthroscopic anterior cruciate ligament reconstruction (ACLR) via an outside-in drilling technique. At 4 weeks after surgery, she presented with a pulsatile painful mass on the lateral femoral condyle. Imaging confirmed a superolateral genicular artery pseudoaneurysm. Thrombin injections were administered twice, resulting in reduced size and minimal pain. This case emphasises the rare occurrence of pseudoaneurysms post-ACLR and highlights the importance of early detection and intervention for vascular complications. Although debated, we suggest tourniquet deflation before closure to facilitate identification and management of vascular issues. This report contributes valuable insights into managing pseudoaneurysms following ACLR., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Risk factors for the development of symptomatic cyclops lesion after anterior cruciate ligament reconstruction (ACLR) surgery are not entirely identified yet. This study aimed to investigate whether the choice of hamstring graft (semitendinosus-gracilis; STG vs. semitendinosus; ST) affects the risk of developing a symptomatic cyclops lesion after ACLR., Methods: This retrospective cohort study included 1416 patients receiving either an ST graft (n = 1209) or an STG graft (n = 207) ACLR with a follow-up of at least 2 years. A persisting extension limitation was clinically determined, and cyclops lesions were confirmed by magnetic resonance imaging (MRI) and second-look arthroscopy. Graft-specific incidence of cyclops lesions was examined with χ 2 test and combined with the factors number of graft bundles, graft diameter and sex evaluated with a binominal logistic regression model., Results: In total, 46 patients developed symptomatic cyclops lesions (3.2%), with 36 having ACLR with an ST graft (3.0%) and 10 with an STG graft (4.8%) (n.s). The mean time from ACLR to the second-look arthroscopy for cyclops removal was 1.1 ± 0.6 years. Female patients were 2.5 times more likely to develop a cyclops lesion than male patients. Patients with an STG graft and larger graft diameters did not have a higher risk of developing cyclops lesions. Patients who received an STG graft with both tendons folded four times (double-quadruple) had significantly higher risk of developing a cyclops compared with all other numbers of graft bundles combined (8.3%, respectively 3.0%; p = 0.014)., Conclusion: This study could not prove an increased risk of developing a symptomatic cyclops lesion for patients with an STG graft compared with an ST graft used for ACLR. However, patients with a double-quadruple ACLR had a higher percentage of cyclops lesions compared with all other numbers of graft bundles. Female sex was associated with an increased risk of developing cyclops lesions., Level of Evidence: Level III., (© 2024 European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Background: The optimal timing of anterior cruciate ligament (ACL) reconstruction (ACLR) remains a controversial topic. Previous reviews have demonstrated that there are no differences between early and delayed ACLR; however, these studies have been limited by heterogeneous definitions of acute ACL injury., Purpose: To evaluate postoperative patient functional outcomes and risk for arthrofibrosis after acute arthroscopic ACLR performed ≤10 days after injury., Study Design: Systematic review; Level of evidence, 4., Methods: A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using multiple medical databases. Inclusion criteria were studies that evaluated postoperative range of motion outcomes for patients undergoing ACLR ≤10 days after initial ACL injury. For included comparative studies comparing patient groups undergoing ACLR ≤10 days and patients undergoing "delayed" ACLR after ≥3 weeks of initial injury, quantitative analysis was performed to assess for differences in postoperative arthrofibrosis, reoperation rates, and patient-reported outcomes between groups. DerSimonian-Laird binary random-effects models were constructed to quantitatively describe the association between the ACLR time period and patient outcomes by generating effect estimates in the form of odds ratios with 95% CIs. Qualitative analysis was performed to describe variably reported patient outcomes and the risk of arthrofibrosis after ACLR for noncomparative studies., Results: Screening yielded 6 full-text articles with 448 patients who underwent ACLR (296 ACLR <10 days, 152 ACLR >3 weeks), with a pooled mean age of 28.1 years. For studies amenable to quantitative analysis, there were no significant differences between ACLR performed ≤10 days and ACLR performed at the 3-week point or after in terms of postoperative stiffness (3 studies; odds ratio, 1.27; P = .508), Tegner scores (2 studies; mean difference, -0.056; P = .155), or reoperation for stiffness (3 studies; odds ratio, 0.869; P = .462). The overall incidence of postoperative arthrofibrosis after 12 months of follow-up was 11 of 296 (3.7%) for ACLRs performed ≤10 days versus 6 of 152 (3.9%) for those performed at the 3-week point or after., Conclusion: ACLR performed ≤10 days after the inciting injury does not increase the risk of postoperative arthrofibrosis and demonstrates similar patient-reported outcomes compared with ACLR performed at the 3-week point or after., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: E.M. has received support for education from Medinc Texas and has a family member employed by Medinc of Texas (Arthrex Inc). J.F.D. has received support for education from Supreme Orthopedic Systems and speaking fees from Arthrex. T.J.D. has received hospitality payments from Zimmer BioMet Holdings, Inc; travel expenses from Arthrex; support for education from Smith & Nephew and CGG Medical; and a grant from DJO. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Introduction: Anterior cruciate ligament (ACL) ruptures are common injuries that typically affect young, physically active individuals and may require surgical reconstruction. Studies have shown that the long time success of ACL reconstruction depends on the surgical technique and the postoperative rehabilitation strategy. However, there is still no consensus on the content of rehabilitation programs. Hence, additional research is required to elucidate the significance of early weight-bearing in the rehabilitation process following ACL reconstruction. The aim of this article is to examine the impact of weight-bearing on the clinical results of ACL reconstruction., Materials and Methods: We retrospectively reviewed patient records who had undergone arthroscopic reconstruction using a semitendinosus-gracilis tendon graft for anterior cruciate ligament rupture between January 2018 and December 2020. The study included the data of 110 patients. The patients were split into two groups: Group 1 underwent early weight-bearing, while Group 2 followed a non-weight-bearing regimen for three weeks. We assessed the patients using the anterior drawer test, Lachman test, range of motion, Lysholm knee scale, Cincinnati scale, Tegner scale, International Knee Documentation Committee (IKDC) form and clinical records. Analytical tests were conducted to compare the results., Results: The complication rates did not show a significant difference between the groups. Group 1 had higher frequencies of positive anterior drawer and Lachman tests. The Lysholm and Cincinnati knee scores of patients in Group 1 were notably lower than those of patients in Group 2. Additionally, the Tegner activity scores and IKDC scores of patients in Group 1 were also meaningfully lower than those of patients in Group 2. In Group 1 patients, there was no notable relationship observed between body mass index (BMI) and the results of the anterior drawer test (ADT) or Lachman test. However, patients with a BMI of 25 or higher in Group 1 showed a decrease in postoperative IKDC scores. In Group 2 patients, no significant relationship was identified between BMI and either the ADT or the Lachman test outcome., Conclusion: Based on current literature and current rehabilitation guidelines following ACL reconstruction, the decision to initiate early weight-bearing is based on a limited number of studies with low levels of evidence. In our study, we found that patients who followed a non-weight-bearing regimen for 3 weeks after surgery had better mid-term results than those who were allowed to bear weight early. It appears that further prospective studies on this topic are needed to update rehabilitation guidelines in the next., (© 2024. The Author(s).)

Background: Enlargement of the bone tunnel has become an unavoidable early complication after anterior cruciate ligament (ACL) reconstruction, whether it is a single or double-bundle ACL reconstruction. Preservation of the ACL stump in ACL reconstruction reduces enlargement of the bone tunnel. The purpose of this study was to investigate the question of whether single-bundle ACL reconstruction using the ACL femoral side retained stump technique reduces enlargement of the femoral tunnel., Methods: Forty patients who underwent single-bundle reconstruction of the ACL were included in this study. The patients were categorized into a Remnant preservation group (Group R) and the Non-remnant preservation group (Group N). In the Remnant preservation group, a high-flexion femoral side retained stump technique was used intraoperatively for the establishment of the femoral side bone tunnel, and in the Non-remnant preservation group, the conventional femoral positioning method was used (we used a femoral positioning drill for localization and drilling of the femoral bone tunnel), and MRI of the operated knee joints was performed at 6 months postoperatively. We measured the internal diameter of the femoral bone tunnel at 5 mm from the intra-articular outlet of the femoral bone tunnel on an MRI scan image perpendicular to the femoral bone tunnel. The size of the tunnel was compared between the intraoperative drilling of the bone tunnel and the size of the bone tunnel at 6 months postoperatively. Postoperative clinical assessment was Lysholm score., Results: After a 6-month follow-up of 40 patients, the diameter of the femoral tunnel at a distance of 5 mm from the inner opening of the femoral tunnel was 10.96 ± 0.67 mm and 10.11 ± 0.62 mm in patients of group N and group R, respectively, and the difference was statistically significant (P < 0.05).The diameter of the femoral tunnel at 6 months postoperatively in group N and group R compared to the intraoperative bone tunnel increased by 2.58 ± 0.24 mm and 1.94 ± 0.31 mm, and the difference was statistically significant (P < 0.05).The femoral tunnel enlargement rates of group N and group R were 30.94 ± 3.00% and 24.02 ± 5.10%, respectively, and the differences were significant (P < 0.05)., Conclusion: ACL femoral side retained stump technique does not sacrifice the ideal location of the femoral tunnel and is able to preserve the possible benefits of the ACL stump: reduced femoral tunnel enlargement., (© 2024. The Author(s).)

Purpose: Non-weight bearing improves and immobilization worsens contracture induced by anterior cruciate ligament reconstruction (ACLR), but effect persistence after reloading and remobilization remains unclear, and the combined effects of these factors on ACLR-induced contracture are unknown. We aimed to determine 1) whether the effects of short-term (2-week) non-weight bearing or immobilization after ACLR on contracture would be sustained by reloading or remobilization during a 10-week observation period, and 2) how the combination of both interventions compared to the outcome of either alone., Methods: We divided 88 ACL-reconstructed male rats into four groups: non-intervention, non-weight bearing, joint immobilization, and both interventions. Interventions were performed for 2 weeks, followed by rearing without intervention. Twelve untreated rats were used as controls. At 2, 4, and 12 weeks post-surgery, we assessed range of motion (ROM) and histological changes., Results: ACLR resulted in persistent loss of ROM, accompanied by synovial shortening, capsule thickening, and osteophyte formation. Two weeks of non-weight bearing increased ROM and reduced osteophyte size, but the beneficial effects disappeared within 10 weeks after reloading. Two-week immobilization decreased ROM and facilitated synovial shortening. After remobilization, ROM partially recovered but remained below non-intervention levels at 12 weeks. When both interventions were combined, ROM was similar to immobilization alone., Conclusions: The beneficial effects of 2-week non-weight bearing on contracture diminished within 10 weeks after reloading. The adverse effects of 2-week immobilization on contracture persisted after 10 weeks of remobilization. The effects of the combined use of both interventions on contracture were primarily determined by immobilization.

Studies are lacking that evaluate early postoperative pain after all-soft-tissue quadriceps tendon anterior cruciate ligament reconstruction (ACLR), particularly in young patients. The purpose of this study was to investigate differences in early postoperative pain between adolescent patients undergoing ACLR with quadriceps tendon versus hamstring autograft. A retrospective review was performed of 60 patients (mean age, 15.6 ± 1.3 years) who underwent ACLR using either quadriceps tendon ( n  = 31) or hamstring ( n  = 29) autografts between January 2017 and February 2020. Intraoperative and postoperative milligram morphine equivalents (MMEs), postanesthesia care unit (PACU) length of stay and PACU pain scores were recorded. Pain scores and supplemental oxycodone use were recorded on postoperative days (POD) 1-3. Differences were compared between the two groups. There were no statistically significant differences in age, sex, body mass index or concomitant meniscus repairs between the two groups ( P  > 0.05). There were no statistically significant differences in intraoperative MMEs, PACU MMEs or PACU length of stay between groups ( P  > 0.05). There were no statistically significant differences in maximum PACU pain scores (3.7 ± 3.0 vs. 3.8 ± 3.2; P  = 0.89). Maximum pain scores on POD 1-3 were similar between groups ( P  > 0.05). There were no statistically significant differences in supplemental oxycodone doses between groups on POD 1-3 ( P  > 0.05). Adolescent patients undergoing ACLR with quadriceps tendon and hamstring autografts have similar pain levels and opioid use in the early postoperative period., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

The prevalence of primary osteoarthritis is higher in females than males. However, it remains unclear if there are sex differences in the incidence of post-traumatic osteoarthritis after anterior cruciate ligament (ACL) reconstruction. In this study, we aimed to investigate the effects of sex on osteoarthritic changes after ACL reconstruction using an animal model. Rats were divided into the following four groups: male control, male ACL reconstruction, female control, and female ACL reconstruction. ACL reconstruction surgery was performed on the right knees of rats in the ACL reconstruction groups, while rats in the control groups did not undergo knee surgery. At 1, 4, and 12 weeks after surgery, cartilage degeneration in the medial tibial plateau and osteophyte formation in the proximal tibia were histologically assessed. After ACL reconstruction, an increase in the Mankin score, cartilage fissures, and osteophyte formation were detected within 12 weeks in both male and female rats, with similar degrees of these changes between males and females. However, changes in cartilage thickness and chondrocyte density after ACL reconstruction differed between males and females. Cartilage thickening was observed in male rats but not in female rats. The increase in chondrocyte density in the anterior region was detected in both males and females but was more pronounced in female rats. In conclusion, osteoarthritic changes were observed after ACL reconstruction in both male and female rats, but differences in changes in cartilage thickness and chondrocyte density were observed between males and females., (Copyright © 2024 Elsevier GmbH. All rights reserved.)

Purpose: The purpose of this study was to investigate the incidence and anatomic distribution of meniscus injury in patients who have sustained acute ACL injuries with and without concomitant Segond fracture. We hypothesized that patients who have sustained a torn ACL with a concomitant Segond fracture would have a higher incidence of lateral meniscal injuries than patients with an isolated ACL injury., Methods: Patients who underwent ACL reconstruction from 2012 to 2022 were retrospectively reviewed. Segond fractures were identified on knee radiographs. Inclusion criteria were age 18-40, injury during sports activity, and reconstruction within 90 days of injury. Sports activity, anatomic location of meniscus injury, and meniscus treatment were documented. Multivariable regression was used to identify predictors of meniscus injury/treatment., Results: There were 25 of 603 (4.1%) patients who had an ACL tear with concomitant Segond fracture. The incidence of lateral meniscus injury in the Segond group (72%) was significantly higher than in the non-Segond cohort (49%; p = 0.024). A significantly smaller proportion of medial meniscus injuries among patients with Segond fractures were repaired (23.1%) compared to the non-Segond group (54.2%; p = 0.043). Multivariate analysis found patients with Segond fractures to have increased odds of lateral meniscus injury (OR 2.68; [1.09, 6.60], p = 0.032) and were less likely to have medial meniscus injuries repaired (OR 0.35; [0.15, 0.81], p = 0.014). Additionally, males had increased odds of lateral meniscus injury (OR 1.54; [1.08 - 2.91], p = 0.017), which were more likely to require repair (OR 1.48; [1.02, 2.14], p = 0.038)., Conclusions: Among acute ACL injuries, the incidence of lateral meniscus injury is greater among patients with Segond fractures. Patients with Segond fracture were less likely to undergo repair of medial meniscal injuries., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

We sought to assess the current literature to present a comprehensive summary of the incidence, common pathogens, and risk factors for infection after anterior cruciate ligament (ACL) reconstruction. PubMed, CINAHL, EMBASE, and Scopus databases were searched for relevant studies reporting on infection after ACL reconstruction. Two reviewers independently screened the extracted studies for adherence to inclusion and exclusion criteria. Studies were selected if they reported on the incidence of infection, pathogens cultured from infected knees, or risk factors for infection after primary ACL reconstruction. Exclusion criteria consisted of studies with fewer than 100 patients or studies that included revision ACL reconstruction. Fifty studies met the inclusion and exclusion criteria, reporting on a total of 316,214 ACL reconstructions. Included studies evaluated between 123 and 104,255 patients. The overall incidence of infection was 0.60% (0.15-2.44%). The most common pathogens were Staphylococcus aureus, S. epidermidis , and coagulase-negative Staphylococci. Five studies reported that the use of hamstring autograft was a statistically significant risk factor for infection after ACL reconstruction, thus making hamstring autograft the most commonly reported risk factor. Other reported risk factors included male sex, use of immuno-suppressive medications or intraarticular steroid injections, prior knee surgery, and diabetes. Systematic review of the literature revealed that infection after ACL reconstruction remains an infrequent event with an incidence of 0.60% (0.15-2.44%). Furthermore, the most common pathogens are from the Staphylococcus genus of bacteria, comprising 84% of all culture-positive infections. Multiple risk factors have been reported for ACL reconstruction; however, statistical significance varied across studies. Together, these findings may help guide physicians in the prevention and treatment of infection after ACL reconstruction., Competing Interests: None declared., (Thieme. All rights reserved.)

Purpose: To determine what patient or surgical factors are associated with an increased risk of arthrofibrosis requiring manipulation under anesthesia (MUA) or lysis of adhesions (LOA) after anterior cruciate ligament reconstruction (ACLR)., Methods: A systematic review was performed in adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Cochrane, Embase, and Medline databases were searched for studies published through February 2023. Inclusion criteria were studies that identified risk factors for MUA and/or LOA after ACLR. Studies investigating arthrofibrosis after multiligamentous knee injuries or ACL repair were excluded., Results: Eleven studies including a total of 333,876 ACLRs with 4,842 subsequent MUA or LOA (1.45%) were analyzed. Increasing age was associated with an increased risk in 3 studies (P < .001, P < .05, P < .01) but was found to have no association another two. Other factors that were identified by multiple studies as risk factors for MUA/LOA were female sex (4 studies), earlier surgery (5 studies), use of anticoagulants other than aspirin (2 studies), and concomitant meniscal repair (4 studies)., Conclusions: In total, 1.45% of the patients who underwent ACLR and were included in this systematic review had to undergo a subsequent MUA/LOA to treat arthrofibrosis. Female sex, older age, earlier surgery, use of anticoagulants other than aspirin, and concomitant meniscal repair were associated with increased risk of MUA/LOA. The modifiable risks, including use of anticoagulants and time between injury and surgery, can be considered when making treatment decisions., Level of Evidence: Level IV, systematic review of Level III-IV studies., Competing Interests: Disclosures The authors report no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material., (Copyright © 2023 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Inconsistent results have been obtained regarding the association between return-to-sport (RTS) testing and the risk of subsequent re-injury following anterior cruciate ligament reconstruction (ACLR). We therefore conducted a systematic review and meta-analysis to assess the potential association between passing of RTS and the risk of re-injury for patients after ACLR., Methods: This meta-analysis was registered in INPLASY with the registration number INPLASY202360027. The electronic databases MedLine, EmBase, and the Cochrane library were systematically searched to identify eligible studies from their inception up to September 2023. The investigated outcomes included knee injury, secondary ACL, contralateral ACL injury, and graft rupture. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using the random-effects model., Results: A total number of nine studies involving 1410 individuals were selected for the final quantitative analysis. We noted that passing RTS test was not associated with the risk of subsequent knee injury (OR: 0.95; 95% CI: 0.28-3.21; P = 0.929), secondary ACL injury (OR: 0.98; 95% CI: 0.55-1.75; P = 0.945), and contralateral ACL injury (OR: 1.53; 95% CI: 0.63-3.71; P = 0.347). However, the risk of graft rupture was significantly reduced (OR: 0.49; 95% CI: 0.33-0.75; P = 0.001)., Conclusions: This study found that passing RTS test was not associated with the risk of subsequent knee injury, secondary ACL injury, and contralateral ACL injury, while it was associated with a lower risk of graft rupture. Thus, it is recommended that patients after ACLR pass an RTS test in clinical settings., Competing Interests: The authors declare there are no competing interests., (©2024 Zhou et al.)

The exploration of underlying biological risk factors for anterior cruciate ligament (ACL) injury has generated a substantial body of literature describing the role of bony morphology of the knee. Morphological risk factors, such as poor tibiofemoral joint congruity, a narrow femoral intercondylar notch, and an increased posterior tibial slope (PTS), have been implicated in contributing to knee instability and biomechanical abnormalities. Additionally, investigations into sex-specific differences in bony morphology have unveiled distinct risk profiles for males and females. In light of these findings, surgical considerations for individuals with high-risk bony morphology have been developed. Procedures like anterior closing wedge high tibial osteotomy, aiming to address increased PTS, and lateral extra-articular tenodesis for patients with specific risk factors, have been established. The aim of this review is to provide an overview of the current evidence describing the relationship between bony morphology and ACL injury. Moreover, this review aims to discuss the surgical management and outcomes concerning patients exhibiting high-risk anatomic features.

Background: The goal of anterior cruciate ligament reconstruction (ACLR) is to restore the preinjury level of knee function to return to play (RTP). However, even after completing the rehabilitation programme, some patients may have persistent quadriceps muscle weakness affecting knee function which ultimately leads to a failure in returning to play. Vitamin D has been long recognized for its musculoskeletal effects. Vitamin D deficiency may impair muscle strength recovery after ACLR. Correcting vitamin D levels may improve muscle strength., Methods: This is a double-blinded, randomized controlled trial to investigate the effects of vitamin D supplementation during the post-operative period on quadriceps muscle strength in anterior cruciate ligament (ACL)-injured patients. Patients aged 18-50 with serum vitamin D < 20 ng/ml, unilateral ACL injury, > 90% deficit in total quadriceps muscle volume on the involved leg compared with uninvolved leg, Tegner score 7 + , and no previous knee injury/surgery will be recruited. To assess patient improvement, we will perform isokinetic and isometric muscle assessments, ultrasound imaging for quadriceps thickness, self-reported outcomes, KT-1000 for knee laxity, biomechanical analysis, and Xtreme CT for bone mineral density. To investigate the effect of vitamin D status on quadriceps strength, blood serum samples will be taken before and after intervention., Discussion: Patients with low vitamin D levels had greater quadriceps fibre cross-sectional area loss and impaired muscle strength recovery after ACL. The proposed study will provide scientific support for using vitamin D supplementation to improve quadriceps strength recovery after ACLR., Trial Registration: ClinicalTrials.gov NCT05174611. Registered on 28 November 2021., (© 2024. The Author(s).)

Purpose: The outcomes of anterior cruciate ligament reconstruction in the setting of multiligamentous knee injury (M-ACLR) have not been well characterized compared to isolated ACLR (I-ACLR). This study aims to characterize and compare short-term outcomes between I-ACLR and M-ACLR., Methods: This is a retrospective cohort analysis of the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2017. Current Procedural Terminology codes were used to identify and compare elective I- and M-ACLR patients, excluding patients undergoing concomitant meniscal or chondral procedures. Patient demographics and outcomes after I- and M-ACLR were compared using bivariate analysis. Multiple logistic regression analyzed if multiligamentous ACLR was an independent risk factor for adverse outcomes., Results: There was a total of 13,131 ACLR cases, of which 341 were multiligamentous cases. The modified fragility index-5 was higher in multiligamentous ACLR (p < 0.001). Multiligamentous ACLR had worse perioperative outcomes, with higher rate of all complications (3.8%, p = 0.013), operative time > 1.5 h (p < 0.001), length of stay (LOS) ≥ 1 day (p < 0.001), wound complication (2.1%, p = 0.001), and intra- or post-op transfusions (p < 0.001). In multiple logistic regression, multiligamentous ACLR was an independent risk factor for LOS ≥ 1 (odds ratio [OR] 5.8), and intra-/post-op transfusion (OR 215.1) and wound complications (OR 2.4). M-ACLR was not an independent risk factor for any complication, reoperation at 30 days, readmission, urinary tract infection (UTI), or venous thromboembolism (VTE)., Conclusion: M-ACLR generally had worse outcomes than I-ACLR, including longer LOS, need for perioperative transfusions, and wound complications., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: This study aimed to investigate whether the return to level I sports, concomitant injuries, foot-related problems, and other factors would increase the risk of knee reinjury after anterior cruciate ligament reconstruction (ACLR)., Methods: This study used a prospective cohort study design. Online enrolment from August 2018 to January 2019 in ACL Community Indonesia recruited 148 patients who had undergone ACLR less than one month prior to injury. Knee injury occurrence after ACLR was diagnosed through a physical examination and positive MRI or arthroscopic findings., Results: During the study, 55 knee reinjuries occurred. The proportional hazards model analysis revealed that the risk of knee reinjury at 12 and 24 months for patients who returned to level I sports (hazards ratio (HR)=3.17 and HR=3.90, respectively) was significantly higher than that of the patients who did not return to sports and that the risk for those who returned to level II/III sports did not significantly increase at 12 or 24 months. Patients with concomitant meniscus injury had a significantly higher risk of knee reinjury at 12 and 24 months (HR=3.33 and HR=2.25, respectively) than those without, and the risk of knee reinjury for patients with concomitant posterior cruciate ligament injury was significantly higher at 12 months (HR=3.05) but not at 24 months. Fewer knee symptoms after ACLR were significantly associated with a lower risk of knee reinjury (HR=0.98) at 12 and 24 months., Conclusions: The return to level I sports, concomitant meniscus and posterior cruciate ligament injury, and knee symptoms after ACLR may increase the risk of knee reinjury for post-ACLR patients., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

Purpose: Bone patella-tendon bone (BPTB) and hamstring tendon (HT) autografts are the most used grafts in primary anterior cruciate ligament (ACL) reconstructions (ACLR) in Norway. Quadriceps tendon (QT) autograft has gained more popularity during the past years. The purpose of this study is to compare revision rates and patient-reported outcomes of primary QT with BPTB and HT autograft ACL reconstructions in Norway at 2-year follow-up. It was hypothesized that there would be no difference in 2-year revision rates between all three autografts., Methods: Data included primary ACLR without concomitant ligament surgeries, registered in the Norwegian Knee Ligament Register from 2004 through 2021. Revision rates at 2 years were calculated using Kaplan-Meier analysis. Hazard ratios (HR) for revision were estimated using multivariable Cox regression analysis with revision within 2 years as endpoint. Mean change in patient-reported outcome was recorded preoperatively and at 2 years through the Knee Injury and Osteoarthritis Outcome Score (KOOS) subcategories 'Sport' and 'Quality of Life' was measured for patients that were not revised and analysed with multiple linear regression., Results: A total of 24,790 primary ACLRs were identified, 10,924 with BPTB, 13,263 with HT and 603 with a QT graft. Patients in the QT group were younger (23.5 years), more of them were women (58.2%) and over 50% had surgery <3 months after injury. The QT group had the highest prevalence of meniscal injuries (61.9%). Revision estimates at 2-years were 3.6%, 2.5% and 1.2% for QT, HT and BPTB, respectively (p < 0.001). In a Cox regression analysis with QT as reference, BPTB had a lower risk of revision (HR 0.4, 95% Cl 0.2-0.7, p < 0.001). No significant difference was observed in the revision risk between QT and HT (HR 1.1, 95% Cl 0.7-1.8, n.s.). The two most common reported reasons for revision were: traumatic graft rupture and nontraumatic graft failure. There were no differences between the groups in change of KOOS in subcategories 'Sport' and 'Quality of Life' at 2-years follow-up., Conclusion: The 2-year risk of revision after ACLR with QT was higher than BPTB and similar to HT. No difference was found between the groups in patient-reported outcomes. This study provides valuable insights for both surgeons and patients when making decisions about the choice of autografts in primary ACL reconstructions., Level of Evidence: Level II., (© 2024 The Authors. Knee Surgery, Sports Traumatology, Arthroscopy published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Purpose: To assess the statistical fragility of recently published randomized controlled trials (RCTs) comparing the use of hamstring tendon autograft with bone-patellar tendon-bone autograft for anterior cruciate ligament (ACL) reconstruction., Methods: The PubMed, Embase, and MEDLINE databases were queried for RCTs published since 2010 comparing autograft type (bone-patellar tendon-bone vs hamstring tendon) in ACL reconstruction surgery. The fragility index (FI) and reverse FI (rFI) were determined for significant and nonsignificant outcomes, respectively, as the number of outcome reversals required to change statistical significance. The fragility quotient (FQ) and reverse FQ, representing fragility as a proportion of the study population, were calculated by dividing the FI and rFI, respectively, by the sample size., Results: We identified 19 RCTs reporting 55 total dichotomous outcomes. The median FI of the 55 total outcomes was 5 (interquartile range [IQR], 4-7), meaning a median of 5 outcome event reversals would alter the outcomes' significance. Five outcomes were reported as statistically significant with a median FI of 4 (IQR, 2-6), meaning a median of 4 outcome event reversals would change outcomes to be nonsignificant. Fifty outcomes were reported as nonsignificant with a median rFI of 5 (IQR, 4-7), meaning a median of 5 outcome event reversals would change outcomes to be significant. The FQ and reverse FQ for significant and nonsignificant outcomes were 0.025 (IQR, 0.018-0.045) and 0.082 (IQR, 0.041-0.106), respectively. For 61.8% of outcomes, patients lost to follow-up exceeded the corresponding FI or rFI., Conclusions: There is substantial statistical fragility in recent RCTs on autograft choice in ACL reconstruction surgery given that altering a few outcome events is sufficient to reverse study findings. For over half of outcomes, maintaining patients lost to follow-up may have been sufficient to reverse study conclusions., Clinical Relevance: We recommend co-reporting FIs and P values to provide a more comprehensive representation of a study's conclusions when conducting an RCT., (Copyright © 2023 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

The rate of anterior cruciate ligament (ACL) injuries and reconstruction in pediatric patients is increasing. Perioperative peripheral nerve blocks (PNBs) are widely used for pain management in this population. We used a multi-state administrative claims database to describe the effect of PNB after ACL reconstruction on postoperative opioid consumption. We identified patients 10 to 18 years old undergoing primary ACL reconstruction between 2014 and 2016 in an administrative claims database. Patients filling an outpatient perioperative prescription for opioids with at least 1 year of follow-up were included. We stratified patients based on PNB. Our primary outcome was opioid prescription patterns (in morphine milligram equivalents [MMEs]) and incidence of opioid represcription. Of the 4459 cases, 2432 (54.5%) of the patients were given a PNB during ACL reconstruction while 2027 (45.5%) were not. Patients with PNB were prescribed more MMEs per day (76.1±41.7 vs 62.7±35.7 MMEs, P <.001), more pills (63.6±53.1 vs 54.4±40.6 pills, P <.001), higher MMEs per pill (10.0±9.5 vs 8.3±5.0 MMEs, P <.001), and more total MMEs (460.6±259.4 vs 355.7±215.1 MMEs, P <.001) than patients without PNB. Adjusting for prescription patterns and demographic variables with logistic regression, PNBs were associated with a 60% increase in the odds of opioid represcription within 30 days and a 32% increase in the odds of opioid represcription within 90 days. We demonstrated an increase in postoperative opioid prescription rates with PNB after ACL reconstruction. [ Orthopedics . 2024;47(2):83-88.].

Objective: The optimal agent for thromboprophylaxis following arthroscopic anterior cruciate ligament reconstruction (ACLR) remains unclear, particularly in patients with a low baseline risk for venous thromboembolism (VTE). This retrospective cohort study aims to compare the effectiveness and safety of aspirin versus low molecular weight heparins (LMWHs) in this specific patient population., Methods: We analyzed data from patients who underwent ACLR between March 2016 and March 2021, focusing on those with a low risk for VTE. High-risk individuals, identified by factors such as cardiac disease, pulmonary disease, diabetes mellitus, previous VTE, inflammatory bowel disease, active cancer, and a BMI > 40, were excluded (n = 33). Our approach included a thorough review of medical charts, surgical reports, and pre-operative assessments, complemented by telephone follow-up conducted over a 3-month period by a single investigator. We assessed the incidence of symptomatic VTE, including deep vein thrombosis and pulmonary thromboembolism, as the primary outcome. The secondary outcomes included to complications related to the surgery and thromboprophylaxis. Statistical analysis included descriptive statistics, univariate logistic regression models, and calculations of incidence rates., Result: In our study, 761 patients (761 knees) were included, with 458 (60.18%) receiving aspirin and 303 (39.82%) receiving LMWH. The two groups showed no significant differences in demographic factors except for age. The incidence of VTE was reported at 1.31% (10 individuals). Specifically, five patients in the aspirin group (1.09%) and five patients in the LMWH group (1.65%) developed a symptomatic VTE event (p = 0.53). Additionally, the two groups did not significantly differ in terms of other complications, such as hemarthrosis or surgical site infection (p > 0.05). Logistic regression analysis revealed no statistically significant difference in VTE risk between the two groups., Conclusion: This study, focusing on isolated ACLR in patients with a low baseline risk for venous thromboembolism, demonstrated that aspirin is equally effective as low molecular weight heparins for VTE prophylaxis following this surgery., Level of Evidence: III., (© 2024. The Author(s).)