ISAKOS 2019 12 th -16 th May Cancun, Mexico Impact of surgical timing on the clinical outcomes of anatomic double-bundle anterior cruciate ligament reconstruction Baba R. 1, Kondo E. 2, Iwasaki K. 1, Joutoku Z. 1, Onodera J. 3, Onodera T. 1, Yagi T. 3, Iwasaki N. 1, Yasuda K. 3 1) Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan 2) Department of Advanced Therapeutic Research for Sports Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan 3) Department of Orthopaedic Surgery, Yagi Orthopaedic Hospital, Sapporo, Japan
Impact of surgical timing on the clinical outcomes of anatomic double-bundle anterior cruciate ligament reconstruction Rikiya Baba MD, PhD I have no conflict.
Backgrounds Impact of surgical timing for ACL injury ROM Arthrofibrosis Shelbourne et al. AJSM 1991 1) No influence Hunter et al. Arthroscopy 1996 2) Lysholm score, IKDC evaluation Worse in delayed surgery Ahlen et al. KSSTA 2011 3) No influence Barenius et al. AJSM 2010 4) Associated injuries (meniscus, cartilage) Increase in delayed surgery Maffulli et al. Arthroscopy 2003 5) Optical surgical timing is still controversial
Backgrounds and purpose Anatomic double-bundle ACLR Yasuda et al. Arthroscopy 2004 6) Superior knee stability than SB ACL-R Kondo et al. AJSM 2008 7) AMB and PLB were clearly visible at 2 years after surgery Kondo et al. Arthroscopy 2007 8) Impact of surgical timing on clinical outcomes remains unclear The purpose of this study is To clarify clinical outcomes after anatomic DB ACL-R among the difference of surgical timing
Materials and Methods 179 patients: unilateral ACL injury Anatomic DB ACL-R Group Injury-to-operation interval Number I within 1 month 26 patients II 1 3 months 77 patients III 3 6 months 41 patients IV 6 24 months 35 patients Clinical evaluations @ 2 years postoperatively Background factors Knee stability, Lysholm score, IKDC evaluation Associated injuries
Results Background factors and pre-operative evaluations Male : Female ratio (cases) Age α (years) I (n = 26) II (n = 77) III (n = 41) IV (n = 35) p value 14 : 12 40 : 37 29 : 12 21 : 14 N.S. 27.5 (11.5) BMI α 22.8 (2.3) Anterior knee laxity α (mm) 3.8 (2.6) 26.4 (11.4) 23.5 (3.3) 3.6 (3.2) 27.1 (12.9) 23.5 (3.3) 4.8 (3.0) 28.1 (14.6) 24.0 (3.5) 4.4 (2.5) N.S. N.S. N.S. Muscle strengths α (%) Quad. 71 (19) 69 (22) 79 (19) 82 (18) 0.0243 β Ham. 71 (21) 71 (25) 84 (23) 87 (27) 0.0066 γ α Data are expressed as mean (S.D.) β Post-hoc;II vs IV, p=0.0364 γ Post-hoc;II vs IV, p=0.0173
Results Post-operative knee instability Anterior knee laxity 0.5 (mm) α (1.8) I II III IV p value 1.1 (1.7) 1.3 (1.5) 1.3 (1.8) N.S. Pivot-shift test (-) 88% 79% 81% 63% (+) 12% 18% 12% 34% (2+) 0% 3% 7% 3% 0.034 β α Data are expressed as mean (S.D.) β Cochran-Armitage trend test
Results Post-operative clinical evaluations Lysholm score α (points) IKDC (cases) I II III IV p value 97 (4) 96 (5) 98 (5) 96 (4) N.S. A 24 69 35 27 B 2 6 3 7 C 0 2 3 1 N.S. Loss of motion (cases) Muscle strengths α (%) Ext >5 2 4 1 2 N.S. Flex>15 1 0 1 2 N.S. Quad. 90 (14) 89 (16) 84 (22) 87 (18) N.S. Ham. 97 (16) 91 (19) 91 (22) 86 (20) N.S. α Data are expressed as mean (S.D.)
Results Associated injuries Medial meniscus injury (%) * : ICRS grade 2-4 Medial compartment chondral injury* (%) Repair rate of meniscus lesion α α α α Cochran-Armitage trend test
Discussions Pre-operative muscle strengths were significantly weaker in Group II than in Group IV. Post-operative pivot-shift test was significantly better in early surgery group. Significantly higher rates of MM injury and medial compartment chondral injury were seen in delayed surgery group compared to early cases.
Discussions Post-operative knee stability with respect to surgical timing Author Journal Early Delayed Graft type follow-up Results Barenius et al. 4) Raviraj et al. 9) Sgaglione et al. 10) Ahn et al. 11) AJSM 2010 JBJS 2010 AJSM 1993 KSSTA 2016 <5M 5M< PT/ST 8 yr N.S. <2w 4w< STG 32 M N.S. <3w 6w< ST 36 M Early is better <12w 12w< STG 55 M Early is better Current study Significantly better in early surgery
Discussions Associated injury with respect to surgical timing Author Journal Medial meniscal and chondral injuries Magnussen et al. 12) KSSTA 2013 Increase after 3 months Brambilla et al. 13) AJSM 2015 Increase after 12 months MM is a secondary restraint to anterior drawer of the knee Delayed surgery led to higher rate of MM and chondral lesion Earlier ACLR may be beneficial for patients to stabilize and prevent secondary damages of the ACL injured knee.
Conclusions Pre-operative muscle strengths were significantly weaker in early surgery group than in delayed surgery group. Post-operative pivot-shift test was significantly better in early surgery group. Significantly higher rate of MM injury and medial compartment chondral injury was seen in cases of delayed surgery compared to early cases.
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