Aims. The aim of this study was to compare patient-reported outcomes (PROMs) following isolated anterior cruciate ligament reconstruction (ACLR), with those following ACLR and concomitant meniscal resection or repair. Methods. We reviewed prospectively collected data from the UK National Ligament Registry for patients who underwent primary ACLR between January 2013 and December 2022. Patients were categorized into five groups: isolated ACLR, ACLR with medial meniscus (MM) repair, ACLR with MM resection, ACLR with lateral meniscus (LM) repair, and ACLR with LM resection. Linear regression analysis, with isolated ACLR as the reference, was performed after adjusting for confounders. Results. From 14,895 ACLR patients, 4,400 had two- or five-year Knee injury and Osteoarthritis Outcome Scores (KOOS) available. At two years postoperatively, the MM repair group demonstrated inferior scores in KOOS pain (β = −3.63, p < 0.001), symptoms (β = − 4.88, p < 0.001), ADL (β = − 2.43, p = 0.002), sport and recreation (β = − 5.23, p < 0.001), quality of life (QoL) (β = − 5.73, p < 0.001), and International Knee Documentation Committee (β = − 4.1, p < 0.001) compared with the isolated ACLR group. The LM repair group was associated with worse KOOS sports and recreation scores at two years (β = − 4.264, p < 0.001). At five years, PROMs were comparable between the groups. At five years, PROMs were comparable between the groups. Participants undergoing ACLR surgery within 12 weeks from index injury demonstrated superior PROMs at two and five years. Conclusion. Our study showed that MM repair, and to a lesser extent LM repairs in combination with ACLR, were associated with inferior patient-reported outcome measures (PROMs) compared to isolated ACLR at two years postoperatively, while meniscal resection groups exhibited comparable outcomes. However, by five years postoperation, no significant differences in PROMs were evident. Further longer-term, cross-sectional studies are warranted to investigate the outcomes of ACLR and concomitant meniscal surgery

Introduction. Anterior cruciate ligament (ACL) injuries represent a significant burden of disease to the orthopaedic surgeon and often necessitate surgical reconstruction in the presence of instability. The hamstring graft has traditionally been used to reconstruct the ACL but the quadriceps tendon (QT) graft has gained popularity due to its relatively low donor site morbidity. Methods. This is a single centre comparative retrospective analysis of prospectively collected data of patients who had an ACL reconstruction (either with single tendon quadrupled hamstring graft or soft tissue quadriceps tendon graft). All surgeries were performed by a single surgeon using the All-inside technique. For this study, there were 20 patients in each group. All patients received the same post-operative rehabilitation protocol and were added to the National Ligament Registry to monitor their patient related outcome scores (PROM). Results. The average age of patients in the QT group was 29 years (16 males, 4 females) and in the hamstring group was 28 years (18 males, 2 females). The most common mechanism of injury in both groups was a contact twisting injury. There were no statistical differences between the two patient groups in regards to PROMS and need for further revision surgery as analysed on the National Ligament Registry. Conclusions. The all soft tissue QT graft seems to be equivocal to quadrupled hamstring graft in terms of patient function and recovery graft characteristics. Further research may be needed to elucidate the long-term results of the all soft tissue QT graft given its recent increase in use

Septic arthritis following anterior cruciate ligament reconstruction (ACLR) is a rare and serious complication. Previous studies have shown that septic arthritis is associated with inferior outcome of ACLR. Despite that, there is no standardized treatment protocol, and the course of the disease has mainly been studied within single institutions with a small number of patients. The aim of the present study is to describe the course of septic arthritis following ACLR in a large nationwide cohort. The hypothesis was that the clinical presentation of septic arthritis following ACLR varies according to the infectious agent. The present cohort represents patients with septic arthritis identified in a previous study that analyzed compensation claims reported to the Swedish national insurance company (Löf) in 2005–2014 (1). The diagnosis was confirmed by medical experts at Löf after review of medical records. We conducted a comprehensive analysis of the medical records as well as data available from the Swedish National Knee Ligament Registry (SNKLR) for the study group. The study involved 158 patients who received compensation due to developing septic arhtirits. 94 (59.9%) patients were infected with Coagulase negative staphylococci (CoNS), and 25 patients by Staphyolococcus Aureus (S.Aureus) (15.9%). There was a significant difference between the groups regarding Maximum CRP (p<0.001), and duration between ACLR and first washout operation (p<0.005). S.aureus group had the higest maximum CRP (281) and the shortest duration between ACLR and first washout operation (12 days). The Clinical presentation of septic arthritis following ACLR can vary according to the agent causing the infection, and low virulent agents are responsible for the majority of the infections. Clinicians need to be aware of these differences and consider them when making diagnosis or treatment decisions

Abstract. Aims. Growth disturbances after transphyseal paediatric ACL reconstruction have led to the development of physeal-sparing techniques. However, evidence in their favour remains weak. This study reviews the literature to identify factors associated with growth disturbances in paediatric ACL reconstructions. Materials and Methods. Web of Science, Scopus and Pubmed were searched for case series studying paediatric ACL reconstructions. Titles, abstracts, text, results and references were examined for documentation of growth disturbances. Incidences of graft failures were also studied in these selected studies. Results. 78 studies with 2693 paediatric ACL reconstructions had 70 growth disturbances (2.6%). Of these 17 were varus, 26 valgus, 13 shortening, 14 lengthening and 5 patients had reduced tibial slope. Coronal plane deformities were seen more frequently with eccentric physeal arrest and lengthening with intraepiphyseal tunnelling. Shortening and reduced tibial slope were related to large central physeal arrest and anterior tibial physeal arrest respectively. Extraphyseal technique were least likely to have growth disturbances. 62 studies documented 166 graft failures in 2120 patients (7.83%). Conclusion. Growth disturbances resulting from transphyseal ACL reconstruction can be minimised by keeping drill size small, drilling steep and away from the physeal periphery. Insertion of bone plug, hardware or synthetic material through the drilled physis should be avoided. The evidence to accurately quantify such growth disturbances till skeletal maturity remains weak. Robust long term studies such as national ligament registries may standardise preoperative and postoperative outcome assessment to further characterise the risk of growth disturbance and re-ruptures

Introduction. Anterior cruciate ligament reconstruction (ACLr) is the most widely published operation in the orthopaedic literature. Over recent years there has been increased interest in the surgical technique and role of concomitant procedures performed during ACLr. The National Ligament Registry (NLR) collects robust data on ACLr performed in the UK. In this registry analysis we explore trends in ACLr surgery and how they relate to published literature and the growing industry portfolio available to surgeons. Methods. Using data from the NLR, 14,352 ACLr performed between 2013–2021 were analysed. High impact papers on ACLr were then cross referenced against this data to see if surgical practice was influenced by literature or whether surgical practice dictated publication. Common trends were also compared to key surgical industry portfolios (Arthrex, Smith and Nephew) to see how new technology influenced surgical practice. Results. The number of ACLr performed in isolation is decreasing. The number of ACL reconstructions involving meniscal surgery shows an increasing trend since 2013, with 57% of ACLr in 2021 now involving meniscus surgery. The number of ACLr with lateral extra-articular tenodesis (LET) has increased sharply since 2018, preceding the stability trial publication in 2020. Graft preference and size has remained static despite the introduction of new graft harvest and fixation devices. Additional procedures such as other ligament reconstruction and additional cartilage surgery have also remained static over time. Conclusion. In this analysis we looked at surgical trends in ACLr and their relation to literature and industry. Meniscal intervention is increasing, in keeping with the growing level of literature in this area. In the setting of LET, a high impact level 1 study appears to have significantly changed the practice of UK surgeons with a sharp increase in the number of LET procedures being performed. Industry appears to have little influence on the change in surgical trends, suggesting high quality evidence is what drives innovation in ACLr while industry supports rather than influences innovation. It will be interesting to see the impact of the stability 2 study, recent work on the medial structures of the knee and the commissioning of cartilage centres on future trends

Abstract. Introduction. The use of MCL “pie-crusting” (selective release of the superficial MCL) to improve arthroscopic access to the posteromedial compartment of the knee for isolated meniscal surgery has been demonstrated. However, there are concerns that MCL pie-crusting with concomitant ACL reconstruction (ACLR) might affect knee stability and outcomes postoperatively. The aim of this study was to compare the functional outcomes between patients who underwent MCL pie-crusting at ACLR with those that did not. Methods. We performed a retrospective review of prospectively collected data from on the National Ligament Registry. 55 patients (33 male and 22 female) who had MCL pie-crusting(PC group) to address a meniscal lesion at the time of ACLR were compared with 65 patients (38 male and 27 female) who underwent isolated primary ACLR. All procedures were performed by a single surgeon at a tertiary centre between October 2013 and March 2019. Results. The mean Follow up was 4.2 years(range 2- 7 years). The mean EQ 5D- VAS scores were 82 and 81 in the PC group and ACLR only group respectively. The mean IKDC scores were 81 and 85 in the PC group and ACLR only group respectively. The mean KOOS scores in the PC group and ACLR only group were: Symptoms (81,87); Pain (89,92); ADLs (94,96), sports and recreation function (81,83), QoL (75,78) respectively. The differences in the scores were not statistically significant. Conclusions. This study demonstrates that pie-crusting of the MCL at the time of ACLR does not significantly affect the functional outcomes

External validation of machine learning predictive models is achieved through evaluation of model performance on different groups of patients than were used for algorithm development. This important step is uncommonly performed, inhibiting clinical translation of newly developed models. Recently, machine learning was used to develop a tool that can quantify revision risk for a patient undergoing primary anterior cruciate ligament (ACL) reconstruction (https://swastvedt.shinyapps.io/calculator_rev/). The source of data included nearly 25,000 patients with primary ACL reconstruction recorded in the Norwegian Knee Ligament Register (NKLR). The result was a well-calibrated tool capable of predicting revision risk one, two, and five years after primary ACL reconstruction with moderate accuracy. The purpose of this study was to determine the external validity of the NKLR model by assessing algorithm performance when applied to patients from the Danish Knee Ligament Registry (DKLR). The primary outcome measure of the NKLR model was probability of revision ACL reconstruction within 1, 2, and/or 5 years. For the index study, 24 total predictor variables in the NKLR were included and the models eliminated variables which did not significantly improve prediction ability - without sacrificing accuracy. The result was a well calibrated algorithm developed using the Cox Lasso model that only required five variables (out of the original 24) for outcome prediction. For this external validation study, all DKLR patients with complete data for the five variables required for NKLR prediction were included. The five variables were: graft choice, femur fixation device, Knee Injury and Osteoarthritis Outcome Score (KOOS) Quality of Life subscale score at surgery, years from injury to surgery, and age at surgery. Predicted revision probabilities were calculated for all DKLR patients. The model performance was assessed using the same metrics as the NKLR study: concordance and calibration. In total, 10,922 DKLR patients were included for analysis. Average follow-up time or time-to-revision was 8.4 (±4.3) years and overall revision rate was 6.9%. Surgical technique trends (i.e., graft choice and fixation devices) and injury characteristics (i.e., concomitant meniscus and cartilage pathology) were dissimilar between registries. The model produced similar concordance when applied to the DKLR population compared to the original NKLR test data (DKLR: 0.68; NKLR: 0.68-0.69). Calibration was poorer for the DKLR population at one and five years post primary surgery but similar to the NKLR at two years. The NKLR machine learning algorithm demonstrated similar performance when applied to patients from the DKLR, suggesting that it is valid for application outside of the initial patient population. This represents the first machine learning model for predicting revision ACL reconstruction that has been externally validated. Clinicians can use this in-clinic calculator to estimate revision risk at a patient specific level when discussing outcome expectations pre-operatively. While encouraging, it should be noted that the performance of the model on patients undergoing ACL reconstruction outside of Scandinavia remains unknown

Surgery performed in low-volume centres has been associated with longer operating time, longer hospital stays, lower functional outcomes, and higher rates of revision surgery, complications, and mortality. This has been reported consistently in the arthroplasty literature, but there is a paucity of data regarding the relationship between surgical volume and outcome following anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to compare the ACL reconstruction failure rate between hospitals performing different annual surgical volumes. The hypothesis was that ACL reconstructions performed at low-volume hospitals would be associated with higher failure rates than those performed at high-volume centres. This level-II cohort study included all patients from the Norwegian Knee Ligament Registry that underwent isolated primary autograft ACL reconstruction between 2004 and 2016. Hospital volume was divided into quintiles based on the number of ACL reconstructions performed annually, defined arbitrarily as: 1–12 (V1), 13–24 (V2), 25–49 (V3), 50–99 (V4), and ≥100 (V5) annual procedures. Kaplan-Meier estimated survival curves and survival percentages were calculated with revision ACL reconstruction as the end point. Mean change in Knee Injury and Osteoarthritis Outcome Score (KOOS) Quality of Life and Sport subsections from pre-operative to two-year follow-up were compared using t-test. 19,204 patients met the inclusion criteria and 1,103 (5.7%) underwent subsequent revision ACL reconstruction over the study period. Patients in the lower volume categories (V1-3) were more often male (58–59% vs. 54–55% p=<0.001) and older (27 years vs. 24–25 years, p=<0.001) compared to the higher volume hospitals (V4-5). Concomitant meniscal injuries (52% vs. 40%) and participation in pivoting sports (63% vs. 56%) were most common in V5 compared with V1 (p=<0.001). Median operative time decreased as hospital volume increased, ranging from 90 minutes at V1 hospitals to 56 minutes at V5 hospitals (p=<0.005). Complications occurred at a rate of 3.8% at low-volume (V1) hospitals versus 1.9% at high-volume (V5) hospitals (p=<0.001). Unadjusted 10-year survival with 95% confidence intervals for each hospital volume category were: V1 – 95.1% (93.7–96.5%), V2 – 94.1% (93.1–95.1%), V3 – 94.2% (93.6–94.8%), V4 – 92.6% (91.8–93.4%), and V5 – 91.9% (90.9–92.9%). There was no difference in improvement between pre-operative and two-year follow-up KOOS scores between hospital volume categories. Patients having ACL reconstruction at lower volume hospitals did not have inferior clinical or patient reported outcomes, and actually demonstrated a lower revision rate. Complications occurred more frequently however, and operative duration was longer. The decreased revision rate is an interesting finding that may be partly explained by the fact that patients being treated in these small, often rural hospitals, may be of lower demand as suggested by the increased age and decreased participation in pivoting sports. In addition, patients with more complicated pathology such as meniscal tears were more commonly treated in the larger volume hospitals. The most significant limitation of this study is that provider volume was not assessed, and the number of surgeons dividing up the surgical volume at each hospital is not known

Anterior cruciate ligament (ACL) injuries are among the most common and debilitating knee injuries in professional athletes with an incidence in females up to eight-times higher than their male counterparts. ACL injuries can be career-threatening and are associated with increased risk of developing knee osteoarthritis in future life. The increased risk of ACL injury in females has been attributed to various anatomical, developmental, neuromuscular, and hormonal factors. Anatomical and hormonal factors have been identified and investigated as significant contributors including osseous anatomy, ligament laxity, and hamstring muscular recruitment. Postural stability and impact absorption are associated with the stabilizing effort and stress on the ACL during sport activity, increasing the risk of noncontact pivot injury. Female patients have smaller diameter hamstring autografts than males, which may predispose to increased risk of re-rupture following ACL reconstruction and to an increased risk of chondral and meniscal injuries. The addition of an extra-articular tenodesis can reduce the risk of failure; therefore, it should routinely be considered in young elite athletes. Prevention programs target key aspects of training including plyometrics, strengthening, balance, endurance and stability, and neuromuscular training, reducing the risk of ACL injuries in female athletes by up to 90%. Sex disparities in access to training facilities may also play an important role in the risk of ACL injuries between males and females. Similarly, football boots, pitches quality, and football size and weight should be considered and tailored around females’ characteristics. Finally, high levels of personal and sport-related stress have been shown to increase the risk of ACL injury which may be related to alterations in attention and coordination, together with increased muscular tension, and compromise the return to sport after ACL injury. Further investigations are still necessary to better understand and address the risk factors involved in ACL injuries in female athletes.

Cite this article: Bone Jt Open 2024;5(2):94–100.

Aims

The aim of this study was to compare the preinjury functional scores with the postinjury preoperative score and postoperative outcome scores following anterior cruciate ligament (ACL) reconstruction surgery (ACLR).

Introduction. Unlike the NJR, no surgeon driven national database currently exists for ligament surgery in the UK and therefore information on outcome and adverse event is limited to case series. Methods. Prospectively collected Hospital episode statistics (HES) data for England was analysed so as to determine national rates of 90-day symptomatic deep venous thrombosis (DVT), pulmonary thromboembolism (PTE) rate, significant wound infection and 30-day readmission rates with cause following anterior cruciate ligament (ACL) reconstruction. This diagnostic and operative codes information is routinely collected on every patient admitted to hospital in England NHS. Results. All HES data between April 2008 and March 2010 was analysed for patients undergoing ACL reconstruction (13571 patients). 90-day DVT and PTE rates were 0.29% (40) and 0.20% (27) respectively. There were no deaths. 0.94% (127) had a wound complication recorded and 1.34% (182) were readmitted to an orthopaedic ward within 30 days. Conclusion. We are particularly interested in adverse event reporting from ACL surgery. Our knowledge of current UK ligament practice and outcome is based upon low uptake postal surveys and small number case series. We have been able to quantify the complication rate for thrombotic events, readmission rate and other adverse events following ACL surgery from a national database. Contrary to popular belief there is a real but small risk of PTE following ACL surgery. We believe this data strengthens the argument for a funded prospective UK ligament registry

Aims

The best surgical strategy for the management of displaced bucket-handle (BH) meniscal tears in an anterior cruciate ligament (ACL)-deficient knee is unclear. Combining meniscal repair with ACL reconstruction (ACLR) is thought to improve meniscal healing rates; however, patients with displaced BH meniscal tears may lack extension. This leads some to advocate staged surgery to avoid postoperative stiffness and loss of range of motion (ROM) following ACLR.

The anterior cruciate ligament (ACL) is frequently injured in elite athletes, with females up to eight times more likely to suffer an ACL tear than males. Biomechanical and hormonal factors have been thoroughly investigated; however, there remain unknown factors that need investigation. The mechanism of injury differs between males and females, and anatomical differences contribute significantly to the increased risk in females. Hormonal factors, both endogenous and exogenous, play a role in ACL laxity and may modify the risk of injury. However, data are still limited, and research involving oral contraceptives is potentially associated with methodological and ethical problems. Such characteristics can also influence the outcome after ACL reconstruction, with higher failure rates in females linked to a smaller diameter of the graft, especially in athletes aged < 21 years. The addition of a lateral extra-articular tenodesis can improve the outcomes after ACL reconstruction and reduce the risk of failure, and it should be routinely considered in young elite athletes. Sex-specific environmental differences can also contribute to the increased risk of injury, with more limited access to and availablility of advanced training facilities for female athletes. In addition, football kits are designed for male players, and increased attention should be focused on improving the quality of pitches, as female leagues usually play the day after male leagues. The kit, including boots, the length of studs, and the footballs themselves, should be tailored to the needs and body shapes of female athletes. Specific physiotherapy programmes and training protocols have yielded remarkable results in reducing the risk of injury, and these should be extended to school-age athletes. Finally, psychological factors should not be overlooked, with females’ greater fear of re-injury and lack of confidence in their knee compromising their return to sport after ACL injury. Both intrinsic and extrinsic factors should be recognized and addressed to optimize the training programmes which are designed to prevent injury, and improve our understanding of these injuries.

Cite this article: Bone Joint J 2023;105-B(10):1033–1037.

There is a disparity in sport-related injuries between sexes, with females sustaining non-contact musculoskeletal injuries at a higher rate. Anterior cruciate ligament ruptures are between two and eight times more common than in males, and females also have a higher incidence of ankle sprains, patellofemoral pain, and bone stress injuries. The sequelae of such injuries can be devastating to an athlete, resulting in time out of sport, surgery, and the early onset of osteoarthritis. It is important to identify the causes of this disparity and introduce prevention programmes to reduce the incidence of these injuries. A natural difference reflects the effect of reproductive hormones in females, which have receptors in certain musculoskeletal tissues. Relaxin increases ligamentous laxity. Oestrogen decreases the synthesis of collagen and progesterone does the opposite. Insufficient diet and intensive training can lead to menstrual irregularities, which are common in female athletes and result in injury, whereas oral contraception may have a protective effect against certain injuries. It is important for coaches, physiotherapists, nutritionists, doctors, and athletes to be aware of these issues and to implement preventive measures. This annotation explores the relationship between the menstrual cycle and orthopaedic sports injuries in pre-menopausal females, and proposes recommendations to mitigate the risk of sustaining these injuries.

Cite this article: Bone Joint J 2023;105-B(7):723–728.

Aims. Wales in collaboration with the Welsh Assembly Government, has attempted to start a national ligament register. Introduction. Norway is the lead in Europe for running a successful national quality knee ligament registry. As yet there is no UK wide registry encompassing all forms of knee ligament surgery. The issue has been discussed at previous society meetings, but no consensus has been reached. Method. A pilot study covering three NHS Trusts in South Wales was run between April 2010 and September 2010. Data is gathered prospectively on non-operatively treated and surgically treated knee ligament injuries performed in the regions. This data is recorded on the WKLR form which is then sent to the WKLR centre and entered onto a secure database. Four knee surgeons agreed to take part in the study, from three NHS Health Boards. The data is recorded at the time of the operation on a tick box form akin to that used by the NJR. The prospectively gathered data is stored at the central registry office in Princess of Wales Hospital Bridgend. Results. A total of 68 forms were returned to the registry, 58 Males and 10 Females, average age 30 and 35 years respectively. Four per cent of ACL ruptures were treated non-operatively. Sixty two (96%) ACL ruptures were reconstructed; 57 primary reconstructions; 3 revisions; 2 were multi-ligament injuries. The most common mechanisms of injury in females were basketball and football. Rugby was the most common mechanism for males. Six PCL injuries were reported, half (3) were reconstructed, all using allograft Achilles tendon. Of the fifty seven primary ACL reconstructions, twenty nine (47%) ACL reconstructions were recorded with no meniscal injury, thirty (53%) of ACL reconstructions had concomitant meniscal injury, which equates to 8% requiring repair (5 medial, 1 lateral) and 25 (43%) requiring meniscectomy for non-repairable tears (15 medial, 10 Lateral). Cartilage lesions were seen in 18 reconstructions (27%). Of these 2 (3%) had synthetic mosaic plasty. Four lesions (6%) had chondroplasty and the remaining 12 (18%) treatment was not required but noted. Conclusion. The WKLR, although in its infancy, has shown that a ‘National Quality Database’ of this type is feasible and will provide the necessary quality assurance demanded by this active young group of patients. The WKLR will provide an invaluable research tool for assessing and comparing outcomes of the various techniques, graft types, and fixation devices. Failing implants can be identified early. Under performing institutions can be identified, and performance can be compared to the national average. All of these aims are focused at improving patient safety, satisfaction and outcome