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Newer fixation devices for hamstring (HS) autograft have been introduced over the years, yet the impact of these devices on ACLR outcomes requiring surgical intervention remains unclear. We sought to evaluate the risk of aseptic revision and reoperation after HS autograft ACLR according to various femoral-tibial fixation methods. A cohort study was conducted using the Kaiser Permanente ACLR Registry. Primary isolated unilateral ACLR patients who received a HS autograft were identified (2007–2014). Fixation devices were categorized as crosspin, interference, suspensory, or combination (defined as more than one fixation device used on the same side) and femoral-tibial fixation groups used in more than 500 ACLR were evaluated. Cox proportional-hazard regression was used to evaluate the association between femoral-tibial fixation method and outcomes while adjusting for confounders. 6,593 primary ACLR were included. Four femoral-tibial fixation groups had more than 500 ACLR: suspensory–interference (n = 3004, 45.6%), interference–interference (n = 1659, 25.2%), suspensory–combination (n = 1103, 16.7%), and crosspin–interference (n = 827, 12.5%). After adjusting for covariates, revision risk was lower for crosspin–interference (HR = 0.43, 95% CI 0.29–0.65) and interference–interference (HR = 0.63, 95% CI 0.41–0.95) methods compared to the suspensory–interference. In contrast, reoperation risk was higher for crosspin–interference (HR = 2.13, 95% CI 1.37–3.32) and suspensory–combination (HR = 1.68, 95% CI 1.04–2.69) methods compared to suspensory–interference. ACLR using HS autograft appears to have the lowest risk of aseptic revision when crosspin or interference fixation is used on the femoral side and is coupled with an interference screw on the tibial side. III.

Objectives: Risk factors for anterior cruciate ligament reconstruction (ACLR) revision have included graft type, as well as fixation methods. Newer fixation techniques and devices for hamstring (HS) autograft have been introduced over the years. The purpose of this study was to compare the risk of aseptic revision after HS autograft ACLR between various femoral and tibial fixation methods/devices. Methods: Patients who underwent primary ACLR using a HS autograft from 2007-2014 were identified through a community-based registry for this retrospective cohort study. Bilateral, double bundle, and multiligament ACLRs were excluded. Patients were categorized (crosspin, interference, suspensory, or combination [more than one fixation]) based on the type of fixation utilized for the femur and tibia. Femoral/tibial fixation groupings with more than 500 patients were evaluated as a risk factor for aseptic revision, with adjustment for age, sex, body mass index, and race/ethnicity, using a multivariable Cox proportional-hazards regression model. Results: 6,716 primary ACLR patients were included, of whom 2,894 (38.8%) were younger than 22 years old, 4,111 (61.2%) were male, 2,956 (44.0%) had a BMI < 25 kg/m2, and 3,163 (47.1%) were caucasian. Five femoral/tibial groupings had more than 500 patients: suspensory/interference (n=2,176, 32.4%), suspensory/combination (n=1,940, 28.9%), interference/combination (n=1,025, 15.3%), interference/interference (n=845, 12.6%), and crosspin/combination (n=730, 10.9%). The cumulative failure probability at 5 years was highest for the suspensory/interference group (9.0%, 95% CI 7.2-11.2), followed by suspensory/combination (6.7%, 95% CI 5.4-8.4), interference/interference (5.1%, 95% CI 3.7-7.2), interference/combination (4.3%, 95% CI 2.9-6.3), and crosspin/combination (3.1%, 95% CI 2.0-4.9). After adjusting for the other covariates, the hazard ratio for aseptic revision was 2.9 (95% CI 1.9-4.7) for the suspensory/interference group, 2.7 (95% CI 1.7-4.5) for the suspensory/combination group, 1.6 (95% CI 0.9-3.0) for the interference/combination group, and 2.1 (95% CI 1.2-3.7) for the interference/interference group when compared to the crosspin/combination group. Conclusion: ACLR using HS autograft appears to have the highest risk of aseptic revision when suspensory fixation is used on the femoral side and is coupled with either an interference screw or combination fixation on the tibial side. Understanding the device-related risk of aseptic revision after HS autograft ACLR will help guide surgeons regarding which devices may negatively influence surgical outcomes.

BackgroundKnee hyperextension can be a serious and disabling injury in both the athletic and general patient population. Understanding the pathoanatomy and pathomechanics is critical for accurate surgical soft tissue reconstructions.PurposeTo quantify the effects of knee hyperextension injury on knee laxity in a human cadaveric model and to qualitatively assess the anatomical injury pattern through surgical dissection.Study DesignDescriptive laboratory study.MethodsSix fresh-frozen cadaveric knees were rigidly mounted on a custom knee testing system that simulates clinical laxity tests. The knee laxity measurements consisted of anterior-posterior laxity, internal-external rotational laxity, and varus-valgus laxity using a custom testing setup and a Microscribe 3DLX system. The laxity data were collected at both 30° and 90° of knee flexion for the intact specimens and then after 15° and 30° hyperextension injury. After biomechanical assessment a detailed dissection was performed to document the injured structures in the knee. Repeated-measures analysis of variance with a Tukey post hoc test ( P < .05) was used for statistical comparison.ResultsThe results from this study suggest progressive damage to translational and rotational knee soft-tissue restraints with increasing knee hyperextension. Knee hyperextension to 30° caused the most significant increase in anterior-posterior and rotational laxity. Anatomical dissections showed a general injury pattern to the posterolateral corner, partial femoral anterior cruciate ligament avulsion in 4 of 6 specimens, and no gross posterior cruciate ligament injuries.ConclusionInjuries to the posterolateral corner of the knee can result from isolated knee hyperextension.Clinical RelevanceThe clinician should be aware of the potential for posterolateral corner injuries with isolated knee hyperextension. This will allow early surgical planning and primary surgical repair.

Fixed rotation of either the femur or tibia has a significant influence on the patellofemoral joint contact areas and pressures. This is due to the anatomic asymmetry in the knee with respect to all planes, as well as the laterally directed force vector that naturally exists in bipedal lower-limb biomechanics. Specifically, femoral rotation results in an increase in patellofemoral contact pressures on the contralateral facets of the patella, and tibial rotation results in an increase in patellofemoral contact pressures on the ipsilateral facets of the patella. This difference can be elucidated when one considers that rotation of the femur is biomechanically different than rotation of the tibia. For both tibial and femoral rotations, the patella's distal attachment to the tibial tubercle influences the direction of patellar movement. The biomechanical evidence reviewed in this manuscript suggests that the determining factor in patellofemoral pathology is the derangement of normal joint mechanics. However, despite considerable experimental data supporting this position, there also are theories that suggest otherwise. This illustrates a very important point in patellofemoral joint pathology, where no one factor may be the sole defining etiology. Instead, the patellofemoral joint is one of the most complex diarthrodial joints in the body and there are a number of etiologic factors that can lead to pathology. This should be considered for developing repair and rehabilitation strategies.

Cutaneous electromagnetic position sensors were used to quantify anteroposterior laxity of the shoulder. Forty-three female athletes were tested (27 were soccer players and 16 were swimmers). The athletes had a mean age of 18.8 years (range, 17-24 years), and all were free of shoulder disorders. Dominant and nondominant shoulders were tested. Each shoulder was suspended in 90 degrees abduction and neutral rotation. Serial anteroposterior translations were done manually similar to an anteroposterior drawer examination of the shoulder. The glenohumeral translation for the soccer players was 9.6 mm (range, 5.8-15.1 mm) in the dominant shoulder and 10.7 mm (range, 5.2-16.7 mm) in the nondominant shoulder. The translations in the swimmers were significantly greater at 12.4 mm (range, 8.9-15.9 mm) in the dominant and 13.8 mm (range, 8.8-17.4 mm) in the nondominant shoulders. The mean of the differences between the dominant and nondominant shoulders was 2.1 mm for the swimmers and soccer players. For the soccer players, the range for the side to side differences was 0.1 to 5.3 mm. For the swimmers, the range was 0.1 to 4.3 mm. Finding a clinical device for objective measurement of joint laxity in the shoulder that is accurate, reproducible, noninvasive, and easy to use has been evasive.

Background The International Knee Documentation Committee (IKDC) forms are commonly used to measure outcomes after anterior cruciate ligament (ACL) reconstruction. The knee examination portion of the IKDC forms includes a radiographic grading system to grade degenerative changes. The interrater and intrarater reliability of this radiographic grading system remain unknown. Hypothesis We hypothesize that the IKDC radiographic grading system will have acceptable interrater and intrarater reliability. Study Design Case series (diagnosis); Level of evidence, 4. Methods Radiographs of 205 ACL-reconstructed knees were obtained at 5-year follow-up. Specifically, weightbearing posteroanterior radiographs of the operative knee in 35° to 45° of flexion and a lateral radiograph in 30° of flexion were used. The radiographs were independently graded by 2 sports medicine fellowship—trained orthopaedic surgeons using the IKDC 2000 standard instructions. One surgeon graded the same radiographs 6 months apart, blinded to patient and prior IKDC grades. The percentage agreement was calculated for each of the 5 knee compartments as defined by the IKDC. Interrater reliability was evaluated using the intraclass correlation coefficient (ICC) 2-way mixed effect model with absolute agreement. The Spearman rank-order correlation coefficient (rs) was applied to evaluate intrarater reliability. Results The interrater agreement between the 2 surgeons was 59% for the medial joint space (ICC = 0.46; 95% confidence interval [CI] = 0.35-0.56), 54% for the lateral joint space (ICC = 0.45; 95% CI = 0.27-0.58), 49% for the patellofemoral joint (ICC = 0.40; 95% CI = 0.26-0.52), 63% for the anterior joint space (ICC = 0.20; 95% CI = 0.05-0.34), and 44% for the posterior joint space (ICC = 0.28; 95% CI = 0.15-0.40). The intrarater agreement was 83% for the medial joint space (rs = .77, P < .001), 86% for the lateral joint space (rs = .76, P < .001), 81% for the patellofemoral joint (rs = .79, P < .001), 91% for the anterior joint space (rs = .48, P < .001), and 69% for the posterior joint space (rs = .64, P < .001). Conclusions While intrarater reliability was acceptable, interrater reliability was poor. These findings suggest that multiple raters may score the same radiographs differently using the IKDC radiographic grading system. The use of a single rater to grade all radiographs when using the IKDC radiographic grading system maximizes reliability.

Background: The incidence of nonrevision reoperations after anterior cruciate ligament reconstruction (ACLR) is less commonly studied and quantified. Purpose: To describe the incidence of short-term reoperations after primary ACLR for the 4 most common procedures and to evaluate the risk factors associated with these reoperations. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent ACLRs and were enrolled in an ACLR registry between February 2005 and September 2011 were evaluated. First reoperations after primary ACLR performed for the 4 most common procedures (meniscal procedures, cartilage procedures, hardware removal procedures, and arthrofibrosis procedures) were the primary end points of the study. Patient, surgical, surgeon, and hospital risk factors associated with reoperations were evaluated, and Cox regression models were employed. Hazard ratios (HRs) and 95% confidence intervals (CIs) are reported. Results: A total of 14,522 ACLRs were identified. The patients had a mean age of 29.4 ± 11.5 years and were mostly male (63.3%) and white (48.3%). The mean follow-up was 1.9 ± 1.5 years (range, 0-6.7 years), and the median time to reoperation was 301 days (interquartile range, 172-515 days). The reoperation rate per 100 person-years of follow-up was 1.1 for meniscal reoperations, 0.3 for cartilage reoperations, 0.4 for hardware removal reoperations, and 0.4 for arthrofibrosis reoperations. Meniscal repair at the index ACLR was a significant risk factor for subsequent meniscal procedures (HR, 4.19; 95% CI, 3.10-5.67). Sports medicine fellowship training of the surgeon (HR, 2.17; 95% CI, 1.01-4.62) and older patient age (≤17 vs ≥26 years) (HR, 0.32; 95% CI, 0.12-0.81) were significant risk factors for cartilage reoperations. Use of allografts (HR, 1.90; 95% CI, 1.10-3.30) and female sex (HR, 1.75; 95% CI, 1.16-2.64) were risk factors for hardware removal reoperations. Female sex (HR, 2.48; 95% CI, 1.66-3.71) and prior surgery (HR, 3.02; 95% CI, 1.39-6.53) were risk factors for subsequent surgery for arthrofibrosis. Conclusion: Overall short-term reoperation rates after ACLR are relatively low. Risk factors for subsequent surgery vary depending on the type of surgery evaluated. Some of the risk factors observed for reoperations include previous meniscal repair, female sex, allografts, prior surgery, older patient age, and being operated on by a sports medicine fellowship–trained surgeon.

Patellofemoral instability can be a disabling problem. Numerous techniques are employed for its treatment. Medial patellofemoral ligament (MPFL) reconstruction in combination with other procedures has been explored by many orthopedic surgeons. The purpose of the study was to determine the effectiveness of isolated MPFL reconstruction in treating the symptoms associated with patellofemoral instability, preventing recurrence of patella dislocation, and returning patients to preinjury level of activity. This is a case series study. We conducted a clinical follow-up study on 56 knees (49 patients) after MPFL reconstruction for recurrent patellar instability with a mean follow-up of 4.3 years (range, 1.1–6.8). A single MPFL reconstruction technique was performed in all cases. Patient outcomes were evaluated using: International Knee Documentation Committee (IKDC) subjective knee form, Tegner activity score, functional hop test, and radiographs. Mean age at time of surgery was 24 years old (range, 13–49). Females comprised 75% of the sample. Mean interval from injury to surgery was 7.2 ± 8.6 years (range, 51 days–37 years). At follow-up, there were no recurrent dislocations reported, patella subluxation in 6 (11%) cases, and radiographic degenerative changes were none to mild in all patients. The series mean IKDC scores at follow-up was 76.3 ± 19.2 (range, 30–99), and Tegner activity scores were 5.6 ± 2.5. MPFL reconstruction is an option for treating the symptoms of patellar instability, preventing recurrent dislocation, and returning patients near to their preinjury level of activity. The level of evidence is IV Refereed/Peer-reviewed

Both nonoperative and operative treatments for anterior cruciate ligament (ACL) deficient knees in skeletally immature patients have reported potentially negative outcomes. This study describes primary ACL reconstruction patients with open physes and their concurrent injuries and evaluates whether these patients are at a higher early risk of revision and reoperation than closed physes patients. A retrospective analysis of prospectively collected data was performed. Patients were identified using an ACL Reconstruction Registry. Summary statistics comparing open and closed physes patients of similar ages in regard to patient characteristics and incidence of early revision and reoperation are provided. Adjusted Cox regression models assessed risk of early revision and reoperation for open physes patients. Of 1,867 patients identified, 232 (12.4%) patients had open physes and 1,635 (87.6%) patients had closed physes. Patients with open physes were younger, less likely to be women, and had less medial meniscal injuries than closed physes patients. No significant differences were observed in cartilage injury, overall menisci injury and repair, and early revision and reoperation rate. According to the our results, no significant differences in risk of early revision or early reoperation in open physes compared with closed physes patients when adjusting for age were observed, nor were there any reoperations for physeal closure. Refereed/Peer-reviewed

Background: It has been suggested that a surgeon’s experience and training are the most important factors associated with graft selection, but no studies have qualified this association. Graft usage prevalence has not been described for large anterior cruciate ligament reconstruction (ACLR) populations in the United States. Purpose: To describe the prevalence of graft usage in a large community-based practice and evaluate the association of patient, surgeon, and site characteristics with choice of primary ACLR graft. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Primary ACLRs performed between February 2005 and June 2010 were selected for the study. A community-based ligament registry was used to identify cases and variables used for analysis. Graft choice (any allograft, hamstring autograft, and bone–patellar tendon–bone [BPTB] autograft) was compared by patient characteristics and surgeon and site characteristics. Associations between independent variables and graft choice were evaluated using a polychotomous regression model. Results: Of the 9849 patients included in the study, 64% were male, and overall median age was 28 years. Of these, 2796 (28.4%) received BPTB autografts, 3013 (30.6%) received hamstring autografts, and 4040 (41.0%) received allografts. The prevalence of graft source by patients’ gender, race, age, body mass index (BMI), as well as surgeons’ fellowship training status, average volume, and site volume were significantly different (all P < .001). Adjusted models showed that patients’ gender ( P < .001), race ( P = .018), age ( P < .001), BMI ( P < .001), as well as surgeons’ fellowship training status ( P < .001), average volume ( P < .001), and site volume ( P < .001) are associated with graft selection. Older and female patients with lower BMI were more likely to receive allografts and hamstring autografts than BPTB autografts. Cases performed by non–fellowship-trained surgeons, lower volume sites, and/or lower volume surgeons were also more likely to be performed with allografts or hamstring autografts than BPTB autografts. Conclusion: Gender, age, race, as well as facility and surgeon characteristics such as volume and location are associated with ACL graft choices.

Background: Functional instability after anterior cruciate ligament injury can be successfully treated with ligament reconstruction. However, the associated meniscus and cartilage lesions often cannot be repaired and may have long-term detrimental effects on knee function. Purpose: The authors used the large database within the Kaiser Permanente Anterior Cruciate Ligament Reconstruction Registry to evaluate time to surgery, age, and gender as risk factors for meniscus and cartilage injury and associations with meniscus repair rates in patients. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective review of the Kaiser Permanente Anterior Cruciate Ligament Reconstruction Registry was performed. The associations between time to surgery, age, and gender with meniscus and cartilage lesions and meniscus repair were analyzed using binary logistic regression modeling to calculate odds ratios (ORs) while adjusting for potential confounding variables. Results: A total of 1252 patients met the inclusion criteria. The risk of medial meniscus injury increased only with time to surgery (6–12 months: OR = 1.81, 95% confidence internal [CI] 1.29-2.54, P = .001; and >12 months: OR = 2.19, 95% CI 1.58-3.02, P < .001). The risk of lateral meniscus injury decreased only with female gender (OR = 0.65, 95% CI 0.51-0.83, P = .001). The risk of cartilage injury increased with age (OR = 1.05 per year, 95% CI 1.04-1.07, P < .001) and time to surgery >12 months (OR = 1.57, 95% CI 1.12-2.20, P = .009), but decreased with female gender (OR = 0.71, 95% CI 0.54-0.92, P = .009). Medial meniscus repairs relative to medial meniscus injury decreased with increasing time to surgery (3-6 months: OR = 0.61, 95% CI 0.37-1.00, P = .050; and >12 months: OR = 0.41, 95% CI 0.25-0.67, P < .001) and increasing age (OR = 0.96 per year, 95% CI 0.94-0.98, P < .001). Conclusion: Increased risk of medial meniscus injury and decreased repair rate were strongly associated with increasing time to surgery. Increased risk of cartilage injury was associated with increasing age, increasing time to surgery, and male gender.

Context: Anterior cruciate ligament (ACL) reconstructions are among the most common sports medicine procedures performed in the US each year. Differences have been reported in the incidence rates (IRs) of ACL tears among male and female national elite athletes. However, there is little information in the published literature that assesses IRs for ACL reconstructions done in the Health Maintenance Organization (HMO) setting specifically. Different populations may show variation in ACL reconstruction IRs. Objective: This study reports on the IR of ACL reconstructions in a predefined population and compares the differences in age and sex over time. Design: A retrospective analysis of 4485 ACL reconstructions performed within Kaiser Permanente Southern California between 2001 and 2005 was completed by a query of an administrative database. Trends in IRs per 100,000 members were calculated and compared across age, sex, and the five-year study period. Main Outcome Measures: Linear regression was used to test trends in IR. Sex distribution was compared using the χ 2 test. Analysis of variance was used to compare the mean age from year to year in males and females. The independent sample t-test was used to compare mean age between males and females for each independent year. Results: The IR of ACL reconstructions in females rose significantly (p = 0.010) from 14.4 in 2001 (95% confidence interval [CI], 12.6–16.3) to 19.3 in 2005 (95% CI, 17.2–21.5). Within specific age groups, IR increased significantly for females age 14 to 17 (p = 0.013), 18 to 21 (p = 0.017), and 45 to 49 years (p = 0.014). The most dramatic change was seen in the female age category of 14 to 17 years, which increased at a rate of 8.14 cases/100,000 members per year. Conclusion: Identifying the sex and age groups with most rapidly increasing rates of ACL reconstructions is important in implementing ACL injury-prevention programs.

BackgroundExternal rotational torque is one of the mechanisms that may occur during a pivoting or twisting injury to the knee.HypothesisSimulated external rotational injury by applying external rotational torque will increase knee laxity and cause soft tissue damage to the knee.Study DesignControlled laboratory study.MethodsSix cadaveric knees and a custom testing system were used to produce external rotational torque of 30°, 45°, and 60° with the knee at 30° of flexion. Anterior-posterior, valgus-varus, and rotational knee laxity were quantified. After sequential rotational torque to 60°, the specimens were dissected to identify injured structures.ResultsExternal rotational torque of 45° and 60° significantly increased knee joint laxity in all directions (P ConclusionExternal rotational torque to 60° increased knee laxity, and dissection revealed a consistent pattern of injury to the medial and lateral collateral and anterior cruciate ligaments and posterolateral corner.Clinical RelevanceBecause isolated ligament injuries are rare, recognizing these combined ligamentous injuries early is essential for repair in the acute stage.

BackgroundSpecific guidelines for operative versus nonoperative management of anterior cruciate ligament injuries do not yet exist.HypothesisSurgical risk factors can be used to indicate whether reconstruction or conservative management is best for an individual patient.Study DesignProspective nonrandomized controlled clinical trial; Level of evidence, 2.MethodsPatients were classified as high, moderate, or low risk using preinjury sports participation and knee laxity measurements. Early anterior cruciate ligament reconstruction (within 3 months of injury) was recommended to high-risk patients and conservative care to low-risk patients. It was recommended that moderate-risk patients have either early reconstruction or conservative care, according to the day of presentation. Assessment of subjective outcomes, activity, physical measurements, and radiographs was performed at mean follow-up of 6.6 years.ResultsEarly phase conservative management resulted in more late phase meniscus surgery than did early phase reconstruction at all risk levels (high risk, 25% vs 6.5%; moderate risk, 37% vs 7.7%, P =. 01; low risk, 16% vs 0%). Early- and late-reconstruction patients’ Tegner scores increased from presurgery to follow-up (P ConclusionsEarly phase reconstruction reduced late phase knee laxity, risk of symptomatic instability, and the risk of late meniscus tear and surgery. Moderate- and high-risk patients had similar rates of late phase injury and surgery. Reconstruction did not prevent the appearance of late degenerative changes on radiographs. Relationship between bone contusion on initial magnetic resonance images and the finding of degenerative changes on follow-up radiographs were not detected. The treatment algorithm used in this study was effective in predicting risk of late phase knee surgery.

Patellofemoral pain is associated with patellar malalignment and quadriceps weakness which are seen more commonly in women. The objective of the current study was to determine the effects of gender, vastus medialis strength, and tibial rotation on patellofemoral joint biomechanics. Twelve fresh-frozen knees from cadavers were tested using a custom knee jig. Anatomic multiplane loading of the extensor mechanism was used with varying vastus medialis loads. Patellofemoral contact area and pressure were measured using pressure sensitive film at knee flexion angles of 0 degrees, 30 degrees, 60 degrees, and 90 degrees with the tibia in neutral and 15 degrees internal and external tibial rotation. Patellofemoral joint contact areas in specimens from men were larger at knee flexion angles greater than 30 degrees. A significant increase in mean patellofemoral contact pressures was seen for specimens from women when compared with specimens from men at 0 degrees and 30 degrees knee flexion. The knees from women also showed a greater change in contact pressures to varying vastus medialis load at knee flexion angles of 0 degrees, 30 degrees, and 60 degrees. The results of the current study indicate that there are gender differences in patellofemoral contact areas and pressures. These differences may help explain the increased incidence of patellofemoral disorders in women.