Clinical evaluation and management of anterior cruciate ligament (ACL) injury is one of the most widely researched topics in orthopedic sports medicine, giving providers ample data on which to base their practices. The ACL is also the most commonly treated knee ligament. This study reports on current topics and research in clinical management of ACL injury, starting with evaluation, operative versus nonoperative management, and considerations in unique populations. Discussion of graft selection and associated procedures follows. Areas of uncertainty, rehabilitation, and prevention are the final topics before a reflection on the current state of ACL research and clinical management of ACL injury. Level of evidence V.

A trend within the orthopedic community is rejection of the belief that "one size its all." Freddie Fu, among others, strived to individualize the treatment of anterior cruciate ligament (ACL) injuries based on the patient's anatomy. Further, during the last two decades, greater emphasis has been placed on improving the outcomes of ACL reconstruction (ACL-R). Accordingly, anatomic tunnel placement is paramount in preventing graft impingement and restoring knee kinematics. Additionally, identiication and management of concomitant knee injuries help to re-establish knee kinematics and prevent lower outcomes and registry studies continue to determine which graft yields the best outcomes. The utilization of registry studies has provided several large-scale epidemiologic studies that have bolstered outcomes data, such as avoiding allografts in pediatric populations and incorporating extra-articular stabilizing procedures in younger athletes to prevent re-rupture. In describing the anatomic and biomechanical understanding of the ACL and the resulting improvements in terms of surgical reconstruction, the purpose of this article is to illustrate how basic science advancements have directly led to improvements in clinical outcomes for ACL-injured patients. Level of evidence V.

Purpose To evaluate the efect of posterior tibial slope (PTS) on patient-reported outcomes (PROs) and posterior cruciate ligament (PCL) graft failure after PCL reconstruction. Methods Patients undergoing PCL reconstruction with a minimum 2-year follow-up were included in this retrospective cohort study. A chart review was performed to collect patient-, injury-, and surgery-related data. Medial PTS was measured on preoperative lateral radiographs. Validated PROs, including the International Knee Documentation Committee Subjective Knee Form, Knee injury and Osteoarthritis Outcome Score, Lysholm Score, Tegner Activity Scale, and Visual Analogue Scale for pain, were collected at inal follow-up. A correlation analysis was conducted to assess the relationship between PTS and PROs. A logistic regression model was performed to evaluate if PTS could predict PCL graft failure. Results Overall, 79 patients with a mean age of 28.6 ± 11.7 years and a mean follow-up of 5.7 ± 3.3 years were included. After a median time from injury of 4.0 months, isolated and combined PCL reconstruction was performed in 22 (28%) and 57 (72%) patients, respectively. There were no statistically signiicant diferences in PROs and PTS between patients undergoing isolated and combined PCL reconstruction (non-signiicant [n.s.]). There were no signiicant correlations between PTS and PROs (n.s.). In total, 14 (18%) patients experienced PCL graft failure after a median time of 17.5 months following PCL reconstruction. Patients with PCL graft failure were found to have statistically signiicantly lower PTS than patients without graft failure (7.0 ± 2.3° vs. 9.2 ± 3.3°, p < 0.05), while no diferences were found in PROs (n.s.). PTS was shown to be a signiicant predictor of PCL graft failure, with a 1.3-fold increase in the odds of graft failure for each one-degree reduction in PTS (p < 0.05). Conclusions This study showed that PTS does not afect PROs after PCL reconstruction, but that PTS represents a surgically modiiable predictor of PCL graft failure. Level of evidence III.

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Background: Surgery for degenerative foot and ankle conditions often results in a lengthy recovery. Current outcome measures do not accurately assess postoperative mobility, especially in older patients. The Life-Space Assessment (LSA), a questionnaire quantifying patients’ mobility after a medical event, was used in this study to assess perioperative mobility in total hip arthroplasty (THA) and foot and ankle surgery patients. We hypothesized that patients undergoing elective foot and ankle surgery would have greater postoperative mobility limitation than THA patients. Methods: Preoperative, 3-month, and 6-month postoperative LSA data were collected from THA and foot and ankle cohorts. Twelve-month postoperative data were obtained for the foot and ankle group as well. Patient demographics were recorded, and data were analyzed using a Mann-Whitney U test. Results: Twenty-eight degenerative foot and ankle operative patients and 38 THA patients met inclusion criteria. Only patients aged ≥60 years were included in this study. The mean preoperative LSA score was lower in the foot and ankle group (68.8) compared with THA (74.0), although the difference was not statistically significant ( P = .602). THA patients showed a significant increase in LSA score from preoperative (74) to 6 months postoperation (95.9) ( P = .003); however, foot and ankle patients showed no significant difference between preoperative (68.8) and 6-month (61.2) scores ( P = .468). Twelve months postoperatively, foot and ankle patients showed improvement in LSA score (88.3) compared with preoperation ( P = .065). Conclusion: Compared with THA, recovery of mobility after foot and ankle surgery was slower. THA patients exhibited improved mobility as early as 3 months after surgery, whereas foot and ankle patients did not show full improvement until 12 months. This work will assist the foot and ankle specialist in educating patients about challenges in mobility during their recovery from surgery. Level of Evidence: Level II, prospective cohort study.

Purpose The purpose of this study was to evaluate whether there was a diference in clinical outcomes between patients who underwent primary ACL reconstruction (ACLR) with all-soft tissue quadriceps tendon (sQT) autograft versus QT with bone block (bQT). Methods A retrospective cohort study of 708 patients who underwent QT ACLR was conducted. Primary ACLR patients with at least 1 year of follow-up were identiied and those who received sQT were compared to those who received bQT. Data collection entailed patient demographics, surgical variables, patient reported outcomes (PROs), knee stability testing, and complications. The primary outcome of interest was International Knee Documentation Committee (IKDC) score, reported as mean score, pre-and postoperative diference, and number who met minimum clinically important diference (MCID). Secondary outcomes included Lachman and pivot shift grade, other patient reported outcomes (PROs), complication rates, and return to sport (RTS). Results A total of 195 patients (147 sQT, 48 bQT) who underwent primary QT ACLR met criteria for analysis, with mean follow-up of 17.0 ± 7.9 months. No diference was detected between cohorts with respect to postoperative IKDC score (sQT: n = 120, 81.0 ± 18.9, bQT: n = 10, 80.9 ± 20.4, n.s.), proportion of patients who met MCID (sQT: 68/78 [87%], bQT: 6/7 [86%], n.s.), or results of stability testing. In the sQT cohort, 86% (106/123) of athletes achieved full RTS, compared to 85% (34/40) in the bQT cohort (n.s.). Time to RTS was less than a year in both cohorts (sQT: 10.5 ± 3.8 months [n = 106], bQT: 11.1 ± 3.9 months [n = 31], n.s.). Graft rupture occurred in 7 (5%) sQT patients and 3 (6%) bQT patients (n.s.), and all clinical failures were due to graft rupture (n.s.). No diferences were detected for rates of postoperative complications. Conclusion No diferences in clinical outcomes were detected between patients who underwent primary ACLR with sQT autograft versus bQT autograft. Currently, the decision to employ sQT or bQT is largely determined by surgeon preference. This study demonstrates excellent outcomes with both preparations and supports the use of either graft type at the discretion of the treating surgeon. Level of evidence III KeywordsACL reconstruction • Anterior cruciate ligament • Knee • Quadriceps tendon autograft • Sports medicine * Joshua C. Setlif

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