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Background: A disadvantage of using hamstring tendon autograft consisting of the semitendinosus and gracilis tendons for anterior cruciate ligament reconstruction is pain from tendon harvesting and persistent hamstring weakness. In the tendon-sparing all-inside technique, a quadrupled semitendinosus graft and adjustable-loop cortical fixation are suggested to give less postoperative flexion deficits while displaying overall similar clinical results to the traditional hamstring technique. However, there are a limited number of high-quality studies comparing these techniques with inconsistent results. Purpose: To investigate differences between the all-inside (quadrupled semitendinosus) and traditional hamstring (double-stranded semitendinosus and gracilis) technique regarding (1) self-reported function, (2) hamstring strength, and (3) knee laxity. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 98 patients were randomized to either the all-inside or the traditional hamstring technique. Perioperatively, duration of surgery and graft size were obtained. The International Knee Documentation Committee 2000 Subjective Knee Form score, Knee injury and Osteoarthritis Outcome Score, Tegner Activity Scale score, knee laxity (KT-1000 arthrometer side-to-side difference and pivot shift), range of motion, isokinetic knee strength, and hop test score were collected preoperatively and 2 years postoperatively. Return-to-sport readiness was evaluated 9 months postoperatively. Results: A total of 89 patients completed 2-year follow-up, 45 patients with the all-inside technique and 44 patients with the traditional hamstring technique. There were no significant differences between groups in any of the outcome measures 2 years after surgery, but there was a tendency in the all-inside group toward having increased anterior translation (mean, 3.6 mm vs 2.7 mm), a higher number of revision surgeries (5 patients vs 2 patients), and more patients having +1 and +2 pivot-shift values (29 vs 18 patients) when compared with the traditional group. Conclusion: The all-inside technique yields equivalent results to the traditional hamstring technique 2 years after surgery and should be considered a reliable technique to use for ACL reconstruction. Sparing the gracilis tendon does not lead to less persistent hamstring weakness. Long-term follow-up is needed to further determine whether the tendency of increased anterior translation seen at 2 years postoperatively will lead to a higher risk of graft failure. [ABSTRACT FROM AUTHOR]

Introduction: Motor control deficits persist after anterior cruciate ligament reconstruction (ACLR), and are more than often responsible for bad return to play ability and reinjuries.Current information still lacks on the potential deficits in specific lower limb muscle activation during sport's specific tasks, or even basic tasks such as jumping Objective: The aim of this study was to measure muscular activity of the lower limb in patients performing single leg tasks during their rehabilitation process after ACLR. Design: Non randomized, Prospective, Case control study Methods: This study included 59 participants divided into two groups, a test group (n=31) which included patients after ACLR (5.6 ± 2.1 months) with a hamstring graft and a control group (n=28) including healthy subjects. Partici- pants were asked to perform four tries of both a Single Leg Counter Movement Jump (SLCMJ) and a Single Leg Drop Landing (SLDL), on each leg in a randomized order.1,2 The muscular activity of Vastus Medialis, Gluteus Medius, Soleus and of the Lateral et Medial Gastrocnemii was recorded. Raw EMG data was treated via Root Mean Square and maximum normalized value were used for the analysis and compared between groups. Results: Significant results showed a lower Soleus activity (-26.1%, p-value = 0.01), as well as a higher Vastus Medialis (+17.2, p-value = 0.03) and lower Gluteus Medius (-7.50%, p-value = 0.01) in the test group for the SLCMJ. Similar results were found in the SLDL, adding a lower Medial Gastrocnemius activity (-41.0%, p < 0.01). Other muscle showed non-significant differences between both groups. Conclusion: Neuromotor deficits are present after ACLR and can be linked to specific neuromuscular patterns, which may also help our current strength and function-based return to sport decision making, allowing athletes to return to their practice in better condition and decreased risks of injury. [ABSTRACT FROM AUTHOR]

Introduction: After anterior cruciate ligament reconstruction (ACLR), jump tests allow to help return to sport decision making. Objective: The main objective was to examine countermovement jump (CMJ) measures to identify which parameters can best distinguish between ACLR and control participants. The secondary objective was to determine whether performance alterations between operated and non-operated limb exist during vertical two-legged activities after ACLR Design: Non randomized, single blinded, prospective case control study Methods: This study included 67 patients with hamstring graft and no contact injury at 6 postoperative months (203.5 days ± 32.2) and 47 healthy athletes (25,2 ± 6,6 years old) with no knee injury history. Two groups were formed, an ACLR group (n=67) and a control group (n=47). The evaluation of CMJ by force plate was performed to calculate vertical ground reaction force (vGRF), maximal power (MP) and eccentric rate force development (RFDe) during landing and limb symmetry index (LSI). (1-3) First analysis compared LSI vGRF, LSI MP and LSI RFDe between both groups during CMJ. Secondary analysis compared vGRF, MP and RFDe between operated/non-operated limb in the ACLR group and dominant/non-dominant limb in the control group. Results: At 6 months after ACLR, CMJ measures in the ACLR group were significantly reduced compared to the control group for LSI vGRF (- 8.7% ; p < 0,001), LSI MP (- 10.8% ; p < 0,001) and LSI RFDe (- 8.7% ; p < 0,001). Secondary analysis showed no significant result in control group between dominant/non-dominant limb. ACLR group showed significant results between operated / non-operated limb for vGRF (+1.4 N.kg-1 ; p < 0,001), MP (+2.6 W.kg-1 ; p < 0,001) and RFDe (+ 375.3 N.s-1 ; p < 0,01). Conclusion: Landing performance and deceleration should be better considered at time to return to sport after ACLR. [ABSTRACT FROM AUTHOR]

Background: Meaningful change scores in the Knee injury and Osteoarthritis Outcome Score (KOOS) in patients undergoing anterior cruciate ligament (ACL) reconstruction have not yet been established. Purpose: To define the minimal important change (MIC) for the KOOS after ACL reconstruction. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: KOOS and anchor questions with 7-point scales ranging from “better, an important improvement” to “worse, an important worsening” were completed postoperatively by randomly chosen participants from the Norwegian Knee Ligament Registry. Presurgery KOOS scores were retrieved from the registry. The MIC for improvement was calculated with anchor-based approaches using the predictive modeling method adjusted for the proportion of improved patients, the mean change method, and the receiver operating characteristic (ROC) method. Results: Complete data for at least one of the KOOS subscales were obtained from 542 (45.3%) participants. Predictive modeling MIC values were 12.1 for the KOOS subscales of Sport and Recreational Function and 18.3 for Knee-Related Quality of Life. These values aid in interpreting within-group improvement over time and can be used as responder criteria when comparing groups. The corresponding and much lower values for the subscales of Pain (2.5), Symptoms (–1.2), and Activities of Daily Living (2.4) are the results from patients reporting, on average, only mild problems with these domains preoperatively. Although 4% to 10% of patients reported subscale-specific worsening, MIC deterioration calculations were not possible. The ROC MIC values were associated with high degrees of misclassification. Values obtained by the mean change method were considered less reliable because these estimates are derived from subgroups of patients. Average KOOS change scores were approximately similar for patients reporting acceptable symptoms postoperatively and patients reporting important improvements on the anchor items after surgery. Conclusion: KOOS users should apply subscale-specific cutoffs for meaningful improvement. Our results confirm using the subscales of Sport and Recreational Function and Knee-Related Quality of Life as primary patient-reported outcomes after ACL reconstruction. The predictive modeling approach gave the most robust estimates of MIC values. Our data suggest that reporting acceptable symptoms postoperatively corresponds to reporting an important improvement after ACL reconstruction. [ABSTRACT FROM AUTHOR]

Background: The administration of nonsteroidal anti-inflammatory drugs (NSAIDs) to patients undergoing anterior cruciate ligament reconstruction (ACLR) is controversial because it may impair tissue healing and clinical outcomes. Purpose: To assess the effect of NSAID administration on patients undergoing ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: Included patients were aged >15 years and were registered in the Norwegian Knee Ligament Registry from 2008 until 2013 after the primary ACLR. Patients with insufficient data regarding administration of NSAIDs and those with associated knee ligament injuries requiring surgical treatment were excluded from this study. Graft survival was estimated using Kaplan-Meier survival curves, and hazard ratios (HRs) for revision were evaluated using Cox regression analysis. Logistic regression analysis was used to calculate the odds ratio (OR) for a Knee Injury and Osteoarthritis Outcome Score (KOOS)–quality of life (QOL) subscale score <44 at 2-year follow-up. Results: A total of 7822 patients were included in the analysis for graft survival and assessment for risk of revision. Of these, 4144 patients were administered NSAIDs postoperatively. The mean duration of follow-up was 2.8 years (range, 0-5.9 years). Administration of NSAIDs did not influence graft survival (P = .568). Adjusted Cox regression analyses demonstrated the same finding regarding risk of revision (HR, 1.0; 95% CI, 0.8-1.3). ACLR using a bone–patellar tendon–bone autograft showed a reduced risk of revision (HR, 0.3; 95% CI, 0.1-0.8) among patients administered NSAIDs. In subgroup analyses of 3144 patients, administration of NSAIDs demonstrated a beneficial effect on the risk of a KOOS-QOL score <44 at 2-year follow-up (OR, 0.8; 95% CI, 0.6-0.9). Conclusion: Administration of NSAIDs to patients after ACLR does not have a negative effect on graft survival, risk of revision, or risk of a KOOS-QOL score <44 at 2-year follow-up. We emphasize using caution when administering NSAIDs by keeping the duration and dosage of NSAIDs as short and low as possible to ensure sufficient pain relief while limiting unwanted exposure to any known and unknown adverse effects of these drugs. [ABSTRACT FROM AUTHOR]

Background:The proportion of patients perceiving their symptoms as either acceptable or as a failure of treatment after anterior cruciate ligament reconstruction (ACLR) is unknown. Commonly used outcome scores such as the Knee injury and Osteoarthritis Outcome Score (KOOS) suffer from poor interpretability, and little is known about which scores represent an acceptable or failed postoperative outcome.Purpose:To determine the proportion of patients reporting acceptable symptoms or treatment failure at 6 to 24 months after ACLR and to define KOOS values corresponding to the patients’ perceptions of treatment outcome.Study Design:Cross-sectional study; Level of evidence, 3.Methods:In 2012, a total of 1197 patients were randomly extracted from the Norwegian Knee Ligament Registry at 3 postoperative time points: 397 at 6 months, 400 at 12 months, and 400 at 24 months. The inclusion criterion was unilateral primary ACLR. Questions about acceptable symptoms and treatment failure and the KOOS questionnaire were sent to the patients, and those who answered “yes” to the acceptable symptoms question were considered to have acceptable symptoms. Patients who answered “no” to the same question and “yes” to the treatment failure question were considered to have treatment failure. Mean KOOS values and 95% CIs were calculated for each category.Results:A complete data set was obtained from 598 (50%) responders. Fifty-five percent of the patients perceived their symptoms as acceptable at 6-month follow-up versus 66% at 12- to 24-month follow-up. Similarly, 7% at 6-month follow-up perceived their treatment to have failed versus 12% at 12- to 24-month follow-up. Postoperative mean KOOS subscale values ranged from 72 (95% CI, 70-74) to 95 (95% CI, 94-96) for patients with acceptable symptoms and from 28 (95% CI, 22-34) to 71 (95% CI, 65-76) for patients with treatment failure. For both categories, the worst subscale values were seen in the sport and recreation and quality of life subscales and the best in the activities of daily living subscale.Conclusion:Only half of the patients at 6 months and about two-thirds at 1 to 2 years perceived their symptoms as acceptable after ACLR. For these patients, KOOS values reflected no problems to mild problems on average, while for patients reporting treatment failure, KOOS values reflected moderate to severe problems. [ABSTRACT FROM AUTHOR]

The article discusses a study which aimed to determine the distribution of grafts for anterior cruciate ligament (ACL) reconstruction in Scandinavian and to compare the risk of revision between patellar tendon autografts and hamstring autografts. Results show that the majority of primary ACL reconstructions in the country are performed with hamstring autografts. It concluded that those receiving patellar tendon autografts have a lower risk of revision compared with hamstring autografts.

The article discusses a study evaluating outcome of employing single-legged hop-tests as a functional performance measure to capture limb asymmetrics in patients after anterior crucial ligament (ACL) reconstruction. Logistic regression analyses were performed, along with IKDC 2000 scores, and discriminative accuracy was measured. Findings suggests that hop tests can be a predictive factor of self reported knee function.

Background: The Norwegian Knee Ligament Register was founded in 2004 to provide representative and reliable data on cruciate ligament surgery. The aim of this study was to evaluate the validity of key variables in the Norwegian Knee Ligament Register to reveal and prevent systematic errors or incompleteness, which can lead to biased reports and study conclusions., Method: We included a stratified cluster sample of 83 patients that had undergone both primary and revision anterior cruciate ligament surgery. A total of 166 medical records were reviewed and compared with their corresponding data in the database of the Norwegian Knee Ligament Register. We assessed the validity of a selection of key variables using medical records as a reference standard to compute the positive predictive values of the register data for the variables., Results: The positive predictive values for the variables of primary and revision surgery ranged from 92 to 100% and from 39 to 100% with a mean positive predictive value of 99% and 88% respectively. Data on intraoperative findings and surgical details had high positive predictive values, ranging from 91 to 100% for both primary and revision surgery. The positive predictive value for the variable "date of injury" was 92% for primary surgeries but only 39% for revision surgeries. The positive predictive value for "activity at the time of injury" was 99% for primary surgeries and 52% for revisions., Conclusion: Overall, the data quality of the key variables examined in the Norwegian Knee Ligament Register was high, making the register a valid source for research., (© 2022. The Author(s).)

Background: Several factors are associated with an increased risk of anterior cruciate ligament (ACL) reconstruction revision. However, the ability to accurately translate these factors into a quantifiable risk of revision at a patient-specific level has remained elusive. We sought to determine if machine learning analysis of the Norwegian Knee Ligament Register (NKLR) can identify the most important risk factors associated with subsequent revision of primary ACL reconstruction and develop a clinically meaningful calculator for predicting revision of primary ACL reconstruction., Methods: Machine learning analysis was performed on the NKLR data set. The primary outcome was the probability of revision ACL reconstruction within 1, 2, and/or 5 years. Data were split randomly into training sets (75%) and test sets (25%). Four machine learning models were tested: Cox Lasso, survival random forest, generalized additive model, and gradient boosted regression. Concordance and calibration were calculated for all 4 models., Results: The data set included 24,935 patients, and 4.9% underwent a revision surgical procedure during a mean follow-up (and standard deviation) of 8.1 ± 4.1 years. All 4 models were well-calibrated, with moderate concordance (0.67 to 0.69). The Cox Lasso model required only 5 variables for outcome prediction. The other models either used more variables without an appreciable improvement in accuracy or had slightly lower accuracy overall. An in-clinic calculator was developed that can estimate the risk of ACL revision (Revision Risk Calculator). This calculator can quantify risk at a patient-specific level, with a plausible range from near 0% for low-risk patients to 20% for high-risk patients at 5 years., Conclusions: Machine learning analysis of a national knee ligament registry can predict the risk of ACL reconstruction revision with moderate accuracy. This algorithm supports the creation of an in-clinic calculator for point-of-care risk stratification based on the input of only 5 variables. Similar analysis using a larger or more comprehensive data set may improve the accuracy of risk prediction, and future studies incorporating patients who have experienced failure of ACL reconstruction but have not undergone subsequent revision may better predict the true risk of ACL reconstruction failure., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G758)., (Copyright © 2021 The Authors. Published by the Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Purpose: To analyse patient-related risk factors for 2-year ACL revision after primary reconstruction. The hypothesis was that younger athletes would have a higher incidence of an early ACL revision., Methods: This prospective cohort study was based on data from the Norwegian and Swedish National Knee Ligament Registries and included patients who underwent primary ACL reconstruction from 2004 to 2014. The primary end-point was the 2-year incidence of ACL revision. The impact of activity at the time of injury, patient sex, age, height, weight, BMI, and tobacco usage on the incidence of early ACL revision were described by relative risks (RR) with 95% confidence intervals (CI)., Results: A total of 58,692 patients were evaluated for eligibility and 30,591 patients were included in the study. The mean incidence of ACL revision within 2 years was 2.82% (95% CI 2.64-3.02%). Young age (13-19) was associated with an increased risk of early ACL revision (males RR = 1.54 [95% CI 1.27-1.86] p < 0.001 and females RR = 1.58 [95% CI 1.28-1.96] p < 0.001). Females over 1 SD in weight ran an increased risk of early ACL revision (RR = 1.82, [95% CI 1.15-2.88] p = 0.0099). Individuals with a BMI of over 25 ran an increased risk of early ACL revision (males: RR = 1.78, [95% CI 1.38-2.30] p < 0.001 and females: RR = 1.84, [95% CI 1.29-2.63] p = 0.008)., Conclusion: Young age, a BMI over 25, and overweight females were risk factors for an early ACL revision., Level of Evidence: II.