Abstract Purpose To evaluate factors affecting the risk of contralateral anterior cruciate ligament reconstruction (ACLR) within 5 years of primary ACLR. Methods Primary ACLRs performed at Capio Artro Clinic, Stockholm, Sweden, during the period 2005–2014, were reviewed. The outcome of the study was the occurrence of contralateral ACLR within 5 years of primary ACLR. Univariable and multivariable logistic regression analyses were employed to identify preoperative [age, gender, body mass index (BMI), time from injury to surgery, pre-injury Tegner activity level], intraoperative [graft type, medial meniscus (MM) and lateral meniscus (LM) resection or repair, cartilage injury] and postoperative [limb symmetry index (LSI) for quadriceps and hamstring strength and single-leg-hop test performance at 6 months] risk factors for contralateral ACLR. Results A total of 5393 patients who underwent primary ACLR were included. The incidence of contralateral ACLR within 5 years was 4.7%. Univariable analysis revealed that age ≥ 25 years, BMI ≥ 25 kg/m 2 , time from injury to surgery ≥ 12 months and the presence of a cartilage injury reduced the odds, whereas female gender, pre-injury Tegner activity level ≥ 6, quadriceps and hamstring strength and a single-leg-hop test LSI of ≥ 90% increased the odds of contralateral ACLR. Multivariable analysis showed that the risk of contralateral ACLR was significantly affected only from age ≥ 25 years (OR 0.40; 95% CI 0.28–0.58; P < 0.001), time from injury to surgery ≥ 12 months (OR 0.48; 95% CI 0.30–0.75; P = 0.001) and a single-leg-hop test LSI of ≥ 90% (OR 1.56; 95% CI 1.04–2.34; P = 0.03). Conclusion Older age (≥ 25 years) and delayed primary ACLR (≥ 12 months) reduced the odds, whereas a symmetrical (LSI ≥ 90%) 6-month single-leg-hop test increased the odds of contralateral ACLR within 5 years of primary ACLR. Knowledge of the factors affecting the risk of contralateral ACLR is important when it comes to the appropriate counselling for primary ACLR. Patients should be advised regarding factors affecting the risk of contralateral ACLR. Level of evidence Level III.
Objectives: Clinical practice has been to avoid acute ACL reconstruction due to the risk of complications, especially arthrofibrosis. Thus, a general rule has been to wait with reconstruction until he knee is “calm” which usually means 4-8 weeks following injury. Furthermore there is often also a prolonged waiting time due to operating space and other logistic factors. Since most of the patients undergoing ACL reconstruction are of working age, there is a potentially large socio-economic loss due to the fact that many of these patients are unable to work from the time of injury to the time of reconstruction. The aim of this study was to assess and compare the total number of sick leave days caused by the knee injury from the day of injury and over the first year between sub acute and delayed reconstruction. Methods: 70 patients with high recreational activity level, Tegner level of 6 or more, who presented with an acute ACL injury were randomized to acute reconstruction within 8 days from the injury or delayed reconstruction 6-10 weeks post injury. Four surgeons performed the ACL reconstructions with quadrupled semitendinosus tendon grafts. Patients were assessed at 6,12 and 24 months and these follow ups included Biodex strength test, Lachman, Rolimeter, pivot shift, one leg hop, IKDC, KOOS, Lysholm and Tegner activity level. With data from the Swedish Social Insurance Agency (Försäkringskassan) information about the number of sick leave days from the day of the knee injury and over the following twelve months was collected. The data was recalled based on diagnostic numbers related to the specific knee-injury and compared between the two groups. Results: Seventy percent of the patients were males, mean age at the time of inclusion was 27 years (18 -41) and the pre-injury median Tegner level was 9 (5-10), with no differences between the groups. 15/70 patients were students without registered compensation for sick leave, 5 in the acute and 10 in the delayed group. 4 patients in the acute group and 1 in the delayed group were neither students nor registered for any compensation for sick leave from work. One patient from the delayed group resigned from the study before surgery. The remaining 49 patients, 26 patients in the acute and 23 in the delayed group received compensation for sick leave due to the injury. The number of sick leave days for the acute group was significantly lower, mean 57 (median 53) days compared to the delayed group, mean 99 (median 66) days (p<0.05). Conclusion: Acute ACL reconstruction seems to significantly reduce socio economic costs (compensation for sick leave) compared to delayed reconstruction. From a nation based perspective this could have major implications in health care spending.
Abstract Purpose The aim of this ESSKA consensus is to give recommendations based on scientific evidence and expert opinion to improve the diagnosis, preoperative planning, indication and surgical strategy in Anterior Cruciate Ligament revision. Methods Part 2, presented herein, followed exactly the same methodology as Part 1: the so‐called ESSKA formal consensus derived from the Delphi method. Eighteen questions were ultimately asked. The quality of the answers received the following grades of recommendation: Grade A (high level scientific support), Grade B (scientific presumption), Grade C (low level scientific support) or Grade D (expert opinion). All answers were scored from 1 to 9 by the raters. Once a general consensus had been reached between the steering and rating groups, the question–answer sets were submitted to the peer‐review group. A final combined meeting of all the members of the consensus was then held to ratify the document. Results The review of the literature revealed a rather low scientific quality of studies examining the surgical strategy in cases of ACL reconstruction failure. Of the 18 questions, only 1 received a Grade A rating; 5, a Grade B rating; and 9, grades of C or D. The three remaining complex questions received further evaluations for each portion of the question and were looked at in more detail for the following grades: B and D; A, C and D; or A, B, C and D. The mean rating of all questions by the rating group was 8.0 + − 1.1. The questions and recommendations are listed in the article. Conclusion ACL revision surgery, especially the surgical strategy, is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardization. Therefore, this international European consensus project is of great importance and clinical relevance for guiding the management of ACL revision in adults. Level of evidence Level II.
The best treatment for the active and lucid elderly patient with a displaced intracapsular fracture of the femoral neck is still controversial. Randomised controlled trials have shown that a primary total hip replacement is superior to internal fixation as regards the need for secondary surgery, hip function and health-related quality of life. Despite good results achieved with total hip replacement in this group, most orthopaedic surgeons still advocate hemiarthroplasty for this injury. We studied 120 patients with a mean age of 81 years (70 to 90) with an acute displaced intracapsular fracture of the femoral neck. They were randomly allocated to be treated with either a bipolar hemiarthroplasty or total hip replacement. Outcome measurements included peri-operative data, general and hip-specific complications, hip function and health-related quality of life. The patients were reviewed at four and 12 months. The duration of surgery was longer in the total hip replacement group (102 minutes (70 to 151)) versus 78 minutes (43 to 131) (p<0.001), and the intra-operative blood loss was increased 460 ml (100 to 1100) versus 320 ml (50 to 850) (p<0.001), but there were no differences between the groups regarding any complications or mortality. There were no dislocations in either group. Hip function measured by the Harris hip score was significantly better in the total hip replacement group at both follow-up periods (p=0.011 and p<0.001, respectively). The health-related quality of life measure was in favour of the total hip replacement group but did not reach statistical significance (p=0.818 at four months and p=0.636 at 12 months). These results indicate that a total hip replacement provides better function than a bipolar hemiarthroplasty as soon as one year post-operatively, without increasing the complication rate. We recommend total hip replacement as the primary treatment for this group of patients.
