Abstract
Background
It has been suggested that the degree of anterior tibial translation (ATT) as measured passively on imaging studies (static ATT) after an anterior cruciate ligament (ACL) injury may influence outcomes after ACL reconstruction. However, there is a lack of evidence supporting these suggestions.
Questions/Purposes
The purpose of this retrospective prognostic study was to assess the predictive value of pre-operative static ATT in knees with ACL injury on return to sport and in satisfaction after ACL reconstruction. Our hypothesis was that greater static ATT would be associated with lower rates of return to sport and lower levels of satisfaction.
Methods
Patients treated with ACL reconstruction were identified from an institutional registry and assigned to one of three groups according to their ACL injury type: acute ACL injury, chronic ACL injury, and failed ACL reconstruction. ATT in each knee compartment was measured using magnetic resonance imaging, and a retrospective telephone questionnaire was used to investigate post-ACL reconstruction return to sport and subjects’ satisfaction.
Results
One hundred thirty patients (52 acute with ACL injury, 29 with chronic ACL injury, and 49 with failed ACL reconstruction) completed the questionnaire, with a mean follow-up of 5.67 years. Ninety-seven patients (74.6%) returned to their primary sport, of whom 63 (65%) returned to the same level of sport. The mean time to return to sport was 10.1 months (range, 2 to 24 months). Overall, 113 patients (87%) were either very satisfied or satisfied with their outcomes. No difference in medial or lateral ATT was found between patients who returned to sport and those who did not. The failed-ACL reconstruction group had significantly lower rates of return to sport than did acutely and chronically injured patients (60.4% versus 88.5% and 75.9%, respectively).
Conclusion
The degree of pre-operative ATT in an ACL-deficient knee was not correlated with return to sport or satisfaction after ACL reconstruction. In this study cohort, only failed-ACL reconstruction patients undergoing revision ACL reconstruction were significantly less likely to return to their main sport. They were also less likely to return to sport at their pre-operative level, if they did return to sport.
Electronic supplementary material
The online version of this article (10.1007/s11420-019-09724-9) contains supplementary material, which is available to authorized users.
Keywords: anterior cruciate ligament reconstruction, static anterior tibial translation, magnetic resonance imaging, return to sport
Introduction
Anterior tibial translation (ATT) refers to an abnormal relationship between the tibia and femur and is typically present after anterior cruciate ligament (ACL) injury. “Static ATT” refers to the abnormal relationship between the femur and tibia as demonstrated on imaging studies, while the knee is in extension and without applying any external or internal stimuli to the knee. Using monopedal lateral standing radiographs with 20° knee flexion, Dejour et al. demonstrated a correlation between a greater extent of ATT and a greater posterior tibial slope [11]. Almekinders et al., using lateral standing radiographs with fully extended knees, found significantly greater ATT in the ACL-deficient knee [1, 3]. Furthermore, it has been shown that in some ACL-deficient knees, ATT cannot be reduced to a normal level when posteriorly directed force is applied to the tibia, and researchers have speculated that the altered tibial position can compromise proper intra-operative tunnel positioning during ACL reconstruction (ACLR) and results in suboptimal knee kinematics and stability, with a greater risk of graft impingement [2–4, 23].
Researchers have used magnetic resonance imaging (MRI) to demonstrate the static tibiofemoral relationship in different states of ACL injury and reported on the correlation between static ATT results and type of ACL injury, showing that patients with failed ACLR had significantly more anterior tibial subluxation than patients with acutely disrupted ACL [17, 22]. In addition, it has been shown that in the setting of primary ACL deficiency, increased ATT is associated with chondral injuries, meniscal tears, and injury to the anterolateral ligament. Although descriptive data on this phenomenon have been published [1, 3, 11, 17, 22], there is still a paucity of data regarding the post-ACLR clinical and functional implications of greater pre-operative ATT.
Bedi et al. demonstrated that a threshold of 6 mm of ATT in the lateral compartment is necessary to produce a pivot shift, and ATT of 10 mm of the lateral compartment results in a grade 1 pivot shift [10]. Based on this observation, McDonald et al. suggested that a knee with static lateral ATT meeting the threshold of 6 mm may be clinically and functionally considered as a knee in “resting pivoted position,” which further emphasizes the question of the clinical and functional influence of increased pre-operative ATT on ACLR outcomes [17].
ACLR has been shown to provide significant improvement, as determined through both short- and long-term patient-reported outcomes. Specifically, in a study by the Multicenter Orthopaedic Outcomes Network (MOON) Knee Group, patients’ International Knee Documentation Committee scores and Knee Injury and Osteoarthritis Outcome Scores were shown to increase after ACLR and were maintained through 10 years of follow-up, whereas Marx scores, which represent the level and characteristics of sport activity after ACLR, significantly increased after ACLR but declined over time [18]. In recent years, the literature has specifically focused on the return to sports after ACLR because it is considered an important indicator of ACLR success in both recreational and professional athletes [6, 7, 15, 19]. In many instances, the desire to return to pre-injury sport activity, particularly in sports involving cutting, pivoting, and jumping maneuvers, is the major indication for ACLR surgery.
The purpose of this study was to assess the predictive value of pre-operative static ATT in knees with ACL injury in return to sport and in satisfaction after ACLR. We hypothesized that greater static ATT would be associated with lower rates of return to sport and lower levels of satisfaction after ACLR surgery.
Methods
This cohort and similar methods have been described previously [17]. After obtaining approval from our institutional review board, we pulled data from our institutional registry on all patients who demonstrated clinical and imaging findings consistent with an ACL injury and who were treated for it between January 1, 2007, and May 31, 2012. We identified a total of 486 patients. Subjects were excluded if they had associated knee ligament injuries requiring surgical treatment, prior knee surgery other than ACLR, or subacute ACL injury with knee MRI performed between 2 and 12 months from the injury; 186 patients were eligible for inclusion. Based on published literature showing a correlation between the degree of static ATT and the type of ACL injury [17, 22], patients in this study were assigned to one of three experimental groups according to their ACL status:
Acute ACL disruption: patients who underwent knee MRI within 2 months of an ACL tear
Chronic ACL disruption: patients who underwent knee MRI more than 12 months after an ACL tear
Failed ACLR: patients presenting for revision ACLR with clinical signs of ACL insufficiency and complete discontinuity of ACL fibers on MRI after primary ACLR
All 186 eligible patients were contacted by one of the authors (L.J.K), who was not blinded to the patient’s group and administered an author-derived questionnaire over the phone; patients were asked what their main sport before surgery had been, whether they had returned to that sport, and, if yes, when and at which level. If patients did not return to their main sport, they were asked what the reason was for not returning. In addition, patients were asked whether they had reinjured the same knee, undergone reoperation on that knee, or both. Finally, patients were asked to rate their knee as a percentage between 0 and 100% (the Single Assessment Numeric Evaluation [SANE] score); their level of satisfaction, which was scored on a five-item Likert scale; and whether they would choose to undergo the procedure again. Patients’ main sports were further categorized as pivoting or partial-nonpivoting. Pivoting sports were defined as level I sports according to the ratings described by Hefti et al. and included soccer, basketball, football, handball, tennis, and other ball games that involve jumping, cutting, and pivoting [13]. Partial-nonpivoting sports were defined as levels II and III according to the criteria of Hefti et al. [13] and included alpine skiing, snowboarding, gymnastics, weight lifting, running, and triathlon. Two patients, both from the failed-ACLR group, were excluded after being contacted: one patient had undergone conservative treatment, and the other had an ACLR with a synthetic graft.
MRI was used to measure pre-operative static anterior tibial translation. Scanning was performed using either a 3-Tesla (70%) or 1.5-Tesla (30%) scanner (GE Medical Systems, Waukesha, WI, USA), using a standardized institutional protocol. Two-dimensional fast spin-echo, proton density–weighted images were acquired to assess morphological changes of the knee joint echo time (TE), 20 to 39 ms; repetition time, 3300 to 6800 ms; echo train length, 9 to 16; bandwidth, 62.5 kHz over entire frequency range; acquisition matrix, 512 by 532 to 512 by 480; number of excitations: one to three; field of view, 14 to 19 cm; slice thickness, 3 to 4 mm with no gap. Examinations were performed in the supine position with the knee in extension inside an eight-channel knee coil (GE Healthcare, Waukesha, WI, USA). In order to ensure consistent positioning of the knee, the extremity was secured in a commercial extremity coil (eight-channel knee coil; Medrad, GE Healthcare, Waukesha, WI, USA).
ATT measurements were performed by a single observer and were determined using a technique first described and validated by Iwaki et al. [14] and later used by Tanaka et al. [22]. On sagittal MRI images, the relative position of the proximal tibia relative to the posterior femoral condyle was determined in each knee compartment separately by a single observer. Standard reference points were used to ensure consistency between all measurements. Medial ATT was measured on the first MRI image that showed the origin of the medial gastrocnemius tendon on the femur; the lateral ATT was measured on the image that showed the most medial aspect of the fibula at the tibiofibular joint. Using the sagittal proton density images, a circle was drawn to best fit the posterior femoral condyle. Along the posterior margin of the circle, a line perpendicular to the tibial plateau was drawn. An additional line perpendicular to the tibial plateau was drawn at the posterior aspect of the tibia. The distance between these lines was the amount of ATT (Fig. 1). This measurement technique has demonstrated good interobserver reliability in the medial compartment (intraclass correlation coefficient [ICC], 0.72) and excellent reliability between observers for the lateral compartment (ICC, 0.96), according to Tanaka et al. [22].
Fig. 1.
Anterior tibial translation (ATT) was measured relative to a posterior femoral condylar reference line on sagittal proton density–weighted images. The yellow circle represents a best-fit circle over the posterior femoral condyle at the subchondral bone. The posterior reference line (yellow) is drawn from the posterior margin of the circle and perpendicular to the tibial plateau. An additional line perpendicular to the tibial plateau represents the posterior tibial plane (red). The distance between these lines (red arrows) is the ATT.
MRI evaluation for the presence of medial or lateral meniscal tears and chondral defects was performed by a board-certified musculoskeletal radiologist. The radiologist was blinded to the clinical information, as well as to which group each patient belonged. Meniscal tears were defined as areas of high signal surfacing on the superior or inferior surface (or both) or displaced meniscal tears.
Statistical Analysis
Descriptive characteristics were reported using means, standard deviation (SD), and ranges for continuous variables and frequencies and percentages (%) for discrete variables. Differences in baseline characteristics and tibial subluxation between the injury groups were evaluated using one-way analysis of variance and post hoc Tukey honest tests, which correct for multiple comparisons across the ACL injury groups. Comparisons between the different ACL injury groups were assessed using χ2 tests for the rate of return and independent t tests were performed to evaluate the ATT separately for each compartment. The multivariate logistic regression analysis was used to identify factors that were predictive for return to sports after the ACL injury. The covariates used in all analyses were age, sex, medial ATT, lateral ATT, meniscal status, presence of chondral defects, and anterolateral ligament injury. A p value of < 0.05 was considered statistically significant. All analyses were conducted using SPSS version 24 (SPSS Inc., Armonk, NY, USA).
Results
Overall, 184 patients met our inclusion criteria (72 acute ACL injuries, 41 chronic ACL injuries, and 71 failed ACLR). All patients had received their ACLR at our institution, performed by fellowship-trained senior surgeons. ACL grafting types included bone-patellar bone-tendon autograft (35.4%), hamstring autograft (30.8%), Achilles tendon allograft (23.1%), combined hamstring autograft and allograft (3.1%), and quadriceps tendon autograft (1.5%).
In total, 130 patients (52 acute ACL injuries, 29 chronic ACL injuries, and 49 failed ACLRs) completed the return-to-sport questionnaire at a mean follow-up of 5.67 years (SD, 0.72; range, 3.13 to 9.31), which represent 71% of the initial cohort. The mean time from MRI to surgery in the acute group was 26.5 days (SD, 20.5 days; range, 1 to 130 days). Demographic and clinical characteristics of the overall study population and subgroups are reported in Table 1. Overall, the mean lateral ATT was 3.9 mm (SD, 3.9; range, − 4.8 to 13) and medial ATT was 1.2 mm (SD, 2.9; range, − 7.2 to 10.3). Comparison of medial and lateral ATT between injury groups showed that the failed-ACLR group demonstrated significantly higher medial and lateral ATT, as compared with the group with acute ACL injury (p < 0.001 and p = 0.007, respectively).
Table 1.
Demographic and clinical characteristics of the entire study population and ACL injury groups
| Total (n = 130) | Acute (n = 52) | Chronic (n = 29) | Failed (n = 49) | |
|---|---|---|---|---|
| Mean (SD) or n (%) | ||||
| Age (years) | 31.8 (12.5) | 29.8 (11.8) | 37.4 (10.9) | 30.7 (13.2) |
| Male | 75 (57.7) | 26 (50) | 18 (62.1) | 31 (63.3) |
| Lateral ATT (mm) | 3.9 (3.9) | 2.8 (3.2) | 3.6 (4.1) | 5.2 (4.1) |
| Medial ATT (mm) | 1.2 (2.9) | 0.2 (2.4) | 0.7 (2.3) | 2.5 (3.2) |
| Lateral chondral defecta | 124 (95.4) | 48 (92.3) | 29 (100) | 47 (96.0) |
| Medial chondral defecta | 46 (35.4) | 10 (19.2) | 16 (55.2) | 20 (40.8) |
| Lateral meniscus teara | 49 (37.7) | 20 (38.5) | 14 (48.3) | 15 (30.6) |
| Medial meniscus teara | 70 (53.9) | 25 (48.1) | 19 (65.5) | 26 (53.1) |
| Lateral and medial meniscus teara | 38 (29.2) | 12 (23.1) | 12 (41.4) | 14 (28.6) |
ACL anterior cruciate ligament, ATT anterior tibial translation, SD standard deviation
aBased on magnetic resonance imaging
Overall, 97 patients (74.6%) returned to their main sport, of whom 63 (65%) returned to the same level. The mean time to return to sport was 10.1 months (SD, 7.3; range, 2 to 24 months). Regarding satisfaction, 89 patients (68.5%) were very satisfied, 24 were (18.5%) satisfied, eight were (6.2%) dissatisfied, and eight were (6.2%) were neither satisfied nor dissatisfied. The mean SANE score at final follow-up was 80.88 (SD, 17.81; range 10 to 100), and 127 patients (97.7%) stated that they would choose to have surgery again. Seven patients (5.5%) reported a failure of their ACLR and underwent revision or rerevision ACLR surgery. The mean ATT in both compartments in these failed cases was not different from the mean compartmental ATT in the rest of the cohort. Return to sport and patient-reported outcomes are reported in Table 2.
Table 2.
Return to sport and patient-reported outcomes of the entire study population and ACL injury groups
| Total (n = 130) | Acute (n = 52) | Chronic (n = 29) | Failed (n = 49) | p value | |
|---|---|---|---|---|---|
| Mean (SD) or n (%) | |||||
| Returned to sport | 97 (75.2) | 46 (88.5) | 22 (75.9) | 29 (60.4) | 0.003a |
| Months to return | 10.1 (7.3) | 10.6 (9.6) | 10.8 (5.2) | 8.9 (3.6) | 0.57 |
| Same level if returned | 62 (63.9) | 35 (76.1) | 12 (54.6) | 15 (51.7) | 0.06b |
| SANE score | 80.9 (17.8) | 82.5 (19.4) | 82.6 (12.7) | 78.1 (18.6) | NS |
| Satisfied | 113 (87.6) | 46 (88.5) | 26 (89.7) | 41 (85.4) | |
| Revision ACLR | 7 (5.5) | 2 (3.9) | 1 (3.5) | 4 (8.5) | |
ACL anterior cruciate ligament, SD standard deviation, SANE Single Assessment Numeric Evaluation, NS not significant, ACLR ACL revision
aPost hoc analysis showed significant difference between acute vs. failed groups p < 0.001
bPost hoc analysis showed significant difference between acute vs. failed groups p = 0.03
No difference in medial or lateral ATT was found between patients who returned to sport and those who did not. In addition, neither medial nor lateral ATT was correlated with time to return, level of return, satisfaction, or SANE score. Further analysis of the correlation between ATT and return to sport within the individual injury groups (acute, chronic, and failed ACLR) demonstrated similar results.
Sports were categorized as pivoting or partial-nonpivoting. Eighty patients had participated in a pivoting sport and 45 in a partial-nonpivoting sport. Five patients did not list their main sport. Grouping the patients into three groups according to lateral ATT value (less than 6 mm, 6 to 10 mm, and greater than 10 mm), we further analyzed return to pivoting and partial-nonpivoting sport and satisfaction within these groups. Patients with more than 10 mm of lateral ATT who participated in a pivoting sport pre-operatively had the lowest rate of returning to their sport (50% versus 68.2% and 70.7% at less than 6 and 6 to 10 mm, respectively). These results are reported in Table 3.
Table 3.
Return to pivoting or partial-nonpivoting sport and satisfaction within ATT groups
| Return to sport | Satisfaction | ||||
|---|---|---|---|---|---|
| Lateral ATT | Pivoting | Partial-nonpivoting | Satisfied | Neutral | Dissatisfied |
| ATT < 6 mm (n = 94) | 70.7% (41/58) | 90.9% (30/33) | 90.4% | 2.1% | 7.5% |
|
6–10 mm (n = 36) |
68.2% (15/22) | 61.5% (8/13) | 80% | 17.1% | 2.9% |
| ATT > 10 mm (n = 9) | 50% (3/6) | 66.7% (2/3) | 88.9% | 11.1% | 0% |
ATT anterior tibial translation
Analyzing the ACL injury groups within our cohort, we found that the failed-ACLR group had significantly lower rates of return to sport, as compared with acutely and chronically injured patients (60.4% versus 88.5% and 75.9%, respectively; p = 0.003). Furthermore, chronically injured and failed-ACLR patients were less likely to return to their pre-operative level of sports after surgery (54.6% and 51.7%, respectively), as compared with the acutely injured patients (76.1%); however, only the failed-ACLR group showed a statistically significant difference when compared with the acute-injury group (p = 0.03). The time to return to sport was not significantly different between groups nor was SANE scores, satisfaction rates, or reoperation rates (Table 2). Reasons for not returning to sport within each injury type group are reported in Fig. 2. The logistic regression analysis revealed that the injury group was predictive of returning to the main sport, showing that the failed-ACL group was less likely to return to sport (odds ratio, 0.08; p = 0.004). Age, sex, medial and lateral ATT, meniscal status, and chondral defects were found not to be predictive (Table 4).
Fig. 2.
Reasons for not returning to sport within injury type groups. Percentages above bars represent percentages of patients within the study group. Patients could choose more than one group.
Table 4.
Multivariate regression analysis of likelihood of return to sport (N = 130)
| Odds ratio | 95% CI | p value | |
|---|---|---|---|
| Age, years | 0.97 | 0.92–1.04 | 0.41 |
| Male sex | 1.09 | 0.33–3.61 | 0.89 |
| ACL injury group | |||
| • Acute | Reference | – | – |
| • Chronic | 0.25 | 0.05–1.22 | 0.09 |
| • Failed | 0.08 | 0.02–0.45 | 0.004a |
| Lateral ATT | 0.98 | 0.81–1.19 | 0.84 |
| Medial ATT | 1.00 | 0.77–1.31 | 0.98 |
| Lateral chondral defectb | 1.31 | 0.08–21.1 | 0.85 |
| Medial chondral defectb | 0.86 | 0.18–4.19 | 0.85 |
| Lateral meniscus tearb | 1.95 | 0.45–8.54 | 0.38 |
| Medial meniscus tearb | 0.60 | 0.15–2.31 | 0.46 |
CI confidence interval, ACL anterior cruciate ligament, ATT anterior tibial translation
aStatistically significant
bBased on magnetic resonance imaging
Discussion
The most important finding of the present study is that neither medial nor lateral pre-operative static ATT, as measured on MRI, influenced return to a patient’s primary sport or satisfaction after ACLR. In addition, to our knowledge, this is the first study that assessed the association between the degree of pre-operative ATT and satisfaction after ACLR surgery.
This study has several limitations. First, no post-operative MRI using a standardized protocol was available to allow evaluation of ATT after surgery, which could further our understanding of refractory ATT and its effect on clinical outcomes. Nevertheless, the goal of the study was to assess whether pre-operative ATT was predictive of post-operative outcomes and specifically return to sport. Second, despite showing the prognostic value of static ATT assessment, this study was a retrospective case series that involved a heterogeneous population of patients practicing different types of sports who were treated by multiple surgeons using several graft types. With regard to this limitation, the MOON Knee Group [18] has shown that type of sport, level of competition, graft type, and operating surgeon are not significant risk factors for poorer outcomes (including Marx score) after ACLR. Third, the data we analyzed came from patient responses to a questionnaire asking about the return to sport and satisfaction, which could reflect selection bias or poor recall among the respondents. Finally, because it involved only two-dimensional imaging, the MRI measurement technique used to assess ATT in each compartment controlled for knee flexion angle variability but could not correct for rotation.
Almekinders et al. [1, 3] speculated that the altered tibiofemoral relationship and specifically greater static ATT in the ACL-deficient knee influences intra-operative visualization and compromises optimal ACLR tunnel placement. This can lead to graft failure and worse outcomes. Further evaluation of knees after ACLR by Almekinders—and other colleagues—showed greater ATT on anterior-posterior stress lateral radiographs, as compared with contralateral ACL-intact knees. Others have confirmed that ACLR surgery does not restore normal tibiofemoral kinematics [9, 16]. Zuiderbaan et al. [23] investigated how static ATT as measured in various states of ACL deficiency corresponds to the risk and location of notch impingement of the ACL graft and reported on recommended notchplasty techniques that should be considered in these circumstances. These data suggest that greater pre-operative ATT in the ACL-deficient knee may predict less favorable clinical outcomes and increase failure rates, which was the rationale behind our hypothesis. However, our findings did not support this hypothesis; we found no correlation between the degrees of pre-operative ATT and return to sport or satisfaction among the entire cohort or in any of the injury groups individually.
When considering the type of primary sport reported by patients, and looking specifically at pivoting sports in comparison with other sports, we did find some trends, although they did not reach significance because of the limited number of patients in each group. These trends showed that patients with more than 10 mm of lateral ATT who participated in a pivoting sport pre-operatively had the lowest rate of returning to their sport (50%). This finding requires further investigation with a larger relevant cohort.
Logan et al. suggested that although ACLR surgery has been successful in restoring joint stability, it does not restore normal tibiofemoral kinematics [16]. Despite the fact that the knee has not been restored to normal tibiofemoral relationship, patients may cope well and return to sporting activities. This might explain our primary finding that pre-operative ATT does not influence return to sport. Moreover, Logan et al. suggested that the altered tibiofemoral kinematics could explain, at least in part, why ACLR may not reduce the incidence of post-surgery osteoarthritis. It would therefore be interesting to study the correlation between pre-operative and post-operative ATT and the development of degenerative joint changes.
In contrast to the theory proposed by Logan et al., another possible explanation for our findings is that ACLR surgery performed in these patients does restore tibiofemoral relationship and the pre-operatively increased ATT returned to normal values after surgery. This should be further investigated with studies evaluating pre- and post-ACLR ATT.
Return to sport after ACLR is an increasingly important outcome when evaluating the success of ACL surgery. Two systematic review and meta-analysis by Ardern et al. on rates of return to sport after ACLR and found 69 eligible articles published between 1994 and 2013 [5, 7]. Overall, in this heterogeneous population, involving a total of 7556 participants, 81% returned to sport. More recent studies have reported higher rates of return (above 87%) to general sport after ACL reconstruction [15, 19, 20]. The overall rate of return to sport in our study was 74.6%. This lower rate may be the result of our inclusion of substantial numbers of patients with a chronic ACL injury and failed ACLR surgery. Also, our questionnaire asked patients specifically about return to their main sport and not sports in general.
Patients’ satisfaction after surgery is lower than it could be within orthopedics in general and in the ACLR literature specifically; an optimal method for evaluating patient satisfaction after orthopedic surgery has not yet been described or validated [12]. Nwachukwu et al. determined satisfaction by employing an ordinal ranking of satisfaction from “very satisfied” to “very dissatisfied.” They reported that 85.4% of the patients were very satisfied and 10.3% were somewhat satisfied with their outcome after ACLR surgery, and 98.1% stated they would chose to have surgery again. Our study found that 68.5% of the patients were very satisfied and 18.5% somewhat satisfied; however, 97.7% stated they would choose to undergo surgery again, which is similar to the rate reported by Nwachukwu et al. [19]. The lower satisfaction rates seen in our study may be explained by the aforementioned reasons and taking in into account that not all of our patients were considered active athletes.
Furthermore, patients in our failed-ACLR group were significantly less likely to return to their main sport after the revision ACLR than the acutely and chronically injured patients after their primary ACLR. The likelihood of returning to the pre-operative level of sport was also lower in the failed-ACLR group. These findings support previously published data [8, 15, 21]. The two most common reasons for not returning to sports after revision ACLR (Fig. 2) were functional limits caused by knee symptoms and the fear of reinjury (61% and 50%, respectively). These findings were similar to those presented by Battaglia et al., who showed that arthritic symptoms and fear of reinjury were the two main reasons by their cohort for not returning to cutting or pivoting sports [8].
In conclusion, this study found that the degree of pre-operative ATT in ACL-deficient knees, as measured on MRI, was not correlated with return to main sport or satisfaction rates after ACLR surgery. Patients in the failed-ACLR group who underwent revision ACLR were less likely to return to their main sport, as compared with primary ACLR patients and more likely to return to lower level of sport; however, patients’ satisfaction after ACLR surgery was high in all injury groups. Continued research should focus on ATT and additional patient-reported outcomes, as well as pre-operative and post-operative ATT and the development of post-ACLR degenerative joint changes.
Electronic supplementary material
(PDF 1224 kb)
(PDF 1224 kb)
(PDF 1224 kb)
(PDF 1224 kb)
(PDF 1224 kb)
(PDF 1224 kb)
(PDF 1224 kb)
Compliance with Ethical Standards
Conflict of Interest
Niv Marom, MD, Laura J. Kleeblad, MD, Daphne Ling, PhD, MPH, Benedict U. Nwachukwu, MD, MBA, and Hollis G. Potter, MD, declare that they have no conflicts of interest. Robert G. Marx, MD, FRCSC, reports publishing royalties from Springer and Demo Health and editorial board membership with the Journal of Bone and Joint Surgery, outside the submitted work. Andrew D. Pearle, MD, reports royalties from Zimmer Biomet and fees as a consultant from Stryker and Exactech.
Human/Animal Rights
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.
Informed Consent
All included patients were contacted and chose whether to participate in this study and answer the questionnaire.
Required Author Forms:
Disclosure forms provided by the authors are available with the online version of this article.
Footnotes
Level of Evidence: Level II: Retrospective Prognostic Study.
References
- 1.Almekinders LC, Chiavetta JB. Tibial subluxation in anterior cruciate ligament–deficient knees: implications for tibial tunnel placement. Arthroscopy. 2001;17(9):960–962. doi: 10.1053/jars.2001.25248. [DOI] [PubMed] [Google Scholar]
- 2.Almekinders LC, de Castro D. Fixed tibial subluxation after successful anterior cruciate ligament reconstruction. Am J Sports Med. 2001;29(3):280–283. doi: 10.1177/03635465010290030301. [DOI] [PubMed] [Google Scholar]
- 3.Almekinders LC, Chiavetta JB, Clarke JP. Radiographic evaluation of anterior cruciate ligament graft failure with special reference to tibial tunnel placement. Arthroscopy. 1998;14(2):206–211. doi: 10.1016/S0749-8063(98)70042-8. [DOI] [PubMed] [Google Scholar]
- 4.Almekinders LC, Pandarinath R, Rahusen FT. Knee stability following anterior cruciate ligament rupture and surgery. The contribution of irreducible tibial subluxation. J Bone Joint Surg Am. 2004;86-A(5):983–987. doi: 10.2106/00004623-200405000-00014. [DOI] [PubMed] [Google Scholar]
- 5.Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011;45(7):596–606. doi: 10.1136/bjsm.2010.076364. [DOI] [PubMed] [Google Scholar]
- 6.Ardern CL, Taylor NF, Feller JA, Webster KE. Return-to-sport outcomes at 2 to 7 years after anterior cruciate ligament reconstruction surgery. Am J Sports Med. 2012;40(1):41–48. doi: 10.1177/0363546511422999. [DOI] [PubMed] [Google Scholar]
- 7.Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48(21):1543–1552. doi: 10.1136/bjsports-2013-093398. [DOI] [PubMed] [Google Scholar]
- 8.Battaglia MJ, 2nd, Cordasco FA, Hannafin JA, et al. Results of revision anterior cruciate ligament surgery. Am J Sports Med. 2007;35(12):2057–2066. doi: 10.1177/0363546507307391. [DOI] [PubMed] [Google Scholar]
- 9.Beard DJ, Murray DW, Gill HS, et al. Reconstruction does not reduce tibial translation in the cruciate-deficient knee: an in vivo study. J Bone Joint Surg Br. 2001;83(8):1098–1103. doi: 10.1302/0301-620X.83B8.0831098. [DOI] [PubMed] [Google Scholar]
- 10.Bedi A, Musahl V, Lane C, Citak M, Warren RF, Pearle AD. Lateral compartment translation predicts the grade of pivot shift: a cadaveric and clinical analysis. Knee Surg Sports Traumatol Arthrosc. 2010;18(9):1269–1276. doi: 10.1007/s00167-010-1160-y. [DOI] [PubMed] [Google Scholar]
- 11.Dejour H, Bonnin M. Tibial translation after anterior cruciate ligament rupture. Two radiological tests compared. J Bone Joint Surg Br. 1994;76(5):745–749. doi: 10.1302/0301-620X.76B5.8083263. [DOI] [PubMed] [Google Scholar]
- 12.Graham B, Green A, James M, Katz J, Swiontkowski M. Measuring patient satisfaction in orthopaedic surgery. J Bone Joint Surg Am. 2015;97(1):80–84. doi: 10.2106/JBJS.N.00811. [DOI] [PubMed] [Google Scholar]
- 13.Hefti F, Muller W, Jakob RP, Staubli HU. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc. 1993;1(3–4):226–234. doi: 10.1007/BF01560215. [DOI] [PubMed] [Google Scholar]
- 14.Iwaki H, Pinskerova V, Freeman MA. Tibiofemoral movement 1: the shapes and relative movements of the femur and tibia in the unloaded cadaver knee. J Bone Joint Surg Br. 2000;82(8):1189–1195. doi: 10.1302/0301-620X.82B8.0821189. [DOI] [PubMed] [Google Scholar]
- 15.Lefevre N, Klouche S, Mirouse G, Herman S, Gerometta A, Bohu Y. Return to sport after primary and revision anterior cruciate ligament reconstruction: a prospective comparative study of 552 patients from the FAST cohort. Am J Sports Med. 2017;45(1):34–41. doi: 10.1177/0363546516660075. [DOI] [PubMed] [Google Scholar]
- 16.Logan MC, Williams A, Lavelle J, Gedroyc W, Freeman M. Tibiofemoral kinematics following successful anterior cruciate ligament reconstruction using dynamic multiple resonance imaging. Am J Sports Med. 2004;32(4):984–992. doi: 10.1177/0363546503261702. [DOI] [PubMed] [Google Scholar]
- 17.McDonald LS, van der List JP, Jones KJ, et al. Passive anterior tibial subluxation in the setting of anterior cruciate ligament injuries: a comparative analysis of ligament-deficient states. Am J Sports Med. 2017;45(7):1537–1546. doi: 10.1177/0363546516688673. [DOI] [PubMed] [Google Scholar]
- 18.MOON Knee Group. Spindler KP, Huston LJ, et al. Ten-year outcomes and risk factors after anterior cruciate ligament reconstruction: a MOON longitudinal prospective cohort study. Am J Sports Med. 2018;46(4):815–825. doi: 10.1177/0363546517749850. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Nwachukwu BU, Voleti PB, Berkanish P, et al. Return to play and patient satisfaction after ACL reconstruction: study with minimum 2-year follow-up. J Bone Joint Surg Am. 2017;99(9):720–725. doi: 10.2106/JBJS.16.00958. [DOI] [PubMed] [Google Scholar]
- 20.Rodriguez-Roiz JM, Caballero M, Ares O, Sastre S, Lozano L, Popescu D. Return to recreational sports activity after anterior cruciate ligament reconstruction: a one- to six-year follow-up study. Arch Orthop Trauma Surg. 2015;135(8):1117–1122. doi: 10.1007/s00402-015-2240-8. [DOI] [PubMed] [Google Scholar]
- 21.Shelbourne KD, Benner RW, Gray T. Return to sports and subsequent injury rates after revision anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med. 2014;42(6):1395–1400. doi: 10.1177/0363546514524921. [DOI] [PubMed] [Google Scholar]
- 22.Tanaka MJ, Jones KJ, Gargiulo AM, et al. Passive anterior tibial subluxation in anterior cruciate ligament–deficient knees. Am J Sports Med. 2013;41(10):2347–2352. doi: 10.1177/0363546513498995. [DOI] [PubMed] [Google Scholar]
- 23.Zuiderbaan HA, Khamaisy S, Nawabi DH, et al. Notchplasty in anterior cruciate ligament reconstruction in the setting of passive anterior tibial subluxation. Knee. 2014;21(6):1160–1165. doi: 10.1016/j.knee.2014.08.011. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
(PDF 1224 kb)
(PDF 1224 kb)
(PDF 1224 kb)
(PDF 1224 kb)
(PDF 1224 kb)
(PDF 1224 kb)
(PDF 1224 kb)