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The difficulties of rehabilitation after anterior cruciate ligament (ACL) injuries, subsequent return-to-sport (RTS) let alone achieving pre-injury performance, are well known. Isokinetic testing is often used to assess strength capacities during that process. The aim of the present machine learning (ML) approach was to examine which isokinetic data differentiates athletes post ACL reconstruction (ACLR) and healthy controls. Two Random Forest models were trained from data of unilateral concentric and eccentric knee flexor and extensor tests (30°/s, 150°/s) of 366 male (63 post ACLR) as well as 183 female (72 post ACLR) athletes. Via a cross-validation predictive performance was evaluated and the Random Forest showed outstanding results for male (AUC = 0.90, sensitivity = 0.76, specificity = 0.88) and female (AUC = 0.92, sensitivity = 0.85, specificity = 0.89) athletes. The Accumulated Local Effects plot was used to determine the impact of single features on the predictive likelihood. For both male and female athletes, the ten most impactful features either referred to the disadvantageous (injured, non-dominant in control group) leg or to lateral differences. The eccentric hamstring work at 150°/s was identified as the most impactful single parameter. We see potential for improving the RTS process by incorporating and combining measures, which focus on hamstring strength, leg symmetry and contractional work. [ABSTRACT FROM AUTHOR]

Background: Quadriceps tendon (QT), bone–patellar tendon–bone (BPTB), and hamstring tendon (HT) autografts are widely used for anterior cruciate ligament reconstruction (ACLR), but the optimal autograft choice remains controversial. This study assessed the treatment effects of QT versus BPTB and HT autografts for ACLR. Methods: The PubMed, Embase, and Cochrane Library databases were systematically searched for eligible studies published from inception until July 2022. Effect estimates were presented as odds ratios (OR) and weighted mean differences (WMD) with 95% confidence intervals (CI) for categorical and continuous variables, respectively. All pooled analyses were performed using a random-effects model. Results: Twenty-one studies (3 randomized controlled trials [RCTs], 3 prospective studies, and 15 retrospective studies) involving 2964 patients with ACLR were selected for meta-analysis. Compared with the HT autograft, the QT autograft was associated with a reduced risk of graft failure (OR: 0.46; 95% CI: 0.23–0.93; P = 0.031). Compared with the BPTB autograft, the QT autograft was associated with a reduced risk of donor site pain (OR: 0.16; 95% CI: 0.10–0.24; P < 0.001). Moreover, the QT autograft was associated with a lower side-to-side difference than that observed with the HT autograft (WMD: − 0.74; 95% CI: − 1.47 to − 0.01; P = 0.048). Finally, compared with the BPTB autograft, the QT autograft was associated with a reduced risk of moderate-to-severe kneecap symptoms during sports and work activities (OR: 0.14; 95% CI: 0.05–0.37; P < 0.001). Conclusions: The findings of this study suggest that the QT autograft can be defined as a safe and effective alternative choice for ACLR, but its superiority is yet to be proven by RCTs and prospective studies. Level of evidence Level III. [ABSTRACT FROM AUTHOR]

Anterior cruciate ligament (ACL) injury rates are on the rise, despite improved surgical techniques and prevention programs. While traditional rehabilitation emphasizes the restoration of motion, strength, and physical performance, emerging research highlights the importance of addressing neurocognitive deficits that can persist after injury. These deficits, including altered proprioception, impaired motor control and muscle recruitment, as well as heightened reliance on visual feedback, can significantly increase the risk of re-injury and impede return to sport. The purpose of this clinical commentary is to outline a proposed comprehensive approach to rehabilitation that challenges the neurocognitive system to optimize rehabilitation outcomes and reduce reinjury risk. Thus, this clinical commentary discusses the rationale for integrating neurocognitive training into all phases of ACLR rehabilitation, from initial injury to eight weeks post-surgery. It details the neurophysiological changes caused by ACL injury and presents evidence supporting the use of exercises that challenge visual attention, decision-making, and motor planning. A comprehensive rehabilitation framework incorporating both physical and neurocognitive components is proposed, aiming to improve long-term outcomes and reduce re-injury risk. Level of Evidence: 5 [ABSTRACT FROM AUTHOR]

Background: After anterior cruciate ligament reconstruction (ACLR), asymmetry is likely to persist in single-leg (SL) vertical jump and drop jump performance than in SL hop distance. However, its relationship with the return to sport (RTS) remains unclear. Hypothesis/Purpose: This study aimed to determine the association between vertical jump performance after primary ACLR using hamstring tendon autograft and RTS at a pre-injury competitive level. Study design: Cross-sectional study Methods: Patients who underwent primary ACLR using hamstring tendon autograft were recruited for this study. Participants who returned to pre-injury competition after ACLR were recruited at least eight months postoperatively. Knee condition was assessed, including joint laxity, range of motion, muscle strength, and knee pain intensity during sports activities. Performance variables were also assessed, including SL hop distance, jump height in SL vertical jump, and reactive strength index (RSI; jump height/contact time) in SL drop jump. Participants were asked to subjectively report whether they had returned to the same level of competition as pre-injury and their perceived sport performance intensity. Those who answered "Yes" to the dichotomous question and had a postoperative subjective athletic performance of > 80% were categorized into the Yes-RTS group. The primary outcome was the ability to achieve RTS at the preinjury level. Results: Sixty-five patients (female, 35; male, 30) at 13.0 (13.0) [median (interquartile)] months after ACLR participated in this study. Thirty-nine (60%) were assigned to the Yes-RTS group. Regarding knee conditions, the No-RTS group had a significantly higher knee pain intensity, as assessed using a numerical rating scale (p<0.001, effect size -0.45). In the performance tests, the No-RTS group exhibited a significantly lower limb symmetry index of RSI during the SL drop jump compared to the Yes-RTS group (p=0.002, effect size 0.81). Conclusion: Patients unable to achieve RTS after primary ACLR using hamstring grafts are more likely to exhibit asymmetric performance during the SL drop jump test, suggesting the significance of assessing jump symmetry when evaluating post-ACLR rehabilitation success. Level of Evidence: 3c [ABSTRACT FROM AUTHOR]

BACKGROUND: The maximum muscle strength is typically used for evaluating the recovery of muscle function after anterior cruciate ligament reconstruction. Recent studies have suggested that neuromuscular function should also be considered, such as rate of force development, which measures the slope of the force time curve at different time intervals under conditions of isometric muscle contraction. OBJECTIVE: To elaborate on the current research status and shortcomings of muscle isometric rate of force development in patients undergoing anterior cruciate ligament reconstruction surgery, and analyze the degree of defects in quadriceps femoris and hamstring isometric rate of force development at different times after surgery; to analyze the effect of isometric rate of force development on postoperative functional performance, thereby providing important information for optimizing postoperative rehabilitation following anterior cruciate ligament reconstruction, reducing secondary injury to patients, and reducing the incidence of knee osteoarthritis. METHODS: Literature retrieval of CNKI, VIP, WanFang and PubMed was performed using “anterior cruciate ligament, rate of force development” as Chinese search terms and “anterior cruciate ligament, rate of force development, rate of torque development” as English search terms. Finally, 69 articles were included according to inclusion and exclusion criteria. RESULTS AND CONCLUSION: Most studies have found defects in bilateral muscle isometric rate of force development in patients undergoing anterior cruciate ligament reconstruction within 6 months. Early isometric rate of force development of the bilateral hamstring muscles (i.e. the slope of the force time curve at any time interval during muscle contraction of 100 ms) showed significant improvement after 6 months. However, long-term defects in early isometric rate of force development of the bilateral quadriceps indicate long-term damage to the neuromuscular function of the quadriceps after surgery. There is limited research on late isometric rate of force development (the slope of the force time curve at any time interval after 100 ms of muscle contraction), and conclusions cannot be drawn. Regarding landing exercises (jumping to the ground, lateral cutting, etc.) and daily activities (walking, running), early isometric rate of force development of the quadriceps is more correlated with isometric peak torque. Abnormal biomechanical changes during exercise are considered an important risk factor for secondary injury and traumatic knee osteoarthritis in patients. Actively improving early isometric rate of force development of the quadriceps may reduce the incidence of secondary injury and traumatic knee osteoarthritis. Currently, there is limited evidence to suggest that wholebody vibration training can improve early isometric rate of force development of the quadriceps femoris in patients undergoing anterior cruciate ligament reconstruction. It is recommended to use neuromuscular electrical stimulation to intervene in the quadriceps and hamstring in the early postoperative stage and implement explosive force and high resistance training in the late postoperative stage, which may improve the isometric rate of force development in patients. Generating sufficient muscle strength in a short period of time is necessary to effectively protect the anterior cruciate ligament, while the relationship between isometric rate of force development in the hamstring muscle and functional performance is still unclear, which may provide information on preventing secondary injury in patients. It is recommended to use the isometric rate of force development as one of the evaluation indicators for guiding rehabilitation and restoring movement. In addition to focusing on improving symmetry and differences from normal individuals, the hamstring to quadriceps strength ratio should also be considered. An appropriate range of ratios can ensure the balance of muscles during rapid muscle exertion, which may reduce the occurrence of secondary injuries. However, the normal range of ratios is not yet clear. Future research should consider the effects of graft type and knee flexion angle on isometric rate of force development, in order to identify neuromuscular dysfunction in patients as much as possible and help them recover better. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective Methods Results Conclusions The influence of the graft sagittal inclination angle (SIA) on knee stability, biomechanics, and graft maturity has been elucidated. However, no study has comprehensively described the effects of SIA on the aforementioned postoperative prognostic indicators. So, we aimed to determine whether the sagittal inclination angle (SIA) of a graft is associated with postoperative graft maturity, joint stability, and joint function after anterior cruciate ligament (ACL) reconstruction.Patients who had undergone ACL reconstruction between April 2019 and February 2022 and those with intact ACL were eligible. Using magnetic resonance imaging, graft maturity was evaluated as the mean signal‐to‐noise quotient (SNQ) measured in three regions. Anterior tibial translation (ATT) was used to evaluate knee stability. Correlation analysis was conducted for the SIA, ATT, and clinical outcome scores. Multivariate stepwise regression analysis was used on the SIA and potential risk factors to determine their association with the graft SNQ. The SIA threshold of knee instability was calculated by receiver‐operating characteristic curves.Sixty‐three postoperative patients were enrolled. The SIA was significantly negatively associated with graft SNQ value. A multivariate stepwise regression analysis showed that SIA and body mass index were significant influencing factors associated with the graft SNQ. Correlations between the SIA and medial and lateral ATT were statistically significant. A larger SIA resulted in a decreased probability of medial and lateral ATT ≥ 5 mm. The SIA threshold of an increased risk of lateral ATT ≥ 5 mm was < 44.4°. A positive correlation was observed between SIA and subjective symptom subscales in the KOOS.A low SIA is not conducive to graft maturation after ACL reconstruction. A larger graft SIA was correlated with better postoperative knee stability. However, the effect of the SIA on joint function was only significant in terms of symptoms. Therefore, these new findings provide new ideas for preoperative assessment and intraoperative determination of the ideal graft inclination. [ABSTRACT FROM AUTHOR]

The objectives of this study were to evaluate the reliability of cartilage T2 relaxation time measurements and to identify focal changes in T2 relaxation on the affected knee from 6 to 24 months after anatomic anterior cruciate ligament reconstruction (ACLR). Data from 41 patients who received anatomic ACLR were analyzed. A bilateral 3.0‐T MRI was acquired 6 and 24 months after ACLR. T2 relaxation time was measured in subregions of the femoral condyle and the tibial plateau. The root‐mean‐square coefficient of variation (RMSCV) was calculated to evaluate the reliability of T2 relaxation time in the contralateral knee. Subregion changes in the affected knee T2 relaxation time were identified using the contralateral knee as a reference. The superficial and full thickness layers of the central and inner regions showed good reliability. Conversely, the outer regions on the femoral side and regions in the deep layers showed poor reliability. T2 relaxation time increased in only 3 regions on the affected knee when controlling for changes in the contralateral knee, while changes in T2 relaxation time were identified in 14 regions when not using the contralateral knee as a reference. In conclusion, evaluation of cartilage degeneration by T2 relaxation time after ACLR is most reliable for central and inner cartilage regions. Cartilage degeneration occurs in the central and outer regions of the lateral femoral condyle from 6 to 24 months after anatomic ACLR. [ABSTRACT FROM AUTHOR]

Background: ACL reconstruction is often regarded as the most effective approach of restoring knee stability. Several graft possibilities are available, including (BPTB), four-strand hamstring autografts, quadriceps tendon, and peroneus longus tendon. Each has both advantages and cons. This study compares the effectiveness of peroneus longus and hamstring tendon autografts for single bundle ACL restoration. Patients and Methods: The study involved 60 patients. Thirty of them had their torn anterior cruciate ligaments reconstructed arthroscopically using hamstring tendons, while the other 30 had their ACLs managed arthroscopically with peroneus longus tendon. The follow-up period lasted at least 12 months. Patients were assessed using IKDC score and Lysholm score. Ankle function was assessed using AOFAS score. Results: There was a statistically significant difference in preoperative and postoperative range of motion improvement in each group as an IKDC score item. However, no statistically significant difference existed between both groups. A statistically significant change in Lysholm scores preoperatively and postoperatively in each group was detected, but there was no statistical difference between groups 1 and 2, either in terms of improvement or percentage improvement. The AOFAS score was used also to assess for any donor site morbidity. No significant difference was detected between both ankles range of motion and no ankle joint dysfunction or problems with sports activities. Conclusion: The current study found that the PL tendon autograft might be considered a safe, effective and a technically easy graft option for ACLR. The research shows no substantial difference in postoperative knee stability or graft failure rate between hamstring and peroneus tendons. [ABSTRACT FROM AUTHOR]

Return from sport-related injury requires interprofessional collaboration to progress the athlete through a multistage rehabilitation continuum and successfully re-establish a performance level at or above the preinjury level. To achieve an optimal rehabilitation outcome, evidence-based exercise prescription must be considered throughout the entire continuum alongside typical milestones and testing outcomes. This prescription must also use match-play external load data within a multisystems program. This applied article focuses on the physical characteristics and training aspects after anterior cruciate ligament reconstruction and throughout the full rehabilitation continuum which includes 3 general phases: return to activity, sport, and performance. A 5 step framework is provided for the strength and conditioning specialist to effectively transition elite soccer athletes from return to sport to return to performance. This framework includes an expanded definition of the role of the strength and conditioning specialist during rehabilitation and outlines exercise prescription across the entire rehabilitation continuum. Improved interprofessional collaboration, decision making, and load management throughout transitions can aid in optimizing long-term outcomes for the athlete, including reduced risk of reinjury or new injury. [ABSTRACT FROM AUTHOR]

Background: Hamstring tendon (HT) autografts have become a popular choice for anterior cruciate ligament (ACL) reconstruction. However, small-diameter grafts are inevitably encountered during surgery, which have poor biomechanical properties. Hybrid grafts (HGs) using an allograft combined with small diameter HT are gaining interest from surgeons. Hypothesis: There would be no difference between the HT autograft and HG in terms of failure, knee stability, and patient-reported outcomes. Study design: Systematic review and meta-analysis; Level of evidence, 4. Methods: The PubMed, Embase, web of science and Cochrane databases were systematically searched from their inception until July 1, 2022. Clinical trials that compared HG and HT autografts were included. The quality of the included studies was assessed with the Cochrane Collaboration's risk of bias tool and the modified Newcastle-Ottawa Scale. Extracted data were pooled with fixed or random effects depending on the detected heterogeneity. Results: A total of 14 eligible studies involving 1411 patients (HT: 863; HG: 548) were included in the quantitative meta-analysis. The mean age of the patients involved ranged from 14.6 to 40.4 years. Compared to patients who received HT autografts, patients receiving HGs had similar postoperative failure rate (OR, 0.99; P = 0.97; I2 = 41%), side-to-side difference (MD, -0.16; P = 0.13; I2 = 41%), Subjective IKDC (MD, 0.51; P = 0.58; I2 = 69%), Lysholm (MD, 2.79; P = 0.1; I2 = 79%), Tegner (MD, -0.88; P = 0.56; I2 = 0%). When the available data for failure rate were analyzed by the dose of irradiation, patient age, and mean diameter of the HT, the results of subgroup analyses did not change substantially. Conclusion: This review found no significant differences in failure rates, knee stability, or patient-reported outcomes between autologous HT and HG in ACLR. Surgeons should prioritize autografts of adequate size through optimized techniques and consider hybrid grafts as a last resort, considering the risks associated with allografts. [ABSTRACT FROM AUTHOR]

Background Limitations exist with current ACLR functional testing assessments that may be mitigated by including single-leg multi-directional testing. Hypothesis/Purpose To compare Anterior Cruciate Ligament-Return to Sport after Injury Scale (ACL-RSI) scores, limb symmetry index (LSI) of the single-leg vertical jump (SLVJ), single-leg medial rotation hop (SLMRH), single-leg lateral hop (SLLH), and isokinetic quadriceps strength between participants with an ACLR and healthy controls and assess predictors of quadriceps strength asymmetry. It was hypothesized that ACL-RSI scores and LSIs for all tests would differ between ACLR and healthy control groups and within the ACLR group a strong correlation would exist between all outcome measures and quadriceps strength. Study Design Cross-Sectional Study Methods Twenty-six participants with an ACLR (median 13 months after surgery) and twenty-six matched healthy controls were recruited to participate in this study. Performance was assessed via SLVJ, SLMRH, SLLH, and isokinetic quadriceps strength. Between-group comparisons were made with independent t-tests and Mann-Whitney U test. Within the ACLR group, bivariate correlation and multivariate regression analysis were performed to assess the relationship between the outcome measures and quadriceps strength asymmetry. Results Significant between-limb differences were only identified in the ACLR group (p< 0.05): SLVJ LSI: 88.5%, SLMRH LSI: 93.6%, SLLH LSI: 92.7%, quadriceps strength LSI 80.9% - 83.9%, which were significantly lower (p <0.05) than the healthy control group. Within the ACLR group, a moderate-strong significant (p < 0.05) correlations existed with quadriceps strength and SLVJ (r=0.44-0.65), SLMRH (r =0.43-0.83), and SLLH (r=0.54-0.63); while ACL-RSI had a weak non-significant (p > 0.05) correlation with quadriceps strength (r= 0.12-0.30). Conclusion Single-leg multidirectional test LSIs were less in ACLR participants than matched healthy controls and all were directly related to quadriceps strength. Psychological readiness to return to sport was not related to quadriceps strength. [ABSTRACT FROM AUTHOR]

Arthrogenic Muscle Inhibition (AMI) is a phenomenon observed in individuals with joint injury or pathology, characterized by a reflexive inhibition of surrounding musculature, altered neuromuscular control, and compromised functional performance. After anterior cruciate ligament reconstruction (ACLR) one of the most obvious consequences of AMI is the lack of quadriceps activation and strength. Understanding the underlying mechanisms of AMI is crucial for developing effective therapeutic interventions. The surgical procedure needed to reconstruct the ACL has biochemical et physiological consequences such as inflammation, pain, and altered proprioception. These alterations contribute to the development of AMI. Therapeutic interventions aimed at addressing AMI encompass a multidimensional approach targeting pain reduction, inflammation management, proprioceptive training, and quadriceps activation. Early management focusing on pain modulation through modalities like ice, compression, and pharmacological agents help mitigate the inflammatory response and alleviate pain, thereby reducing the reflexive inhibition of quadriceps. Quadriceps activation techniques such as neuromuscular electrical stimulation (NMES) and biofeedback training aid in overcoming muscle inhibition and restoring muscle strength. NMES elicits muscle contractions through electrical stimulation, bypassing the inhibitory mechanisms associated with AMI, thus facilitating muscle activation and strength gains. Comprehensive rehabilitation programs tailored to individual needs and stage of recovery are essential for optimizing outcomes in AMI. The objective of this clinical viewpoint is to delineate the significance of adopting a multimodal approach for the effective management of AMI, emphasizing the integration of pain modulation, proprioceptive training, muscle activation techniques, and manual therapy interventions. Highlighting the critical role of early intervention and targeted rehabilitation programs, this article aims to underscore their importance in restoring optimal function and mitigating long-term complications associated with AMI. [ABSTRACT FROM AUTHOR]

Background: The healing and remodeling process of tendon grafts after anterior cruciate ligament (ACL) reconstruction (ACLR) has received significant attention. This study aims to identify preoperative factors associated with postoperative signal intensity of the ACL graft after primary ACLR. Methods: A total of 90 patients underwent primary ACLR using hamstring tendon autografts by the same senior surgeon between January 2013 and December 2020 were included. Patients were followed up and scheduled for a 2-year postoperative magnetic resonance imaging (MRI) scan at our institute. Concomitant injuries were confirmed by arthroscopy. Posterior tibial slope (PTS) and anterior tibial subluxation (ATS) were measured on preoperative MRI, whereas the normalized signal intensity of the ACL graft was evaluated on postoperative MRI and calculated as the ratio of the graft signal intensity to that of the patellar tendon. Multivariable linear regression models were performed to identify preoperative factors associated with the postoperative signal intensity of the ACL graft. Results: Multivariable analyses showed that increased global PTS (GPTS) (P = 0.008) and concomitant articular cartilage injuries (P = 0.005) were associated with higher average signal intensity of the ACL graft on two-year postoperative MRI, while preoperative internal rotational tibial subluxation (IRTS) calculated as the difference between lateral ATS and medial ATS did not show a significant association. Specifically, an increased GPTS was significantly associated with higher signal intensity in the proximal section of the ACL graft (P = 0.005), whereas no significant associations were observed in the middle and distal sections. Conclusions: Increased preoperative GPTS was significantly associated with higher signal intensity of the ACL graft on 2-year postoperative MRI after primary ACLR, suggesting that a steep preoperative tibial slope may contribute to a suboptimal ligamentization process in hamstring tendon autografts. Level of evidence: Level III, retrospective cohort study. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to characterize the differences in neural function among patients with different functional abilities 2 years after anterior cruciate ligament reconstruction (ACLR). Design: Resting-state functional magnetic resonance imaging was performed to obtain blood-oxygen-level-dependent values for ACLR returned to sports coper participants (CP), non-coper participants (NP), and healthy controls (HC). The amplitude of low-frequency fluctuations (ALFF) and regional homogeneity (ReHo) calculated changes in the standard frequency band (SFB) (0.01–0.08 Hz), Slow4 (0.027–0.073 Hz), and Slow5 (0.01–0.027 Hz). Clinical correlations were investigated. Results: The right cerebellum_8 and bilateral putamen in SFB, while the right cerebellum_crus2 and left putamen in Slow5 were higher in CP than in NP. The ALLF values of the bilateral putamen in Slow4 were increased, while the right parietal lobule in Slow4 and left upper temporal pole in Slow5 were lower in CP than in HC. The ReHo values in the CP group in the right cerebellum_crus2 was higher than that in the NP group in Slow5 (voxel p < 0.05, cluster p < 0.05, Gaussian Random Field theory correction). Y-balance test was correlated with cerebellum ALFF values; Tegner was moderately correlated with putamen ALFF values (p < 0.05). Knee Injury and Osteoarthritis Outcome Score-sports, International Knee Documentation Committee Subjective Knee Evaluation Form and Tegner scores were correlated with the ReHo values of right cerebellum_crus2 (p < 0.05). Conclusion: Subcortical function transfer was performed in patients with ACLR who returned to sports postoperatively: the function of the somatosensory brain area decreased, while that of the subcortical cerebellum and basal ganglia and cerebellum ReHo increased in CP, which was correlated with clinical function. ALFF and ReHo are consistent to some extent, and sub-band studies can reveal information on different brain functions compared to the classical band. [ABSTRACT FROM AUTHOR]

Background: There have been emerging clinical trials investigating the efficacy of synthetic-graft-augmented autografts in anterior cruciate ligament reconstruction (ACLR) in recent years. Hamstring tendon and Ligament Augmentation and Reconstruction System (LARS) are both widely discussed graft choices for ACLR. Purpose: To compare the clinical efficacy of hamstring tendon grafts with LARS-augmented hamstring tendon grafts in ACLR. Study Design: Systematic review and meta-analysis. Method: A systematic literature search was performed in PubMed, Embase and the Cochrane Library to identify primary evidence related to the comparison of ACLR with a hamstring tendon (HT) versus a hamstring tendon with LARS (HT + LARS). Quality assessment of the included studies was conducted using Newcastle–Ottawa Scale for non-RCTs. Quantitative analysis was conducted with Reviewer Manager 5.4. The primary outcomes compared were the Lysholm scale, Tegnar activity scale, International Knee Documentation Committee (IKDC) evaluation, KT-1000-based laxity, complication/retear rate and rate of return-to-sports. The secondary outcomes were the Knee Injury and Osteoarthritis Outcomes Score (KOOS), Global Rating of Change (GRC) scale, hop tests, isokinetic knee strength tests and radiographic and arthroscopic evaluations. Results: Six cohort studies with 710 participants were included in this study. Compared with the HT group, the HT + LARS group had better Lysholm scores at the 1-year follow-up (P = 0.0007) and at the final follow-up (P = 0.04). HT + LARS group had better IKDC scores at the 1-year follow-up (P = 0.003). The HT + LARS group had a better return-to-sports rate in short term. No significant difference in complications or re-surgery was observed. The secondary results revealed superior or non-inferior outcomes in the HT + LARS group. Conclusions: As grafts for ACLR, the use of hamstring tendons with LARS augmentation, compared with the use of hamstring tendons alone, in the short term, has significantly superior overall functional results and better early sports participation and non-inferior results in other comparisons. In the long term, the use of hamstring tendon with LARS augmentation demonstrated non-inferior results in terms of functional scores, knee stability, knee strength, complications and re-tear rate, etc. [ABSTRACT FROM AUTHOR]

Anterior cruciate ligament (ACL) injury is a common sports injury, and ACL reconstruction is an effective surgery for this trauma. Most cases gain good recovery after surgery, while some patients may experience knee stiffness, which is characterized by joint fibrosis, leading to reduced joint mobility, pain, and dysfunction. Currently, various research studies have been conducted to unveil the mechanisms underlying this condition, identifying pre-, intra-, and post-operative risk factors, and testify the efficacy of different therapeutic methods against it. In this review, we summarize the current progress regarding the advancements in knee fibrosis after ACL reconstruction. The risk factors associated with knee fibrosis are systematically delineated, accompanied by an evaluation of the efficacy of various treatment modalities for both the prevention and mitigation of fibrosis. Furthermore, recommendations for future research directions are proposed, offering a foundational basis for subsequent investigations. [ABSTRACT FROM AUTHOR]

This study aimed to investigate the microstructural and mechanical properties of semitendinosus tendon graft tissues during anterior cruciate ligament reconstruction and the clinical outcomes in skeletally immature and mature patients. Twenty-two patients who underwent primary anterior cruciate ligament reconstruction using a hamstring tendon graft were analyzed and divided into skeletally immature (n = 7) and mature groups (n = 15) based on magnetic resonance imaging findings of the epiphyseal plate of the distal femur. Tissue samples were collected from the mid-portion of the semitendinosus tendon. The collagen fibril diameter, maximum stress, and strain at maximum stress point in the semitendinosus tendon tissues were calculated for comparison of the microstructural and mechanical properties between the two groups. Postoperative outcomes were also assessed between the two groups. The mean and 60th and 80th percentiles of fibril diameters in the skeletally immature group were significantly smaller than those in the mature group (65.9 ± 13.0, 73.5 ± 19.3, and 91.3 ± 27.4 nm in the skeletally immature group; and 90.3 ± 14.7, 94.0 ± 18.4, and 125.3 ± 19.9 nm in the skeletally immature group; p = 0.001, 0.024, and 0.004, respectively). Additionally, the strain at maximum stress was higher in the skeletally immature group (237.2 ± 102.4% vs. 121.5 ± 51.9%, p = 0.024). However, there was no difference in maximum stress between the skeletally immature and mature groups (19.9 ± 14.3 MPa vs. 24.5 ± 23.4 MPa, p = 0.578). Strain was negatively correlated with the mean fibril diameter and the 60th and 80th percentiles of fibril diameters, whereas stress was positively correlated with the mean fibril diameter. The skeletally immature group had a higher pivot shift test-positive rate than the mature group at the last follow-up (p = 0.023). Semitendinosus tendon graft tissues differed microstructurally and mechanically between skeletally immature and mature patients. Level Ⅳ [ABSTRACT FROM AUTHOR]

Background: The use of rehabilitative knee braces after anterior cruciate ligament reconstruction (ACLR) has been controversial. This study aimed to evaluate the early functional outcome associated with post-ACLR brace use. Methods: This prospective observational case–control study was conducted at AKB Center for Arthroscopy, Sports Injury, and Regenerative Medicine, B&B Hospital, Lalitpur, Nepal. A total of 132 patients undergoing arthroscopic ACLR with or without a meniscal procedure were enrolled in this study, with the final analysis consisting of 66 patients in the control group (brace group) and 66 patients in the case group (no brace group). Braces were applied to the affected lower limb in the control group in the operating room immediately after surgery and were continued for 4 weeks post-operatively. The rehabilitation protocol was the same for both groups. The patients were evaluated on the 3rd post-operative day, 2 weeks, 6 weeks, and 12 weeks post-operatively in terms of Lysholm knee scores, clinical tests (Lachman and pivot shift test), range of motion (flexion and extension), VAS scores for pain, thigh girth differences, and the 12-item short-form health survey (SF-12) scores. Results: There were no significant differences between the two groups regarding outcome measures, except the mental component summary of SF-12 which was significantly better in the non-braced group (P = 0.006). Conclusion: There was no significant difference in early functional outcome between the braced and non-braced groups following ACLR with or without a meniscal procedure. Better SF-12 mental component summary scores were seen in the nonbraced group, which indicated possible mental discomfort in patients with brace use. [ABSTRACT FROM AUTHOR]

Background/Objectives: The Achilles tendon is a popular allograft option for anterior cruciate ligament (ACL) reconstruction. Structurally, the tendon is known to have a 90-degree rotational fiber track. Preparation techniques, with this consideration, may influence the strength of the graft. This study aims to assess the tensile strength of a novel Achilles tendon allograft harvest procedure following the rotational fiber track. Methods: Both Achilles tendons were harvested from formalin-embalmed cadavers [(n = 20), male n = 13, female n = 7, average age = 70]. Ten cadavers had the right Achilles as the control and the left Achilles as the fiber track sample; 10 cadavers had the opposing designation. Tensile strength was tested utilizing a Bose machine. An unpaired t-test was used to compare data across groups. Results: The average ultimate load for the control group was 874.17 N, with an average elastic stiffness of 76.01 N/mm. The ultimate load for the fiber track group was 807.84 N, with an average elastic stiffness of 64.75 N/mm. No statistically significant difference (p = 0.21) was determined between the average ultimate loads or elastic loads (p = 0.18) across groups. Conclusions: These data suggest that the rotational fiber track method of Achilles allograft has consistent tensile strength and elastic stiffness as compared to the common harvest procedure. The rotational fiber track method for ACL harvesting is a viable alternative option to the common harvest procedure for usage in an ACL reconstruction. [ABSTRACT FROM AUTHOR]

Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have inferior outcomes compared with primary ACL reconstruction. The reasons why remain unknown. Purpose: To determine whether surgical factors performed at the time of revision ACL reconstruction can influence a patient's outcome at 6-year follow-up. Study Design: Cohort study; Level of evidence, 2. Methods: Patients who underwent revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline patient characteristics, surgical technique and pathology, and a series of validated patient-reported outcome instruments: Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) subjective form, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx activity rating score. Patients were followed up for 6 years and asked to complete the identical set of outcome instruments. Regression analysis was used to control for baseline patient characteristics and surgical variables to assess the surgical risk factors for clinical outcomes 6 years after surgery. Results: A total of 1234 patients were enrolled (716 men, 58%; median age, 26 years), and 6-year follow-up was obtained on 79% of patients (980/1234). Using an interference screw for femoral fixation compared with a cross-pin resulted in significantly better outcomes in 6-year IKDC scores (odds ratio [OR], 2.2; 95% CI, 1.2-3.9; P =.008) and KOOS sports/recreation and quality of life subscale scores (OR range, 2.2-2.7; 95% CI, 1.2-4.8; P <.01). Use of an interference screw compared with a cross-pin resulted in a 2.6 times less likely chance of having a subsequent surgery within 6 years. Use of an interference screw for tibial fixation compared with any combination of tibial fixation techniques resulted in significantly improved scores for IKDC (OR, 1.96; 95% CI, 1.3-2.9; P =.001); KOOS pain, activities of daily living, and sports/recreation subscales (OR range, 1.5-1.6; 95% CI, 1.0-2.4; P <.05); and WOMAC pain and activities of daily living subscales (OR range, 1.5-1.8; 95% CI, 1.0-2.7; P <.05). Use of a transtibial surgical approach compared with an anteromedial portal approach resulted in significantly improved KOOS pain and quality of life subscale scores at 6 years (OR, 1.5; 95% CI, 1.02-2.2; P ≤.04). Conclusion: There are surgical variables at the time of ACL revision that can modify clinical outcomes at 6 years. Opting for a transtibial surgical approach and choosing an interference screw for femoral and tibial fixation improved patients' odds of having a significantly better 6-year clinical outcome in this cohort. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to identify risk factors for subsequent meniscal surgery following anterior cruciate ligament (ACL) reconstruction (ACLR) in patients without recurrent ACL injury. Methods: Patients aged ≥14 years who underwent primary ACLR with minimum 1‐year follow‐up and without recurrent ACL injury were retrospectively reviewed. Patient demographics and surgical data at the time of ACLR were collected. Postoperative radiographs were used to measure femoral and tibial tunnel position, and posterior tibial slope. Univariate and multivariate analyses were performed to identify risk factors for subsequent meniscal surgery. Results: Of 629 ACLRs that fulfilled the inclusion criteria, subsequent meniscal surgery was performed in 65 [10.3%] patients. Multivariate analysis revealed that medial meniscal repair at the time of ACLR, younger age, anterior femoral tunnel position and distal femoral tunnel position were significantly associated with subsequent meniscal surgery (p < 0.001, p = 0.016, p = 0.015, p = 0.035, respectively). The frequency of femoral tunnel placement >10% outside of the literature‐established anatomic position was significantly higher in those who underwent subsequent meniscal surgery compared to those who did not (38.3% vs. 20.3%, p = 0.006). Posterior tibial slope and ACL graft type were not significantly associated with subsequent meniscal surgery. Conclusion: Medial meniscal repair at the time of ACLR, younger age and nonanatomic femoral tunnel placement were risk factors for subsequent meniscal surgery in patients without recurrent ACL injury. Femoral tunnel placement <10% outside of the native anatomic position is important to reduce the risk of subsequent meniscal surgery. Level of Evidence: Level IV. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the postoperative outcomes of the all‐inside technique in arthroscopic anterior cruciate ligament reconstruction (ACLR). Methods: Patients who underwent ACLR using the all‐inside technique between 2018 and 2021 were retrospectively assessed. All patients were followed up for at least 2 years. Functional recovery and pain relief were assessed using the International Knee Documentation Committee (IKDC) score, Lysholm score, Knee Injury and Osteoarthritis Outcome Score (KOOS) and visual analogue scale (VAS). Instrumented laxity was assessed via side‐to‐side difference using the Kneelax3 arthrometer. Graft maturity was estimated using the signal‐to‐noise quotient value based on magnetic resonance imaging (MRI). Adverse events during and after the surgery were recorded. Results: A total of 78 patients were included in this study, with a mean age of 28.1 ± 7.6 years. The IKDC (p < 0.001), Lysholm (p < 0.001) and KOOS (p < 0.001 for all subgroups) scores at the final follow‐up were significantly higher than those before the surgery. The VAS scores (p < 0.05) were significantly lower than those before surgery. The side‐to‐side difference results indicated that 50 patients had a difference of less than 3 mm, indicating a tight graft, whereas only 1 patient had a difference of >5 mm, indicating a loose graft. The median signal‐to‐noise quotient of the graft on MRI was 1.4 (P25, P75: 1.0, 2.0). No intraoperative adverse events were observed. Postoperative adverse events included three cases of infection, three cases of graft rerupture, two cases of cyclops lesion and one case of surgical intervention for a meniscal tear. Conclusion: ACLR using the all‐inside technique offers promising results in patients with ACL rupture. Level of Evidence: Level IV. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to identify risk factors contributing to the early onset of patellofemoral osteoarthritis (PFOA) within the first two years following anterior cruciate ligament reconstruction (ACLR) using a hamstring tendon autograft. Methods: Participants aged 18 to 40 who had undergone ACLR within the past two years were included in this study, along with a control group of healthy volunteers. Magnetic resonance imaging (MRI) data were obtained preoperatively, at two years postoperatively, and from the control group. T-tests were used to assess differences in patellofemoral alignment (PA) and trochlear morphology (TM) between the pre- and post-ACLR patients and healthy controls. The incidence of PFOA was recorded, and associations between PA, TM, and clinical parameters were evaluated in patients with and without PFOA. Logistic regression analysis was conducted to identify potential risk factors for PFOA development. Results: A total of 177 patients, with a mean follow-up period of 22.17 ± 5.09 months and a mean age of 26.4 ± 5.6 years, were included in the study. Following ACL injury, significant alterations in patellar tilt angle (PTA), tuberositas tibae-trochlear groove distance (TT-TG), Insall-Salvati ratio (ISR), and static anterior tibial translation (SATT) were observed compared to the control group. Postoperatively, deviations in PTA and SATT remained significant when compared to healthy controls. Of the 177 patients, 68 (38.42%) developed early-onset PFOA. Factors associated with the early onset of PFOA included age at the time of surgery, the interval between injury and surgery, PTA, bisect offset (BO), sulcus angle (SA), thigh circumference, SATT, and partial meniscectomy. Conclusion: Significant differences in PTA, TT-TG, ISR, and SATT were identified between patients who underwent ACLR and healthy controls. Postoperatively, there was no correction in PTA or SATT, which remained significantly altered. Factors such as age at the time of surgery, PTA, BO, SA, ISR, SATT, thigh circumference, partial meniscectomy, and the time interval between injury and surgery were associated with the early onset of PFOA within two years post-ACLR. These findings may aid in the prevention of PFOA by identifying individuals at higher risk for early development. [ABSTRACT FROM AUTHOR]

Background: Both adductor canal block (ACB) and local infiltration (LI) are effective for postoperative pain management after arthroscopic-assisted anterior cruciate ligament (ACL) reconstruction (ACLR). While LI is a more straightforward procedure, its effectiveness remains debated. Purpose: To evaluate morphine consumption within 48 hours after ACLR with a semitendinosus tendon graft, comparing ACB and LI; secondary objectives: to evaluate pain levels, patient satisfaction, quadriceps strength, range of knee motion, and complications. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients undergoing primary ACLR with a semitendinosus tendon graft were randomized to receive either ACB (0.25% bupivacaine; 20 mL) or LI at the surgical wound, graft harvest area, and intra-articular injection. The LI group received morphine (3 mg), ketorolac (30 mg), and tranexamic acid (1 g). Morphine consumption within 48 hours was monitored using an intravenous patient-controlled analgesia device. Results: A total of 48 patients were analyzed (n = 24 in each group); baseline characteristics were similar between groups. The LI group consumed significantly less morphine than the ACB group at 6 hours (median [interquartile range, IQR], 3 mg [0-4.8 mg] for the LI group vs 5.5 mg [2-9] for the ACB group; P =.003). However, no significant differences were observed in morphine consumption at other time points. Additionally, no significant difference was found in cumulative morphine consumption at 48 hours between the groups (median [IQR], 21.5 mg [11-34.5 mg] for the ACB group vs 16.5 mg [8.5-21.8 mg] for the LI group; P =.137). Postoperative pain scores, quadriceps strength, and patient satisfaction were similar between the 2 groups. Conclusion: Morphine consumption at 48 hours postoperatively was comparable between the LI and ACB groups, and no significant group differences were found in postoperative pain, quadriceps strength, or patient satisfaction. Registration: TCTR20190320003 (Thai Clinical Trial Registry). [ABSTRACT FROM AUTHOR]

Background: Vitamin D deficiency has been linked to poor muscle function, cartilage degeneration, and the development of knee osteoarthritis. However, the impact of serum 25-hydroxyvitamin D [25(OH)D] level on quadriceps muscle strength remains inconclusive, largely due to variations in study designs, differences in study populations, and the influence of confounding factors such as co-supplementation with other vitamins. The existing literature presents mixed findings, highlighting the need for a comprehensive evaluation of the available evidence. Purpose: This systematic review and meta-analysis aim to summarise. Study design: Systematic review; Level of evidence, 4. Methods: Searches were conducted using Medline (Ovid), Embase (Ovid), CINAHL (EBSCOhost), and SPORTDiscus (EBSCOhost), which aimed to summarise recent (published after 2000 and before March 1st, 2024) studies reporting the effects of serum 25(OH)D levels on quadriceps strength. Appraisal tool for Cross-Sectional Studies (AXIS) for cross-sectional studies and Quality in Prognosis Studies (QUIPS) for longitudinal studies. Results from the AXIS and QUIPS tools were used for GRADE quality assessment. The review was carried out using PRIMSA guidelines and registered in PROSPERO (ID: CRD42022313240). Results: Four hundred studies were screened and 28 studies with 5752 participants were included. 28 published studies (24 cross-sectional and 4 longitudinal) were identified. Key results supported the significant positive correlation between serum 25(OH)D levels and isokinetic quadriceps strength at 180°/s in elderly and athletic populations with a correlation coefficient of 0.245 (95%CI: 0.078–0.398, p = 0.004). However, no significant correlation was found with isometric quadriceps strength or isokinetic strength at 60°/s (r = 0.190, p = 0.085). There was only a weak negative correlation with MVC. Conclusion: This review found a statistically significant positive correlation between serum 25(OH)D levels and isokinetic quadriceps strength. This has important clinical implications, especially in the elderly cohort, with higher 25(OH)D levels being associated with a reduced incidence of falls and fragility fractures. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusion An important reason for the poor recovery of anterior cruciate ligament (ACL) injuries is the poor recovery of muscle function. Therefore, we used surface electromyography (sEMG) and gait analysis to explore the muscle activation patterns and gait characteristics between lower limbs under different exercise states in patients, following anterior cruciate ligament reconstruction (ACLR).Forty‐one adults with unilateral ACL injuries in Binzhou Medical University Hospital from October 2022 to June 2023 were allocated to three groups according to the time after ACL reconstruction: group A (≤3 months, 16), group B (3 months–1 year, 13), and group C (>1 year, 12). Patients were tested by sEMG and gait, while straight leg raising (SLR), walking at normal speed, fast walking, and walking up and down the stairs. Two related sample tests were performed for the normalized root mean square (RMS) values and gait parameters.Muscle function changes varied in different training tasks. The RMS value of the involved side was more than the uninvolved side in biceps femoris and semitendinosus of group A (p < 0.010), and for the bilateral rectus femoris (RS), vastus medialis (VM), and vastus lateralis in group B, only the comparison of the RS was significant in group C during fast walking and going up and down the stairs. The ground impact (0.90 [0.63, 1.33] vs. 0.71 [0.43, 1.02], p = 0.035) of the uninvolved side was significantly decreased compared to those of the involved side in patients with ACLR when going down the stairs.Different muscles need to be focused on at different stages of the postoperative period. sEMG and gait analysis can guide the development of a rehabilitation program. [ABSTRACT FROM AUTHOR]

Introduction: The current investigation assessed effects of balance exercises both incorporating and excluding cognitive tasks (CTs) and external focus of attention (EFA) on postural control in athletes who have undergone anterior cruciate ligament reconstruction (ACLR). Methods: A total of 48 athletes post-ACLR were randomly assigned to one of the three groups: traditional balance training (BT), balance training with external focus of attention (BTF), and balance training with cognitive demands (BTC). Postural control was evaluated by a force platform before and after an 8-week intervention, during which participants engaged in balance exercises four times a week. The interventions included standard balance exercises, balance exercises with EFA, and balance exercises incorporating CTs. Assessments included sway amplitude, average sway velocity, and standard deviation of sway velocity in both anteroposterior (AP) and mediolateral (ML) directions during single-leg quiet standing. Additionally, the time taken to regain stability following mechanical perturbation was measured. Results: The results indicated a remarkable reduction in the sway amplitude especially in ML direction for intervention groups. Also, standard deviation of sway velocity was significantly reduced in intervention groups when comparing to the control group. In general, time to return to stability after mechanical perturbation did not changed in any group. It just increased in BT group post intervention. Conclusion: incorporating cognitive load and external focus of attention in the conventional balance training of athletes post ACLR surgery reduced sway amplitude and postural control cost, but had no significant effect on time to return to stability after applying mechanical perturbation. [ABSTRACT FROM AUTHOR]

Purpose: To investigate sex‐based recovery differences in patients undergoing anterior cruciate ligament reconstruction (ACLR) with a hamstring (HT) or quadriceps (QT) tendon autograft. Methods: This study included 97 patients, including 50 females (HT = 25, QT = 25) and 47 males (HT = 24, QT = 23), assessed presurgery and at 12‐ and 24‐month postoperatively via surveys, laxity, isokinetic knee extensor and flexor torque and a 6‐hop performance battery. Limb symmetry indices (LSIs) were calculated. Outcomes were compared between males and females, as well as within each graft type. Results: Males reported significantly higher Tegner scores at 12 (p = 0.029) and 24 (p = 0.031) months, Anterior Cruciate Ligament Return to Sport after Injury scores at 12 (p = 0.009) and 24 (p = 0.010) months, and a significantly higher lateral hop LSI at 12 (p = 0.045) months, knee extensor torque LSI at 12 (p = 0.020) months, and knee flexor torque LSI at 12 (p = 0.001) and 24 (p = 0.039) months. Females undergoing ACLR with a QT (vs. HT) graft demonstrated a lower knee extensor torque LSI at 12 (p = 0.006) months, a lower lateral hop LSI at 12 (p = 0.038) months, and a lower medial hop LSI at 12 (p = 0.042) months. Conclusions: Females reported less activity and psychological readiness, as well as strength symmetry. Furthermore, the recovery of quadriceps strength and hop symmetry was delayed in females (vs. males) undergoing ACLR with a QT graft. A better understanding of these differences will assist in counselling on expectations, determining the most appropriate graft construct and permitting more targeted rehabilitation. Level of Evidence: Level IV. [ABSTRACT FROM AUTHOR]

Purpose: Previous evidence indicated that the tibiofemoral bone configuration might elevate the risk of an anterior cruciate ligament (ACL) injury. Furthermore, a low hamstring‐to‐quadriceps muscle ratio predisposes especially females to unfavourable knee kinematics. The primary objective of the present study was to investigate sex‐specific associations between tibiofemoral bone geometry and isokinetic knee flexion torque in patients with primary ACL injury followed by ACL reconstruction. Methods: N = 100 patients (72 = male, 28 = female, age = 31.3 ± 10.2, body mass index = 25.3 ± 3.6) with primary ACL rupture with isokinetic knee flexion torque assessments before and 6 months after ACL reconstruction surgery were analysed. Magnetic resonance imaging scans were analysed for medial posterior tibial slope (MPTS) and lateral posterior tibial slope, notch width index (NWI) and lateral femoral condyle index (LFCI). Additionally, isokinetic knee flexion torque (60°/s) and hamstring–quadriceps ratios were evaluated. Subsequently, functional parameters were correlated with imaging data for gender subgroups. Results: The findings showed that presurgical isokinetic knee flexion torque was not associated with any marker of femoral or tibial bone geometry. Further, while significant differences were observed between female (0.883 ± 0.31 Nm/kg) and male (1.18 ± 0.35 Nm/kg) patients regarding preoperative normalized knee flexion torque (p < 0.001), no significant sex differences were found for percentage increases in normalized knee flexion torque from presurgery to postsurgery. Generally, female patients demonstrated significantly higher MPTS magnitudes (p < 0.05) and lower LFCI values (p < 0.05) compared to men. Conclusion: The present results demonstrated no association between tibial or femoral bone geometry and muscle strength of the hamstrings in patients with ACL reconstruction, indicating an important mismatch of muscular compensation to deviations in bone geometry. There were no sex‐specific differences in tibiofemoral bone parameters. Level of Evidence: Level III. [ABSTRACT FROM AUTHOR]

Background: Posterior tibial slope (PTS) has been identified as a possible modifiable risk factor for anterior cruciate ligament (ACL) injury and ACL reconstruction (ACLR) failure. However, the findings in the literature are inconsistent. This may be explained by several different reasons, including different measurement methods, differing definitions of ACLR failure, and possible inclusion of suboptimal films. Purpose: To compare PTS values obtained using plain radiographs (XR-PTS) in a young (≤21 years of age), skeletally mature patient population with those obtained using magnetic resonance imaging (MRI), as well as to quantify the number of suboptimal lateral knee radiographs obtained across an integrated health care system and determine the potential effect of including these radiographs on summary statistics of XR-PTS. Study Design: Case-control study; Level of evidence, 3. Methods: Skeletally mature adolescent and young adult patients ≤21 years of age were identified from the ACLR registry of Kaiser Permanente. The cases of concern were patients requiring revision ACLR. The controls were patients who had an ACLR and did not require a revision procedure. The XR-PTS measurements were made on plain radiographs by a single blinded reviewer. These results were compared with measurements obtained using MRI. The quality of each plain radiograph was evaluated by measuring posterior/distal femoral condylar overlap and length of tibial diaphysis captured on the radiograph. Summary statistics with and without inclusion of measurements made on suboptimal radiographs were calculated. Results: Of the initial 634 patients with ACLR (317 case-control pairs), 561 (88.5%) had radiographs available and were included for the analysis comparing radiograph to MRI slope measurements. For the evaluation of slope between case and control pairs with radiograph information available, there were 257 case-control pairs; there were 124 pairs when those with suboptimal radiographs were excluded. There was no difference in MRI-measured lateral tibial posterior slope or medial tibial posterior slope for the 257 case-control pairs with XR-PTS information and for the 124 pairs with optimal radiographs. XR-PTS in the revision cohort was significantly steeper than in the control group when suboptimal radiographs were included in the analysis. There was no difference when patients with suboptimal radiographs were excluded. PTS measurements made on plain radiographs were larger than those made on MRI. There was a poor correlation between measurements made using these 2 modalities (r = 0.22 for radiograph and medial PTS). Conclusion: This study did not find a significantly steeper XR-PTS in patients who had to undergo revision ACLR when suboptimal radiographs were not included in the analysis. The present study's results confirmed the findings from a previous study of the same patient population that used MRI. However, there was poor correlation between PTS measurements made using plain radiograph and MRI. [ABSTRACT FROM AUTHOR]

Background: There have been a large number of patient-reported outcome measures (PROMs) used to assess outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR). Purpose/Hypothesis: The purpose was to determine which PROMs are being commonly used in randomized clinical trials (RCTs) to assess patients undergoing ACLR and to compare the responsiveness between them. It was hypothesized that the International Knee Documentation Committee (IKDC) score would be the most commonly used and responsive PROM among patients undergoing ACLR. Study Design: Meta-analysis. Level of evidence, 2. Methods: PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed, and relevant studies were extracted from the PubMed/MEDLINE and Web of Science databases. The inclusion criteria were English-language RCTs reporting on PROMs after ACLR. For articles meeting our inclusion criteria for responsiveness analysis (≥2 PROMs reported, 1 year minimum follow-up, and reported pre- and postoperative PROM means and standard deviations), the responsiveness between PROMs was compared using effect size (ES) and relative efficiency (RE). Results: A total of 108 articles met the inclusion criteria, comprising 9034 patients (mean age, 29.9 years; mean body mass index, 24.3; mean follow-up time, 36.1 months). There were 34 PROMs identified. The top 3 most commonly reported PROMs were the IKDC (n = 68; 63.0%), Lysholm (n = 65; 60.2%), and Tegner (n = 47; 43.5%) scores. The 2 PROMs with the highest ES were the ACL–Quality of Life (QoL) (3.37) and Knee Injury and Osteoarthritis Outcome Score (KOOS) QoL (2.07) scores. Compared with other PROMs, Lysholm and KOOS QoL scores had the greatest RE values. The Lysholm score had a greater RE than the KOOS Pain (RE, 1.17), KOOS Symptoms (RE, 1.22), KOOS Activities of Daily Living (ADL) (RE, 1.42), KOOS Sport/Recreation (RE, 1.55), KOOS QoL (RE, 1.41), and Tegner (RE, 2.89) scores. KOOS QoL had a greater RE than the IKDC (RE, 1.32), KOOS Pain (RE, 1.60), KOOS Symptoms (RE, 2.12), KOOS ADL (RE, 3.03), KOOS Sport/Recreation (RE, 1.27), and Tegner (RE, 2.06) scores. Conclusion: The IKDC score is the most commonly reported PROM in RCTs after ACLR; however, the Lysholm and KOOS QoL scores demonstrated the highest responsiveness in patients undergoing ACLR compared with other PROMs. [ABSTRACT FROM AUTHOR]

Understanding the biomechanical impact of injuries and reconstruction of the anterior cruciate ligament (ACL) is vital for improving surgical treatments that restore normal knee function. The purpose of this study was to develop a technique that enables parametric analysis of the effect of the ACL reconstruction (ACLR) in cadaver knees, by replacing its contributions with that of a specimen-specific virtual ACLR that can be enabled, disabled, or modified. Twelve ACLR reconstructed knees were mounted onto a motion simulator. In situ ACLR graft forces were measured using superposition, and these data were used to design specimen-specific virtual ACLRs that would yield the same ligament force-elongation behaviors. Tests were then repeated using the virtual ACLR in place of the real ACLR and following that in ACL deficient knee by disabling the virtual ACLR. In comparison to the ACL deficient state, the virtual ACLRs were able to restore knee stability to the same extent as real ACLRs. The average differences between the anterior tibial translation (ATT) of the virtual ACLR versus the real ACLR were +1.6 ± 0.9 mm (p = 0.4), +2.1 ± 0.4 mm (p = 0.4), and +1.0 ± 0.9 mm (p = 0.4) during Anterior drawer, Lachman and Pivot-shift tests, respectively, which is small in comparison to the full ATT range of motion (ROM) of these knees. Therefore, we conclude that a virtual ACLR can be used in place of real ACLR during biomechanical testing of cadaveric knees. This capability opens the door for future studies that can leverage parameterization of the ACLR for surgical design optimization. [ABSTRACT FROM AUTHOR]

Background and Objective: Individuals with a history of anterior cruciate ligament (ACL) injury are at a higher risk of reinjury compared to healthy individuals. ACL-injured patients exhibit weaker longitudinal arches and increased foot pronation compared to healthy individuals. This study aimed to determine the effect of short-term use of anti-pronation insoles on plantar pressure variables following ACL reconstruction (ACLR) with a pronated foot during gait. Methods: This quasi-experimental study was conducted on 15 male participants who had undergone ACLR with a pronated foot (mean age= 23.2±4.5 years) and 15 healthy males (mean age= 22.7±4.3 years) in Ardabil, Iran during 2022. Plantar pressure values during gait with and without the use of anti-pronation insoles were recorded and compared using a foot scanner (sampling rate: 300 Hz). Results: The effect of the group factor on the big toe plantar pressure variable was statistically significant (P<0.05). Pairwise comparison results demonstrated a significant increase in pressure in the ACLR group (154.63±41.71 N/cm²) compared to the healthy group (126.54±26.57 N/cm²) (P<0.05). Intragroup comparison results revealed a significant decrease in pressure on the second to fifth toes (215.73±60.74 N/cm²) and the first plantar (420.58±107.56 N/cm²) when using anti-pronation insoles compared to the non-insole condition (the second to fifth toes (201.57±76.21 N/cm²) and the first plantar (400.78±118.20 N/cm²) in the ACL reconstruction group (P<0.05). Conclusion: The use of anti-pronation insoles can effectively reduce plantar pressure after ACLR in individuals with a pronated foot during gait. [ABSTRACT FROM AUTHOR]

Background and Objectives: Remodeling and healing of the graft are crucial processes for long-term graft survival after anterior cruciate ligament reconstruction (ACLR). However, few studies have objectively evaluated the differences in graft healing between autografts and allografts. This study aimed to compare the status of the anterior cruciate ligament (ACL) grafts between hamstring tendon (HT) autografts and tibialis anterior tendon (TAT) allografts using second-look arthroscopy. Materials and Methods: The outcomes of 193 consecutive patients (153 males and 40 females, with an average age of 30.38 and BMI of 25.43 kg/m2) who underwent second-look arthroscopy following primary ACLR were retrospectively reviewed. Prior to participating in this study, all patients provided written informed consent. The patients were divided into two groups: those with HT autografts and those with TAT allografts. Confounding factors were matched between the two groups using propensity score matching (PSM). ACL graft status was assessed during second-look arthroscopy using a numeric scale system based on the degree of four parameters: graft tension, continuity, synovium coverage, and vascular marking. Clinical outcomes were assessed using the Lysholm and International Knee Documentation Committee (IKDC) scores. Graft status and clinical outcomes were compared between the two groups. Additionally, a subgroup analysis based on the timing of the second-look arthroscopy (12–24 months vs. >24 months after the initial ACLR) was conducted. Results: After PSM, 62 patients were included in each group. The second-look arthroscopy was conducted at 23.6 ± 6.6 months for the HT group and at 24.0 ± 7.9 months for the TAT group (p = 0.749). The continuity and tension of the ACL graft were not significantly different between the two groups (p = 0.146 and 0.075, respectively). However, the TAT group exhibited significantly inferior synovial coverage and vascular marking of the ACL graft compared with the HT group (p = 0.021 and 0.007, respectively). These findings were consistent regardless of the timing of the second-look arthroscopy. Clinical outcomes, according to the Lysholm and IKDC scores, significantly improved in both groups with no significant differences (p = 0.386 and 0.733, respectively). Conclusions: Although there were no differences in graft tension and continuity between HT autografts and TAT allografts, the biological healing of ACL grafts, in terms of synovialization and vascularization, was superior in HT autografts compared to TAT allografts. [ABSTRACT FROM AUTHOR]

Purpose: Some patients who undergo anterior cruciate ligament (ACL) reconstruction experience abnormal mechanical stress in the meniscus. Medial meniscal extrusion (MME) is reflected in the pathological condition of the meniscus, which expands owing to repetitive mechanical stress. Thus, the effect of the reconstructed ACL on increasing MME under weight-bearing conditions remains unclear. This study investigated the effect of ACL reconstruction on meniscal extrusion under non-weight-bearing and weight-bearing conditions. Methods: Seventeen patients who underwent unilateral ACL reconstruction (ACL group) and 20 age-matched healthy volunteers (control group) were enrolled. Ultrasonography was performed in the supine, standing, and walking positions in preoperative and postoperative ACL patients. MME during walking was evaluated based on the dynamic behavior of extrusion, and kinetic and kinematic data were synchronously obtained. Moreover, the ACL group underwent magnetic resonance imaging (MRI) evaluation at two points: preoperatively and 12 months postoperatively, and the ultrasound findings were compared. Results: MME in the supine position measured using both ultrasonography and MRI was not significantly different preoperatively and postoperatively in the ACL group. However, postoperative MME and dynamic behavior of extrusion under standing and walking conditions were significantly higher than those in the preoperative state (dynamic behavior: 0.9 ± 0.4 mm preoperatively, 1.2 ± 0.4 mm postoperatively). Moreover, the deficits in knee extension during walking persisted postoperatively and were significantly higher than those in the control group. Conclusion: MME in patients with ACL reconstruction including meniscus repair was different under mechanical stress compared to the non-weight bearing condition. [ABSTRACT FROM AUTHOR]

Background: The extensor apparatus of the knee is of paramount importance in generating the torque needed for a countermovement jump (CMJ), especially in jumping athletes. In anterior cruciate ligament reconstruction (ACLR) procedures, graft harvesting from the extensor apparatus may dramatically affect extensor strength and jumping performance. Hypothesis: The focused jump training of professional jumping athletes would increase the likelihood of restoring jumping performance after ACLR, despite the graft choice (autologous bone-patellar tendon-bone [BPTB] or hamstring [HS] tendon). Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective evaluation of prospectively collected data was carried out. Only professional athletes were included, and all surgical procedures were performed by a single experienced surgeon. Data collection considered the type of surgery, sports activity, and functional evaluation at 3 months after surgery. From the functional evaluation, data on single-leg hop (SLH) test, triple hop (TH) test, and CMJ were extracted. Limb symmetry index (LSI) for maximal voluntary isometric contraction of the quadriceps and for each of the jumping tests was calculated. Multiple analysis of covariance (ANCOVA) models were used to assess mean differences among groups for the LSI in CMJ, SLH, and TH and estimate the effect of confounders. Results: From a subsequent series of 208 athletes, 44 professional athletes were included for data collection. Of these, 26 were male and 18 were female. A jumping sport (basketball, volleyball) was played by 17 athletes, while a running sport (soccer, judo, rugby, tennis, ski) was performed by 27 athletes. The mean time from injury to surgery was 17.8 ± 14.5 days. At 90 days from surgery, the overall mean LSI for CMJ was 85.3% ± 8.9%, for SLH was 92.2% ± 6.4%, and for TH was 90.8% ± 6.1%. When ANCOVA was fitted using the interaction term with BPTB autograft and jumping sport, a nonsignificant effect on LSI for CMJ (P =.56), SLH (P =.72), and TH (P =.98) was observed. Conclusion: The results of the present investigation on professional athletes showed that no difference occurred within the study cohort in overall jumping performance between jumping and running athletes undergoing ACLR either with BPTB or with HS tendon grafts. Although some evidence suggests that quadriceps strength may be dramatically affected by the harvesting of BPTB, the overall performance of the jump was not compromised. [ABSTRACT FROM AUTHOR]

Background: New digital technology–based rehabilitation may be a viable option for patients after anterior cruciate ligament reconstruction (ACLR), with advantages such as easy access to treatment and learning as well as cost-effectiveness. Purpose: To investigate the effects of an augmented reality (AR)–based, telerehabilitation system in patients after ACLR compared with a brochure-based rehabilitation program in terms of patient-reported outcomes and functional performance measures. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: This was a multicenter, assessor-blinded study. Enrolled participants were allocated randomly to either the intervention group, who underwent AR-based telerehabilitation system, or to the control group, who underwent a brochure-based rehabilitation program with a self-log. Both groups performed the same postoperative rehabilitation exercise protocol. Subjective knee function was assessed using the International Knee Documentation Committee (IKDC) as the primary outcome; secondary outcomes were a numeric rating scale for pain, the EuroQol 5-Dimension 5-Level, isometric knee strength, range of motion, and the single-leg hop test. The intervention group also completed a satisfaction survey. Follow-up was conducted at 2, 6, 12, and 24 weeks postoperatively. Results: A total of 28 patients were enrolled in each group; 1 patient in the control group was lost to follow-up. Patients in both groups demonstrated improvement on all outcomes over time. There were no significant between-group differences in the IKDC score from baseline to 12 weeks postoperatively. The intervention group saw a greater increase in the relative isometric strength of the quadriceps on the involved limb at 6, 12, and 24 weeks postoperatively (P <.05 for all). No significant group differences were observed in the remaining secondary outcomes. Conclusion: Study findings indicated that patients who underwent AR-based telerehabilitation in the early rehabilitation phase after ACLR demonstrated similar improvements as those who followed a brochure-based rehabilitation program and had a quicker recovery of knee extensor strength. Registration: NCT04513327 (ClinicalTrials.gov identifier). [ABSTRACT FROM AUTHOR]

Background: Tibial bone tunnel widening (TW) is a common postoperative phenomenon after anterior cruciate ligament reconstruction (ACLR). Purpose: To compare the physical, biomechanical, osteoinductive, and histological characteristics of 2 fabricated bioabsorbable interference screws: (1) a modified poly(l -lactide- co - d, l -lactide) and hydroxyapatite (mPLA/HA) screw and (2) a poly(l -lactide- co -glycolide) and β-tricalcium phosphate (PLGA/β-TCP) screw; and to evaluate the effect of the PLA/HA screw on ameliorating postoperative TW in a canine ACLR model. Study Design: Controlled laboratory study. Methods: In vitro, the physical and biomechanical properties of the mPLA/HA and PLGA/β-TCP screws were tested. The osteoinductive activity of the screws was studied by cell experiments. In vivo, ACLR was performed on 48 beagle dogs, divided into the mPLA/HA group and the PLGA/β-TCP group. The femoral and tibial ends of the graft were both fixed with screws. Six animals in each group were sacrificed after live computed tomography (CT) scanning at 1, 3, 6, and 12 months postoperatively. For six knee samples of each group, three knee samples underwent biomechanical testing, and 1 of them, along with the other 3 samples, underwent micro-CT and histological examination to evaluate tibial TW. Results: The mPLA/HA screw exhibited better particle dispersion, bending strength, desirable self-locking effect, and optimized degradation behavior both in vivo and in vitro. Histologically, the mPLA/HA screw had comparative osteoinductive activity. There was good screw-bone integration using the mPLA/HA screw, while most fibrous scar healing was in the PLGA/β-TCP group. There were significant differences between the mPLA/HA and PLGA/β-TCP groups in tibial bone tunnel diameter at the screw body (6 months postoperatively: 5.09 ± 0.44 vs 7.12 ± 0.67; 12 months postoperatively: 4.83 ± 0.27 vs 6.23 ± 0.56; P <.01 for both) and the screw tail (6 months postoperatively: 4.84 ± 0.28 vs 5.97 ± 0.73; 12 months postoperatively: 4.77 ± 0.29 vs 5.92 ± 0.56; P <.01 for both). Conclusion: Compared with the PLGA/β-TCP screw commonly used in clinics at present, the mPLA/HA screw had comparative biosafety and mechanical properties, satisfactory biomechanical properties, and osteoinductive activity in vivo and in vitro. It effectively ameliorated the postoperative tibial TW in a canine ACLR model and increased the quality of screw-bone integration. Clinical Relevance: The good mechanical and biological properties of the mPLA/HA screws may provide an option to reduce the incidence of complications after ACLR. [ABSTRACT FROM AUTHOR]

Failure rates among primary Anterior cruciate ligament reconstruction range from 3.2 to 11.1 %. Recently, there has been increased focus on surgical and anatomic considerations which predispose patients to failure, including excessive posterior tibial slope (PTS), unaddressed high-grade pivot shift, and improper tunnel placement. The purpose of this review was to provide a current summary and analysis of the literature regarding patient-related and technical factors surrounding revision ACLR, rehabilitation considerations, overall outcomes, and return to sport (RTS) for patients who undergo revision ACLR. In revision ACLR patients, those receiving autografts are 2.78 times less likely to experience a re-rupture compared to patients who receive allografts. Additionally, individuals with properly positioned tunnels and removable implants are considered strong candidates for one-stage revision procedures. Conversely, cases involving primary tunnel widening of approximately 15 mm are typically indicative of two-stage revision ACLR. These findings underscore the importance of graft selection and surgical approach in optimizing outcomes for patients undergoing revision ACLR. Given the high rates of revision surgery in young, active patients who return to pivoting sports, the literature recommends strong consideration of a combined ACLR + anterolateral ligament (ALL) or lateral extra-articular tenodesis (LET) procedure in this population. Unrecognized posterolateral corner (PLC) injury is a common cause of ACLR failure and current literature suggests concurrent operative management of high-grade PLC injuries. Excessive PTS has been identified as an independent risk factor for ACL graft failure. Consider revision ACLR with combined slope-reducing tibial osteotomy in cases of posterior tibial slope greater than 12°. [ABSTRACT FROM AUTHOR]

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Abstract Background Septic arthritis is a rare but devastating complication after anterior cruciate ligament reconstruction (ACLR). While early treatment can prevent significant graft complications, outcomes are often inferior to those in uncomplicated ACLR. Furthermore, whether to retain or remove the graft after infection remains debatable. Therefore, we sought to compare the outcomes of septic arthritis post ACLR with uncomplicated ACLR and evaluate graft retention versus removal in infected patients. Methods We conducted a systematic review and meta-analysis in which PubMed, Embase, and Cochrane Library databases were searched. Clinical studies were included if they compared patient-reported, clinician-reported, or radiographic outcomes (minimum follow-up of 12 months) between patients with post-ACLR septic arthritis and those with uncomplicated ACLR or that compared graft retention and removal in patients with post-ACLR septic arthritis. Results Thirteen studies were retrieved. Patients with post-ACLR septic arthritis reported inferior Lysholm Knee Scoring Scale scores (mean difference (MD) 7.53; 95% confidence interval (CI) 3.20–11.86; P = 0.0006), Tegner Activity Scale scores (MD, 1.42; 95% CI 1.07–1.76; P

Background ACL reconstruction is often regarded as the most effective approach of restoring knee stability. Several graft possibilities are available, including (BPTB), four-strand hamstring autografts, quadriceps tendon, and peroneus longus tendon. Each has both advantages and cons. This study compares the effectiveness of peroneus longus and hamstring tendon autografts for single bundle ACL restoration.Patients and Methods The study involved 60 patients. Thirty of them had their torn anterior cruciate ligaments reconstructed arthroscopically using hamstring tendons, while the other 30 had their ACLs managed arthroscopically with peroneus longus tendon. The follow-up period lasted at least 12 months. Patients were assessed using IKDC score and Lysholm score. Ankle function was assessed using AOFAS score.Results There was a statistically significant difference in preoperative and postoperative range of motion improvement in each group as an IKDC score item. However, no statistically significant difference existed between both groups. A statistically significant change in Lysholm scores preoperatively and postoperatively in each group was detected, but there was no statistical difference between groups 1 and 2, either in terms of improvement or percentage improvement. The AOFAS score was used also to assess for any donor site morbidity. No significant difference was detected between both ankles range of motion and no ankle joint dysfunction or problems with sports activities.Conclusion The current study found that the PL tendon autograft might be considered a safe, effective and a technically easy graft option for ACLR. The research shows no substantial difference in postoperative knee stability or graft failure rate between hamstring and peroneus tendons.

Abstract Background Hamstring tendon (HT) autografts have become a popular choice for anterior cruciate ligament (ACL) reconstruction. However, small-diameter grafts are inevitably encountered during surgery, which have poor biomechanical properties. Hybrid grafts (HGs) using an allograft combined with small diameter HT are gaining interest from surgeons. Hypothesis There would be no difference between the HT autograft and HG in terms of failure, knee stability, and patient-reported outcomes. Study design Systematic review and meta-analysis; Level of evidence, 4. Methods The PubMed, Embase, web of science and Cochrane databases were systematically searched from their inception until July 1, 2022. Clinical trials that compared HG and HT autografts were included. The quality of the included studies was assessed with the Cochrane Collaboration’s risk of bias tool and the modified Newcastle-Ottawa Scale. Extracted data were pooled with fixed or random effects depending on the detected heterogeneity. Results A total of 14 eligible studies involving 1411 patients (HT: 863; HG: 548) were included in the quantitative meta-analysis. The mean age of the patients involved ranged from 14.6 to 40.4 years. Compared to patients who received HT autografts, patients receiving HGs had similar postoperative failure rate (OR, 0.99; P = 0.97; I 2 = 41%), side-to-side difference (MD, -0.16; P = 0.13; I 2 = 41%), Subjective IKDC (MD, 0.51; P = 0.58; I 2 = 69%), Lysholm (MD, 2.79; P = 0.1; I 2 = 79%), Tegner (MD, -0.88; P = 0.56; I 2 = 0%). When the available data for failure rate were analyzed by the dose of irradiation, patient age, and mean diameter of the HT, the results of subgroup analyses did not change substantially. Conclusion This review found no significant differences in failure rates, knee stability, or patient-reported outcomes between autologous HT and HG in ACLR. Surgeons should prioritize autografts of adequate size through optimized techniques and consider hybrid grafts as a last resort, considering the risks associated with allografts.

Abstract Background The healing and remodeling process of tendon grafts after anterior cruciate ligament (ACL) reconstruction (ACLR) has received significant attention. This study aims to identify preoperative factors associated with postoperative signal intensity of the ACL graft after primary ACLR. Methods A total of 90 patients underwent primary ACLR using hamstring tendon autografts by the same senior surgeon between January 2013 and December 2020 were included. Patients were followed up and scheduled for a 2-year postoperative magnetic resonance imaging (MRI) scan at our institute. Concomitant injuries were confirmed by arthroscopy. Posterior tibial slope (PTS) and anterior tibial subluxation (ATS) were measured on preoperative MRI, whereas the normalized signal intensity of the ACL graft was evaluated on postoperative MRI and calculated as the ratio of the graft signal intensity to that of the patellar tendon. Multivariable linear regression models were performed to identify preoperative factors associated with the postoperative signal intensity of the ACL graft. Results Multivariable analyses showed that increased global PTS (GPTS) (P = 0.008) and concomitant articular cartilage injuries (P = 0.005) were associated with higher average signal intensity of the ACL graft on two-year postoperative MRI, while preoperative internal rotational tibial subluxation (IRTS) calculated as the difference between lateral ATS and medial ATS did not show a significant association. Specifically, an increased GPTS was significantly associated with higher signal intensity in the proximal section of the ACL graft (P = 0.005), whereas no significant associations were observed in the middle and distal sections. Conclusions Increased preoperative GPTS was significantly associated with higher signal intensity of the ACL graft on 2-year postoperative MRI after primary ACLR, suggesting that a steep preoperative tibial slope may contribute to a suboptimal ligamentization process in hamstring tendon autografts. Level of evidence Level III, retrospective cohort study.

Abstract Background There have been emerging clinical trials investigating the efficacy of synthetic-graft-augmented autografts in anterior cruciate ligament reconstruction (ACLR) in recent years. Hamstring tendon and Ligament Augmentation and Reconstruction System (LARS) are both widely discussed graft choices for ACLR. Purpose To compare the clinical efficacy of hamstring tendon grafts with LARS-augmented hamstring tendon grafts in ACLR. Study Design Systematic review and meta-analysis. Method A systematic literature search was performed in PubMed, Embase and the Cochrane Library to identify primary evidence related to the comparison of ACLR with a hamstring tendon (HT) versus a hamstring tendon with LARS (HT + LARS). Quality assessment of the included studies was conducted using Newcastle–Ottawa Scale for non-RCTs. Quantitative analysis was conducted with Reviewer Manager 5.4. The primary outcomes compared were the Lysholm scale, Tegnar activity scale, International Knee Documentation Committee (IKDC) evaluation, KT-1000-based laxity, complication/retear rate and rate of return-to-sports. The secondary outcomes were the Knee Injury and Osteoarthritis Outcomes Score (KOOS), Global Rating of Change (GRC) scale, hop tests, isokinetic knee strength tests and radiographic and arthroscopic evaluations. Results Six cohort studies with 710 participants were included in this study. Compared with the HT group, the HT + LARS group had better Lysholm scores at the 1-year follow-up (P = 0.0007) and at the final follow-up (P = 0.04). HT + LARS group had better IKDC scores at the 1-year follow-up (P = 0.003). The HT + LARS group had a better return-to-sports rate in short term. No significant difference in complications or re-surgery was observed. The secondary results revealed superior or non-inferior outcomes in the HT + LARS group. Conclusions As grafts for ACLR, the use of hamstring tendons with LARS augmentation, compared with the use of hamstring tendons alone, in the short term, has significantly superior overall functional results and better early sports participation and non-inferior results in other comparisons. In the long term, the use of hamstring tendon with LARS augmentation demonstrated non-inferior results in terms of functional scores, knee stability, knee strength, complications and re-tear rate, etc.

Abstract Objective This study aimed to identify risk factors contributing to the early onset of patellofemoral osteoarthritis (PFOA) within the first two years following anterior cruciate ligament reconstruction (ACLR) using a hamstring tendon autograft. Methods Participants aged 18 to 40 who had undergone ACLR within the past two years were included in this study, along with a control group of healthy volunteers. Magnetic resonance imaging (MRI) data were obtained preoperatively, at two years postoperatively, and from the control group. T-tests were used to assess differences in patellofemoral alignment (PA) and trochlear morphology (TM) between the pre- and post-ACLR patients and healthy controls. The incidence of PFOA was recorded, and associations between PA, TM, and clinical parameters were evaluated in patients with and without PFOA. Logistic regression analysis was conducted to identify potential risk factors for PFOA development. Results A total of 177 patients, with a mean follow-up period of 22.17 ± 5.09 months and a mean age of 26.4 ± 5.6 years, were included in the study. Following ACL injury, significant alterations in patellar tilt angle (PTA), tuberositas tibae-trochlear groove distance (TT-TG), Insall-Salvati ratio (ISR), and static anterior tibial translation (SATT) were observed compared to the control group. Postoperatively, deviations in PTA and SATT remained significant when compared to healthy controls. Of the 177 patients, 68 (38.42%) developed early-onset PFOA. Factors associated with the early onset of PFOA included age at the time of surgery, the interval between injury and surgery, PTA, bisect offset (BO), sulcus angle (SA), thigh circumference, SATT, and partial meniscectomy. Conclusion Significant differences in PTA, TT-TG, ISR, and SATT were identified between patients who underwent ACLR and healthy controls. Postoperatively, there was no correction in PTA or SATT, which remained significantly altered. Factors such as age at the time of surgery, PTA, BO, SA, ISR, SATT, thigh circumference, partial meniscectomy, and the time interval between injury and surgery were associated with the early onset of PFOA within two years post-ACLR. These findings may aid in the prevention of PFOA by identifying individuals at higher risk for early development.

Abstract Background Vitamin D deficiency has been linked to poor muscle function, cartilage degeneration, and the development of knee osteoarthritis. However, the impact of serum 25-hydroxyvitamin D [25(OH)D] level on quadriceps muscle strength remains inconclusive, largely due to variations in study designs, differences in study populations, and the influence of confounding factors such as co-supplementation with other vitamins. The existing literature presents mixed findings, highlighting the need for a comprehensive evaluation of the available evidence. Purpose This systematic review and meta-analysis aim to summarise. Study design Systematic review; Level of evidence, 4. Methods Searches were conducted using Medline (Ovid), Embase (Ovid), CINAHL (EBSCOhost), and SPORTDiscus (EBSCOhost), which aimed to summarise recent (published after 2000 and before March 1st, 2024) studies reporting the effects of serum 25(OH)D levels on quadriceps strength. Appraisal tool for Cross-Sectional Studies (AXIS) for cross-sectional studies and Quality in Prognosis Studies (QUIPS) for longitudinal studies. Results from the AXIS and QUIPS tools were used for GRADE quality assessment. The review was carried out using PRIMSA guidelines and registered in PROSPERO (ID: CRD42022313240). Results Four hundred studies were screened and 28 studies with 5752 participants were included. 28 published studies (24 cross-sectional and 4 longitudinal) were identified. Key results supported the significant positive correlation between serum 25(OH)D levels and isokinetic quadriceps strength at 180°/s in elderly and athletic populations with a correlation coefficient of 0.245 (95%CI: 0.078–0.398, p = 0.004). However, no significant correlation was found with isometric quadriceps strength or isokinetic strength at 60°/s (r = 0.190, p = 0.085). There was only a weak negative correlation with MVC. Conclusion This review found a statistically significant positive correlation between serum 25(OH)D levels and isokinetic quadriceps strength. This has important clinical implications, especially in the elderly cohort, with higher 25(OH)D levels being associated with a reduced incidence of falls and fragility fractures.

Background and Objective: Individuals with a history of anterior cruciate ligament (ACL) injury are at a higher risk of re-injury compared to healthy individuals. ACL-injured patients exhibit weaker longitudinal arches and increased foot pronation compared to healthy individuals. This study aimed to determine the effect of short-term use of anti-pronation insoles on plantar pressure variables following ACL reconstruction (ACLR) with a pronated foot during gait. Methods: This quasi-experimental study was conducted on 15 male participants who had undergone ACLR with a pronated foot (mean age= 23.2±4.5 years) and 15 healthy males (mean age= 22.7±4.3 years) in Ardabil, Iran during 2022. Plantar pressure values during gait with and without the use of anti-pronation insoles were recorded and compared using a foot scanner (sampling rate: 300 Hz). Results: The effect of the group factor on the big toe plantar pressure variable was statistically significant (P

Between 1982 and 1986, 126 patients who had undergoneACL reconstruction were followed in a prospectivemanner. One year follow-up statistics were reviewedfor the presence of 13 different complications.The most prevalent complications were quadricepsweakness, flexion contracture, and patellofemoral pain.Quadriceps weakness (strength less than 80% of thenormal side) was present in 65% of patients and correlatedpositively with flexion contracture, patellar irritability,and ACL reconstructions using patellar tendongrafts. Flexion contracture of 5° or more was presentin 24% of patients and correlated positively with increasedage and patellar irritability. Patellofemoral painwas present in 19% of patients and correlated positivelywith flexion contracture.Clinical relevance: The three most common complicationsof knee ligament surgery are shown to bestrongly interrelated. It is likely that a causal relationshipis present in which flexion contracture causes patellofemoralirritability, and that both of these factors, aloneor in combination, result in quadriceps weakness. If thistheory is correct, then it is crucial that postoperativerehabilitation programs place a major emphasis on theavoidance of flexion contracture.

This technical note explores the novel use of an imageless robotic surgical system for simultaneous unicompartmental knee arthroplasty (UKA) and anterior cruciate ligament reconstruction (ACLR). Knee osteoarthritis (OA) and anterior cruciate ligament (ACL) insufficiency are common conditions that traditionally require separate management. The integration of robotic assistance offers enhanced precision in surgical procedures, addressing both medial compartment OA and ACL insufficiency in a single operation.We present a case involving a 47-year-old patient with medial compartment osteoarthritis and complete ACL rupture. The patient underwent a simultaneous robotic-assisted UKA and ACLR using the CORI Surgical System (Smith&Nephew, London, UK). This approach enables accurate tibial tunnel placement and precise soft tissue balancing. The robotic system facilitates real-time gap assessment and balancing, reducing the risk of over- or under-constraint during ACL graft tensioning.The procedure was performed with a standard medial parapatellar approach. Key steps included hamstring autograft harvesting, femoral and tibial tunnel creation, and robotic-assisted implant positioning. Post-operative rehabilitation allowed full weight-bearing by the third week.This case represents the first reported instance of using an imageless robotic system for simultaneous UKA and ACLR, highlighting its potential to standardize and improve results in complex knee surgeries.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.