Does Revision Anterior Cruciate Ligament (ACL) Reconstruction Provide Similar Clinical Outcomes to Primary ACL Reconstruction? A Systematic Review and Meta‐Analysis
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More revisionary reconstruction procedures are required following failing anterior cruciate ligament (ACL) reconstructions, which are often regarded as a technique challenge with very limited goals. This study will be performed to compare the outcomes between groups of primary and revision knee reconstruction. Two observers conducted the literature retrieval from the platforms of PubMed, Embase, and CENTRAL. Studies which compared knee function and stability between primary and revisionary reconstructions were included. The data was synthesized by meta-analysis with fixed- or random-effects models as appropriate. A total of 10 eligible studies were included with 954 subjects in the primary group and 378 in the revision group. The International Knee Documentation Committee International Knee Documentation Committee (IKDC) subscores, side-to-side difference, and Lysholm score were demonstrated to be significantly improved at final follow-up in both groups, while Tegner score was not. The overall IKDC, Knee injury and Osteoarthritis Outcome Score (KOOS), and Lysholm scores were significantly inferior in the revision group compared to the primary group. However, knee laxity according to side-to-side difference was demonstrated to be similar between the two groups. Revision ACL reconstruction (RACLR) could provide patients with excellent restoration of knee outcomes compared to the status before revision. Also, while knee function in the revision group was inferior to the primary group, knee stability was equivalent between the two groups at the final follow-up.Background The intent of double-bundle anterior cruciate ligament reconstruction is to reproduce the normal anterior cruciate ligament anatomy and improve knee joint rotational stability. However, no consensus has been reached on the advantages of this technique over the single-bundle technique. Hypothesis We hypothesized that double-bundle anterior cruciate ligament reconstruction could provide better intraoperative stability and clinical outcome than single-bundle reconstruction. Type of study: Cohort study; Level of evidence, 2. Methods Forty patients with anterior cruciate ligament injury in one knee were recruited; 20 were allocated to a double-bundle anterior cruciate ligament reconstruction group and 20 to a single-bundle anterior cruciate ligament reconstruction group. Intraoperative stabilities at 30° of knee flexion were compared between the 2 groups using a navigation system. Clinical outcomes including Lysholm knee scores, Tegner activity scores, Lachman and pivot-shift test results, and radiographic stabilities were also compared between the 2 groups after a minimum of 2 years of follow-up. Results Intraoperative anterior and rotational stabilities after anterior cruciate ligament reconstruction in the double-bundle group were significantly better than those in single-bundle group (P = .020 and P < .001, respectively). Nineteen patients (95%) in each group were available at a minimum 2-year follow-up. Clinical outcomes including Lysholm knee and Tegner activity scores were similar in the 2 groups at 2-year follow-up (P > .05). Furthermore, stability results of the Lachman and pivot-shift tests, and radiologic findings at 2-year follow-up failed to reveal any significant intergroup differences (P > .05). Conclusion Although double-bundle anterior cruciate ligament reconstruction produces better intraoperative stabilities than single-bundle anterior cruciate ligament reconstruction, the 2 modalities were found to be similar in terms of clinical outcomes and postoperative stabilities after a minimum of 2 years of follow-up.
Lachman test
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Day-case anterior cruciate ligament reconstruction has the potential benefit of reduced hospital stay and reduced cost of care. The goal of this preliminary report was to compare the outcome of day-case arthroscopic anterior cruciate ligament reconstruction with those of in-patient care in terms of pain control and short-term functional outcome.This was a prospective comparative study involving patients who had anterior cruciate ligament reconstruction performed in our unit between January 2019 to July 2021 for isolated anterior cruciate ligament rupture. The patients were offered the option of in-patient and day-case anterior cruciate ligament reconstruction. All cases were isolated anterior cruciate ligament ruptures with no other ligament injury.A total of twenty-one-day case and twenty-five in-patient anterior cruciate ligament reconstruction were managed during the period of the study. The median numeric pain scores at day 2 and 7 in the day case group was 8.0 (IQR=2.0) and 5.0 (IQR= 3.0) respectively and in-patient group was 7.0 (IQR =1.5) and 4.0 (IQR= 2.0) respectively. The international knee documentation score (IKDC) at 6 months in the day case and in-patient groups were 68.6 (IQR= 9.3) and 67.2 (IQR= 25.0) respectively. The Mann-Whitney U test indicated that patients who had ACL reconstruction on in-patient care basis had statistically significant lower visual analogue scale pain scores on the second (z=-2.58, P = 0.01) and seventh (z=-3.41 P = 0.001) post-operative days compared to patients who had ACL reconstruction on day case basis. There was no statistically significant difference in the median IKDC scores of both groups at 6 months. The cost of care in the day case group was 40% lower than those of the in-patient group.Although the cost of care in the day case group appeared lower as compared to the in-patient group, the day case group had higher post-operative pain scores compared to the in-patient group. Although the post-operative functional scores were similar in both groups, this was not statistically significant.
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Anterior cruciate ligament graft orientation has been proposed as a potential mechanism for failure of single-bundle anterior cruciate ligament reconstruction and has been considered important in the restoration of normal ambulatory knee mechanics.To evaluate the possibility that patients adapt their mechanics of walking to the orientation of the anterior cruciate ligament graft. This was determined by testing the hypothesis that peak external knee flexion moment (net quadriceps moment) during walking in patients with anterior cruciate ligament reconstruction is correlated with coronal and sagittal anterior cruciate ligament graft orientations.Cross-sectional study; Level of evidence, 3.Gait analysis was performed to assess dynamic knee function during walking in 17 subjects with unilateral anterior cruciate ligament reconstructions. Magnetic resonance imaging was used to measure coronal and sagittal anterior cruciate ligament graft orientations.A negative correlation was observed between peak external knee flexion moment during walking and coronal angle of the anterior cruciate ligament graft (1.0 m/s walking speed, r = -0.87, P < .001; 1.3 m/s, r = -0.66, P = .004; 1.6 m/s, r = -0.24, P > .05); no correlation was found with the sagittal graft angle (1.0 m/s walking speed, r = 0.21, P > .05; 1.3 m/s, r = 0.20, P > .05; 1.6 m/s, r = 0.13, P > .05).The negative correlation between peak external knee flexion moment during walking and the coronal angle of the anterior cruciate ligament graft indicates that as the anterior cruciate ligament graft is placed in a more vertical coronal orientation, patients reduce their net quadriceps usage during walking.This finding supports the hypothesis that graft placement plays a critical role in the restoration of normal ambulatory mechanics after anterior cruciate ligament reconstruction and thus could provide a partial explanation for the increased incidence of premature osteoarthritis at long-term follow-up in patients with anterior cruciate ligament reconstruction.
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Background Anatomic double-bundle reconstruction has been thought to better simulate the anterior cruciate ligament anatomy. It is, however, a technically challenging procedure, associated with longer operation time and higher cost. Hypothesis Double-bundle anterior cruciate ligament reconstruction using a single femoral and tibial tunnel can closely reproduce intact knee kinematics. Study Design Controlled laboratory study. Methods Eight fresh-frozen human cadaveric knee specimens were tested using a robotic testing system to investigate the kinematic response of the knee joint under an anterior tibial load (130 N), simulated quadriceps load (400 N), and combined torques (5 N·m valgus and 5 N·m internal tibial torques) at 0°, 15°, 30°, 60°, and 90° of flexion. Each knee was tested sequentially under 4 conditions: (1) anterior cruciate ligament intact, (2) anterior cruciate ligament deficient, (3) single-bundle anterior cruciate ligament reconstruction using quadrupled hamstring tendon, and (4) single-tunnel—double-bundle anterior cruciate ligament reconstruction using the same tunnels and quadrupled hamstring tendon graft as in the single-bundle anterior cruciate ligament reconstruction. Results Single-tunnel—double-bundle anterior cruciate ligament reconstruction more closely restored the intact knee kinematics than single-bundle anterior cruciate ligament reconstruction at low flexion angles (≤30°) under the anterior tibial load and simulated muscle load (P < .05). However, single-tunnel—double-bundle anterior cruciate ligament reconstruction overconstrained the knee joint at high flexion angles (≥60°) under the anterior tibial load and at 0° and 30° of flexion under combined torques. Conclusion This double-bundle anterior cruciate ligament reconstruction using a single tunnel can better restore anterior tibial translations to the intact level compared with single-bundle anterior cruciate ligament reconstruction at low flexion angles, but it overconstrained the knee joint at high flexion angles. Clinical Relevance This technique could be an alternative for both single-bundle and double-tunnel—double-bundle anterior cruciate ligament reconstructions to reproduce intact knee kinematics and native anterior cruciate ligament anatomy.
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Surgical management of the anterior cruciate ligament-deficient knee has evolved from primary repair to extracapsular augmentation to anterior cruciate ligament reconstruction using biologic tissue grafts. The technique of anterior cruciate ligament reconstruction has improved over the last few decades with the aid of knowledge gained from basic science and clinical research. The biology and biomechanics of anterior cruciate ligament reconstruction were analyzed in the previously published first part of this article. In this second part, current operative concepts of anterior cruciate ligament reconstruction as well as clinical correlations are discussed. The latest information regarding anterior cruciate ligament reconstruction is presented with a goal of demonstrating the correlation between the application of basic science knowledge and the improvement of clinical outcomes.
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Anterior cruciate ligament reconstruction is performed as an outpatient procedure in selected cases. Whether it can be safely performed on a routine basis in day clinic remains unclear. Our hypothesis was that routinely performing outpatient anterior cruciate ligament reconstruction would be equally safe as compared to inpatient procedures. A cohort of 355 patients who underwent outpatient primary reconstruction was analysed at an average follow-up of 3.8 years. Four patients (1.1%) could not be discharged or were readmitted within 24 hours. The 1-month readmission rate was 1.4%. The overall complication rate was 12.1% (43 cases) of which 4.2% (15 patients) occurred within the first 30 days. Performing anterior cruciate ligament reconstructions routinely in day clinic is associated with almost negligible readmission rates and has similar complication rates as for standard in-hospital anterior cruciate ligament reconstructions. Outpatient anterior cruciate ligament reconstructions can therefore be safely performed without specific preoperative patient selection protocols.
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Arthrometry has an established role in the measurement of knee laxity in anterior cruciate ligament injury and following reconstruction. The role of routine intraoperative arthrometry in anterior cruciate ligament reconstruction is poorly defined, and this study was designed to test the hypothesis that intraoperative arthrometry provides an objective method of documenting successful knee stabilisation following anterior cruciate ligament reconstruction. A consecutive cohort of 100 patients with unilateral isolated anterior cruciate ligament disruption were prospectively evaluated using a Rolimeter arthrometer. A maximal manual force method was utilised by a single examiner. This allowed for side-to-side comparisons with the uninjured contralateral knee. Analysis of tibial translation was recorded preoperatively with patients both awake and asleep, intraoperatively following anterior cruciate ligament reconstruction, and postoperatively at 2 weeks and 3 months. Statistical analysis was performed using Spearman's correlation coefficients. Intraoperative arthrometry of anterior cruciate ligament reconstructed knees revealed statistically significant correlation with measurements of uninjured knees (p < 0.0001). These findings were reproducible at 2 weeks (p < 0.0001) and at 3 months (p = 0.0002). Based on our findings, we conclude that intraoperative arthrometry can be simple and provide reproducible results. It is a useful method of immediately and objectively documenting successful anterior cruciate ligament reconstruction.
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