Purpose To determine how concomitant medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries affect outcome after anterior cruciate ligament (ACL) reconstruction. Methods Patients aged > 15 years who were registered in the Swedish National Knee Ligament Registry for primary ACL reconstruction between 2005 and 2016 were eligible for inclusion. Patients with a concomitant MCL or LCL injury were stratified according to collateral ligament treatment (non-surgical, repair or reconstruction), and one isolated ACL reconstruction group was created. The outcomes were ACL revision and the 2-year Knee Injury and Osteoarthritis Outcome Score (KOOS), which were analyzed using univariable and multivariable Cox regression and an analysis of covariance, respectively. Results A total of 19,457 patients (mean age 27.9 years, 59.4% males) met the inclusion criteria. An isolated ACL reconstruction implied a lower risk of ACL revision compared with presence of a non-surgically treated MCL injury (HR = 0.61 [95% CI 0.41–0.89], p = 0.0097) but not compared with MCL repair or reconstruction. A concomitant LCL injury did not impact the risk of ACL revision. Patients with a concomitant MCL or LCL injury reported inferior 2-year KOOS compared with isolated ACL reconstruction. The largest difference was found in the sports and recreation subscale across all groups, with MCL reconstruction resulting in the maximum difference (14.1 points [95% CI 4.3–23.9], p = 0.005). Conclusion Non-surgical treatment of a concomitant MCL injury in the setting of an ACL reconstruction may increase the risk of ACL revision. However, surgical treatment of the MCL injury was associated with a worse two-year patient-reported knee function. A concomitant LCL injury does not impact the risk of ACL revision compared with an isolated ACL reconstruction. Level of evidence Cohort study, Level III.

Background: A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sport and their previous activity level. Purpose: The aim of the Panther Symposium ACL Injury Return to Sport Consensus Group was to provide a clear definition of RTS after ACL injury and a description of the RTS continuum as well as provide clinical guidance on RTS testing and decision-making. Study Design: Consensus statement. Methods: An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence. Results: Key points include that RTS is characterized by achievement of the preinjury level of sport and involves a criteria-based progression from return to participation to RTS and, ultimately, return to performance. Purely timebased RTS decision-making should be abandoned. Progression occurs along an RTS continuum, with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors, and concomitant injuries. Conclusion: The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing, and methods for the biological assessment of healing and recovery.

PurposeTo analyse patient-related risk factors for 2-year ACL revision after primary reconstruction. The hypothesis was that younger athletes would have a higher incidence of an early ACL revision.MethodsThis prospective cohort study was based on data from the Norwegian and Swedish National Knee Ligament Registries and included patients who underwent primary ACL reconstruction from 2004 to 2014. The primary end-point was the 2-year incidence of ACL revision. The impact of activity at the time of injury, patient sex, age, height, weight, BMI, and tobacco usage on the incidence of early ACL revision were described by relative risks (RR) with 95% confidence intervals (CI).ResultsA total of 58,692 patients were evaluated for eligibility and 30,591 patients were included in the study. The mean incidence of ACL revision within 2 years was 2.82% (95% CI 2.64–3.02%). Young age (13–19) was associated with an increased risk of early ACL revision (males RR = 1.54 [95% CI 1.27–1.86] p < 0.001 and females RR = 1.58 [95% CI 1.28–1.96] p < 0.001). Females over 1 SD in weight ran an increased risk of early ACL revision (RR = 1.82, [95% CI 1.15–2.88] p = 0.0099). Individuals with a BMI of over 25 ran an increased risk of early ACL revision (males: RR = 1.78, [95% CI 1.38–2.30] p < 0.001 and females: RR = 1.84, [95% CI 1.29–2.63] p = 0.008).ConclusionYoung age, a BMI over 25, and overweight females were risk factors for an early ACL revision.Level of evidenceII.

Purpose A stringent outcome assessment is a key aspect for establishing evidence-based clinical guidelines for anterior cruciate ligament (ACL) injury treatment. The aim of this consensus statement was to establish what data should be reported when conducting an ACL outcome study, what specific outcome measurements should be used and at what follow-up time those outcomes should be assessed. Methods To establish a standardized approach to assessment of clinical outcome after ACL treatment, a consensus meeting including a multidisciplinary group of ACL experts was held at the ACL Consensus Meeting Panther Symposium, Pittsburgh, PA; USA, in June 2019. The group reached consensus on nine statements by using a modified Delphi method. Results In general, outcomes after ACL treatment can be divided into four robust categories—early adverse events, patient-reported outcomes, ACL graft failure/recurrent ligament disruption and clinical measures of knee function and structure. A comprehensive assessment following ACL treatment should aim to provide a complete overview of the treatment result, optimally including the various aspects of outcome categories. For most research questions, a minimum follow-up of 2 years with an optimal follow-up rate of 80% is necessary to achieve a comprehensive assessment. This should include clinical examination, any sustained re-injuries, validated knee-specific PROs and Health-Related Quality of Life questionnaires. In the mid- to long-term follow-up, the presence of osteoarthritis should be evaluated. Conclusion This consensus paper provides practical guidelines for how the aforementioned entities of outcomes should be reported and suggests the preferred tools for a reliable and valid assessment of outcome after ACL treatment. Level of evidence V.

Treatment strategies for ACL injuries continue to evolve. Evidence supporting best practice guidelines to manage ACL injury is largely based on studies with low-level evidence. An international consensus group of experts was convened determine consensus regarding best available evidence on operative versus non-operative treatment for ACL injury. The purpose of this study is to report the consensus statements on operative versus non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organising Committee and Session Chairs. Panel participants reviewed preliminary statements prior to the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty per cent agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus non-operative treatment of ACL injury reached consensus during the Symposium. Nine statements achieved unanimous support, two reached strong consensus, one did not achieve consensus, and one was removed due to redundancy in the information provided. In highly active patients engaged in jumping, cutting and pivoting sports, early anatomical ACL reconstruction is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomical ACL reconstruction is indicated. The consensus statements derived from international leaders in the field may assist clinicians in deciding between operative and non-operative treatment with patients after an ACL injury. Level of evidence: Level V