BACKGROUND:Anterior cruciate ligament (ACL) graft tears and contralateral ACL tears are both relatively common after primary ACL reconstruction (ACLR). There is little prior work comparing the outcomes of reconstruction after these injuries. HYPOTHESIS:The authors hypothesize that patient-reported outcome measures (PROMs) and activity level are lower after revision ACLR than after primary contralateral ACLR. STUDY DESIGN:Cohort study; Level of evidence, 3. METHODS:From a cohort of 2333 patients who underwent primary unilateral ACLR, 267 were identified who underwent subsequent revision ACLR or primary contralateral ACLR within 5 years of primary ACLR. After exclusion of 11 patients who had both injuries, 256 were eligible for the study, including 124 who underwent revision ACLR and 132 who underwent primary contralateral ACLR. Patients were contacted for follow-up at 6 years after the primary ACLR, and PROMs were collected, including subjective International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score for pain (KOOS-Pain) and knee-related quality of life (KOOS-QOL), and Marx activity level. Patient demographics, surgical factors, and PROMs were compared between groups. Beta regression models with identity link were used to determine whether side of subsequent surgery (revision vs primary contralateral ACLR) was a significant predictor of outcome. RESULTS:Of 256 patients, 223 (87%) were contacted and completed PROMs at 6 years after the primary ACLR. At baseline, there were no significant differences between groups except that the subsequent revision group had a lower incidence of partial lateral meniscectomy and a higher incidence of lateral meniscal repair and was more likely to have received allograft for the primary ACLR than the subsequent contralateral reconstruction group. The median time from primary ACLR to second ACL surgery was lower in the revision group (1.3 years) than the contralateral group (2.0 years; P < .001). When controlling for demographics, surgical factors, and baseline PROMS, the revision ACL group demonstrated a 7.8-point lower International Knee Documentation Committee score (P < .001), a 3.2-point lower KOOS-Pain score (P = .012), a 10.4-point lower KOOS-QOL score (P < .001), and 2.0-point lower Marx score (P = .002) than the contralateral ACLR group. CONCLUSION:Patients who undergo revision ACLR within 5 years of primary ACLR demonstrate poorer PROMs and lower activity levels than those who undergo primary contralateral ACLR during this period. These 2 groups of patients should not be pooled to study outcomes of ACLR.

Objectives: Even young patients without prior injury to the knee develop radiographic changes during the first two years after anterior cruciate ligament reconstruction (ACLR), but it’s unknown whether these early changes are predictive of increased pain over the next several years. The purpose of this study is to determine whether radiographic changes at 2 years are predictive of increased pain at 6 years while controlling for factors known to be predictive of worse pain after ACLR. We hypothesized that worse radiographic changes would not be predictive of increased pain. Methods: Patients were part of a nested cohort who underwent ACLR for an athletic injury, had no prior injury to their knee, and were 35 years of age or younger at 2-year follow-up. These patients underwent standardized posteroanterior semi-flexed knee radiographs using the metatarsophalangeal (MTP) positioning technique at 2 years and completed questionnaires at baseline (at time of enrollment, just prior to their ACL surgery), 2 years, and 6 years. These questionnaires included demographic questions, the SF-36, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and the Marx Activity Level Scale. Surgeons completed an intraoperative data form that included physical examination and arthroscopy findings and treatments administered to the knee. Radiographs were graded by 2 graders using the semiquantitative atlas-based Osteoarthritis Research Society International (OARSI) scoring system, where scores of 0-3 are assigned in the medial and lateral compartments for features including osteophytes, joint space narrowing, sclerosis, and bony attrition. A directed acyclic graph (DAG) was used to plan the statistical models to assess the direct effect of radiographic change on pain at 6 years. A model was built using proportional odds logistic regression, and missing data were imputed using multivariate imputation via chained equation (MICE) for 20 cycles. The model controlled for baseline pain, age, sex, body mass index, years of education, baseline Marx, baseline SF-36, medial and lateral meniscus treatment, presence of cartilage lesion(s), allograft use, and incidence of subsequent surgery before 2 years. Results: A total of 421 subjects were included in the analysis cohort. The median age was 18 years at the time of enrollment (interquartile range [IQR]16-21 years), and 216 (51.3%) were female. 297 subjects (70.5%) had a normal medial meniscus, 85 (20.2%) had a repair, and 39 (9.3%) had a partial meniscectomy. A total of 257 subjects (61.0%) had a normal lateral meniscus, 30 (7.1%) had a repair, and 134 (31.8%) had a partial meniscectomy. 107 subjects (25.4%) had at least 1 Outerbridge grade 2 or worse cartilage lesion. Fifty-three subjects (12.6%) had subsequent surgery prior to their 2-year follow-up. The median total radiographic score on the 2-year radiographs was 4 (IQR 2.0-5.5) and ranged from 0 to 12.5. Median KOOS pain (where 100 = no pain) was 75 (IQR 63.9 to 86.1) at baseline, 96.9 (IQR 91.7 to 100) at 2 years, and 97.2 (IQR 88.9 to 100) at 6 years. Marx activity level (where 16 points = highest activity level) at baseline was 16 (IQR 12 to 16). After controlling for the other variables in the model, subjects with a total radiographic score of 5.5 had 6% increased odds of having increased KOOS pain at 6 years compared to patients with a total radiographic score 2, but this effect was not statistically significant (odds ratio = 1.06, 95% CI, 0.79-1.42, p = .698). Greater baseline pain (odds ratio 1.41, 95% CI 1.06-1.86, p = .018) and subsequent surgery prior to 2 years (odds ratio 0.52, 95% CI, 0.3-0.93, p = .026) were both statistically significant predictors of worse pain at 6-year follow-up. Conclusions: Even young, active patients begin to develop radiographic changes by 2 years after ACLR; however, these changes are not associated with increased pain up to 6 years postoperatively. This information is important for counseling patients who may be concerned about radiographic changes that are seen on x-rays obtained during the first few years after ACLR. In addition, this study suggests that treatment decisions around the time of surgery that can minimize baseline pain and decrease the incidence of subsequent surgery may improve patient pain levels at 6 years postoperatively.

Purpose (the aim of the study): Even young patients without prior injury to the knee develop radiographic changes during the first two years after anterior cruciate ligament reconstruction (ACLR), but it's unknown whether these early changes are predictive of increased pain over the next several years. The purpose of this study is to determine whether radiographic changes at 2 years are predictive of increased pain at 6 years while controlling for factors known to be predictive of worse pain after ACLR. We hypothesized that worse radiographic changes would not be predictive of increased pain.

Background: Meniscal and chondral damage is common in the patient undergoing revision anterior cruciate ligament (ACL) reconstruction. Purpose: To determine if meniscal and/or articular cartilage pathology at the time of revision ACL surgery significantly influences a patient’s outcome at 6-year follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: Patients undergoing revision ACL reconstruction were prospectively enrolled between 2006 and 2011. Data collection included baseline demographics, surgical technique, pathology, treatment, and scores from 4 validated patient-reported outcome instruments: International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx Activity Rating Scale. Patients were followed up at 6 years and asked to complete the identical set of outcome instruments. Regression analysis assessed the meniscal and articular cartilage pathology risk factors for clinical outcomes 6 years after revision ACL reconstruction. Results: An overall 1234 patients were enrolled (716 males, 58%; median age, 26 years). Surgeons reported the pathology at the time of revision surgery in the medial meniscus (45%), lateral meniscus (36%), medial femoral condyle (43%), lateral femoral condyle (29%), medial tibial plateau (11%), lateral tibial plateau (17%), patella (30%), and trochlea (21%). Six-year follow-up was obtained on 79% of the sample (980/1234). Meniscal pathology and articular cartilage pathology (medial femoral condyle, lateral femoral condyle, lateral tibial plateau, trochlea, and patella) were significant drivers of poorer patient-reported outcomes at 6 years (IKDC, KOOS, WOMAC, and Marx). The most consistent factors driving outcomes were having a medial meniscal excision (either before or at the time of revision surgery) and patellofemoral articular cartilage pathology. Six-year Marx activity levels were negatively affected by having either a repair/excision of the medial meniscus (odds ratio range, 1.45-1.72; P≤ .04) or grade 3-4 patellar chondrosis (odds ratio, 1.72; P = .04). Meniscal pathology occurring before the index revision surgery negatively affected scores on all KOOS subscales except for sports/recreation ( P < .05). Articular cartilage pathology significantly impaired all KOOS subscale scores ( P < .05). Lower baseline outcome scores, higher body mass index, being a smoker, and incurring subsequent surgery all significantly increased the odds of reporting poorer clinical outcomes at 6 years. Conclusion: Meniscal and chondral pathology at the time of revision ACL reconstruction has continued significant detrimental effects on patient-reported outcomes at 6 years after revision surgery.

Patella alta is a significant contributor to patellar instability. Historically, distalizing tibial tubercle osteotomy has been recommended for this problem; however, complications such as nonunion, fracture and hardware irritation are concerning. Additionally, the procedure cannot be performed on skeletally immature patients without violation of the proximal tibial physis. The authors describe a technique of patellar tendon imbrication that does not involve hardware or osteotomy. This technique allows for reliable correction of patella alta and provides patellar stability without the complications associated with osteotomy.

Background: When meniscal repair is performed during anterior cruciate ligament (ACL) reconstruction (ACLR), the effect of ACL graft type on meniscal repair outcomes is unclear. Hypothesis: The authors hypothesized that meniscal repairs would fail at the lowest rate when concomitant ACLR was performed with bone--patellar tendon--bone (BTB) autograft. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent meniscal repair at primary ACLR were identified from a longitudinal, prospective cohort. Meniscal repair failures, defined as any subsequent surgical procedure addressing the meniscus, were identified. A logistic regression model was built to assess the association of graft type, patient-specific factors, baseline Marx activity rating score, and meniscal repair location (medial or lateral) with repair failure at 6-year follow-up. Results: A total of 646 patients were included. Grafts used included BTB autograft (55.7%), soft tissue autograft (33.9%), and various allografts (10.4%). We identified 101 patients (15.6%) with a documented meniscal repair failure. Failure occurred in 74 of 420 (17.6%) isolated medial meniscal repairs, 15 of 187 (8%) isolated lateral meniscal repairs, and 12 of 39 (30.7%) of combined medial and lateral meniscal repairs. Meniscal repair failure occurred in 13.9% of patients with BTB autografts, 17.4% of patients with soft tissue autografts, and 19.4% of patients with allografts. The odds of failure within 6 years of index surgery were increased more than 2-fold with allograft versus BTB autograft (odds ratio = 2.34 [95% confidence interval, 1.12-4.92]; P = .02). There was a trend toward increased meniscal repair failures with soft tissue versus BTB autografts (odds ratio = 1.41 [95% confidence interval, 0.87-2.30]; P = .17). The odds of failure were 68% higher with medial versus lateral repairs (P < .001). There was a significant relationship between baseline Marx activity level and the risk of subsequent meniscal repair failure; patients with either very low (0-1 points) or very high (15-16 points) baseline activity levels were at the highest risk (P = .004). Conclusion: Meniscal repair location (medial vs lateral) and baseline activity level were the main drivers of meniscal repair outcomes. Graft type was ranked third, demonstrating that meniscal repairs performed with allograft were 2.3 times more likely to fail compared with BTB autograft. There was no significant difference in failure rates between BTB versus soft tissue autografts. Registration: NCT00463099 (ClinicalTrials.gov identifier).

Background: Trochlear dysplasia (TD) is a recognized condition that can become a risk factor for patellofemoral instability. A modified Albee osteotomy procedure using a trapezoidal-shaped wedge to elevate the lateral wall of the trochlea can be used with the goal of preventing further dislocation. However, outcomes studies are lacking, and scores on patient-reported outcome measures (PROMs) are largely unknown. Purpose/Hypothesis: The purpose of this study was to identify PROM scores for the Kujala Anterior Knee Pain Scale (AKPS), International Knee Documentation Committee (IKDC), Activity Rating System (ARS), and 100-point pain visual analog scale (VAS) for patients having undergone the modified Albee osteotomy. The hypothesis was that patients will have acceptable pain and function at mid- to long-term follow-up. Study Design: Case series; Level of evidence, 4. Methods: From 1999 to 2017, a total of 46 consecutive patients (49 knees) underwent a modified Albee procedure by a single surgeon at a single health care system. These 46 patients were contacted and asked to complete the AKPS, IKDC, ARS, and pain VAS. Additional demographic information was obtained via chart review. Frequencies and rates for categorical variables and means and standard deviations for continuous variables of the demographics and PROM scores were calculated. Results: PROM scores were obtained in 28 (30 knees; 61%) of the 46 patients. At minimum follow-up of 82 months, the mean scores were 78.5 ± 18.2 for AKPS, 61.2 ± 11.4 for IKDC, 5.2 ± 5.3 for ARS, and 24.4 ± 28.7 for VAS pain. Notably, only 1 of the 28 patients reported a patellofemoral dislocation since surgery, and this was an isolated incident without further instability. Conclusion: A modified Albee trochlear osteotomy can be a successful adjunctive procedure to prevent recurrent patellar dislocations in patients with mild TD. However, owing to the loss of one-third of patient follow-up scores and the absence of baseline function scores in this study, the procedure deserves further investigation as a way to address a particularly difficult dilemma for a select subset of patients with patellofemoral instability.

Background: Although graft choice may be limited in the revision setting based on previously used grafts, most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome.Hypothesis: In the ACL revision setting, there would be no difference between autograft and allograft in rerupture rate and patient-reported outcomes (PROs) at 6-year follow-up.Study Design: Cohort study; Level of evidence, 2.Methods: Patients who had revision surgery were identified and prospectively enrolled in this cohort study by 83 surgeons over 52 sites. Data collected included baseline characteristics, surgical technique and pathology, and a series of validated PRO measures. Patients were followed up at 6 years and asked to complete the identical set of PRO instruments. Incidence of additional surgery and reoperation because of graft failure were also recorded. Multivariable regression models were used to determine the predictors (risk factors) of PROs, graft rerupture, and reoperation at 6 years after revision surgery.Results: A total of 1234 patients including 716 (58%) men were enrolled. A total of 325 (26%) underwent revision using a bone-patellar tendon-bone (BTB) autograft; 251 (20%), soft tissue autograft; 289 (23%), BTB allograft; 302 (25%), soft tissue allograft; and 67 (5%), other graft. Questionnaires and telephone follow-up for subsequent surgery information were obtained for 809 (66%) patients, while telephone follow-up was only obtained for an additional 128 patients for the total follow-up on 949 (77%) patients. Graft choice was a significant predictor of 6-year Marx Activity Rating Scale scores (P = .024). Specifically, patients who received a BTB autograft for revision reconstruction had higher activity levels than did patients who received a BTB allograft (odds ratio [OR], 1.92; 95% CI, 1.25-2.94). Graft rerupture was reported in 5.8%(55/949) of patients by their 6-year follow-up: 3.5% (16/455) of patients with autografts and 8.4% (37/441) of patients with allografts. Use of a BTB autograft for revision resulted in patients being 4.2 times less likely to sustain a subsequent graft rupture than if a BTB allograft were utilized (P = .011; 95% CI, 1.56-11.27). No significant differences were found in graft rerupture rates between BTB autograft and soft tissue autografts (P = .87) or between BTB autografts and soft tissue allografts (P = .36). Use of an autograft was found to be a significant predictor of having fewer reoperations within 6 years compared with using an allograft (P = .010; OR, 0.56; 95% CI, 0.36-0.87).Conclusion: BTB and soft tissue autografts had a decreased risk in graft rerupture compared with BTB allografts. BTB autografts were associated with higher activity level than were BTB allografts at 6 years after revision reconstruction. Surgeons and patients should consider this information when choosing a graft for revision ACL reconstruction.

Background: Patella alta has been noted to be a risk factor for recurrent patellar instability. Purpose: We conducted a radiographic study to determine whether a patellar tendon imbrication technique normalizes patellar height as well as whether the shortened length is maintained at a minimum 2-year follow-up. Study Design: Case series; Level of evidence, 4. Methods: A total of 54 consecutive patients were identified after a retrospective chart review was performed on patients who underwent patellar tendon imbrication between 2008 and 2013. Preoperative, 3 weeks postoperative, and minimum 2 years postoperative lateral radiographs were analyzed using Insall-Salvati (IS), Blackburne-Peel (BP), and Caton-Deschamps (CD) indices to determine the amount of shortening that was achieved after the procedure and to what degree that shortening was maintained at a minimum 2-year follow-up. Results: A total of 27 patients (32 knees) completed a minimum 2-year follow-up. The mean patellar tendon length preoperatively was 6.1 cm (range, 5-8 cm). At 3 weeks and 2 years, the mean tendon lengths were 5.1 and 5.2 cm, respectively. Thus, the mean ± SD change in patellar tendon length from preoperative to 3 weeks postoperative was 0.97 ± 0.67 cm. IS, BP, and CD ratios had minimal change (loss of correction) from 3-week to 2-year follow-up; the delta values were 0.04, –0.03, and 0.09, respectively. There were no complications directly related to the technique. Conclusion: Patellar tendon imbrication is a safe and effective procedure to correct patella alta in the setting of lateral patellar instability. On average, the technique allowed 1 cm of patellar tendon shortening and maintained the correction at a minimum 2-year follow-up. In the skeletally immature patient, this technique allows correction of patella alta by avoidance of a tibial tuberosity osteotomy.

Infection is a rare occurrence after revision anterior cruciate ligament reconstruction (rACLR). Because of the low rates of infection, it has been difficult to identify risk factors for infection in this patient population. The purpose of this study was to report the rate of infection following rACLR and assess whether infection is associated with patient- and surgeon-dependent risk factors. We reviewed two large prospective cohorts to identify patients with postoperative infections following rACLR. Age, sex, body mass index (BMI), smoking status, history of diabetes, and graft choice were recorded for each patient. The association of these factors with postoperative infection following rACLR was assessed. There were 1423 rACLR cases in the combined cohort, with 9 (0.6%) reporting postoperative infections. Allografts had a higher risk of infection than autografts (odds ratio, 6.8; 95% CI, 0.9-54.5;p = .045). Diabetes (odds ratio, 28.6; 95% CI, 5.5-149.9;p = .004) was a risk factor for infection. Patient age, sex, BMI, and smoking status were not associated with risk of infection after rACLR.

Background: Physicians' and patients' decision-making process between bone-patellar tendon-bone (BTB) and hamstring tendon autografts for anterior cruciate ligament (ACL) reconstruction (ACLR) may be influenced by a variety of factors in the young, active athlete. Purpose: To determine the incidence of both ACL graft revisions and contralateral ACL tears resulting in subsequent ACLR in a cohort of high school- and college-aged athletes who initially underwent primary ACLR with either a BTB or a hamstring autograft. Study Design: Cohort study; Level of evidence, 2. Methods: Study inclusion criteria were patients aged 14 to 22 years who were injured in sports, had a contralateral normal knee, and were scheduled to undergo unilateral primary ACLR with either a BTB or a hamstring autograft. All patients were prospectively followed for 6 years to determine whether any subsequent ACLR was performed in either knee after their initial ACLR. Multivariable regression modeling controlled for age, sex, ethnicity/race, body mass index, sport and competition level, baseline activity level, knee laxity, and graft type. The 6-year outcomes were the incidence of subsequent ACLR in either knee. Results: A total of 839 patients were eligible, of which 770 (92%) had 6-year follow-up for the primary outcome measure of the incidence of subsequent ACLR. The median age was 17 years, with 48% female, and the distribution of BTB and hamstring grafts was 492 (64%) and 278 (36%), respectively. The incidence of subsequent ACLR at 6 years was 9.2% in the ipsilateral knee, 11.2% in the contralateral normal knee, and 19.7% for either knee. High-grade preoperative knee laxity (odds ratio [OR], 2.4 [95% confidence interval [CI], 1.4-3.9]; P = .001), autograft type (OR, 2.1 [95% CI, 1.3-3.5]; P = .004), and age (OR, 0.8 [95% CI, 0.7-1.0]; P = .009) were the 3 most influential predictors of ACL graft revision in the ipsilateral knee. The odds of ACL graft revision were 2.1 times higher for patients receiving a hamstring autograft than patients receiving a BTB autograft (95% CI, 1.3-3.5; P = .004). No significant differences were found between autograft choices when looking at the incidence of subsequent ACLR in the contralateral knee. Conclusion: There was a high incidence of both ACL graft revisions and contralateral normal ACL tears resulting in subsequent ACLR in this young athletic cohort. The incidence of ACL graft revision at 6 years after index surgery was 2.1 times higher with a hamstring autograft compared with a BTB autograft.

Background: Meniscal preservation has been demonstrated to contribute to long-term knee health. This has been a successful intervention in patients with isolated tears and tears associated with anterior cruciate ligament (ACL) reconstruction. However, the results of meniscal repair in the setting of revision ACL reconstruction have not been documented. Purpose: To examine the prevalence and 2-year operative success rate of meniscal repairs in the revision ACL setting. Study Design: Case-control study; Level of evidence, 3. Methods: All cases of revision ACL reconstruction with concomitant meniscal repair from a multicenter group between 2006 and 2011 were selected. Two-year follow-up was obtained by phone and email to determine whether any subsequent surgery had occurred to either knee since the initial revision ACL reconstruction. If so, operative reports were obtained, whenever possible, to verify the pathologic condition and subsequent treatment. Results: In total, 218 patients (18%) from 1205 revision ACL reconstructions underwent concurrent meniscal repairs. There were 235 repairs performed: 153 medial, 48 lateral, and 17 medial and lateral. The majority of these repairs (n = 178; 76%) were performed with all-inside techniques. Two-year surgical follow-up was obtained on 90% (197/218) of the cohort. Overall, the meniscal repair failure rate was 8.6% (17/197) at 2 years. Of the 17 failures, 15 were medial (13 all-inside, 2 inside-out) and 2 were lateral (both all-inside). Four medial failures were treated in conjunction with a subsequent repeat revision ACL reconstruction. Conclusion: Meniscal repair in the revision ACL reconstruction setting does not have a high failure rate at 2-year follow-up. Failure rates for medial and lateral repairs were both <10% and consistent with success rates of primary ACL reconstruction meniscal repair. Medial tears underwent reoperation for failure at a significantly higher rate than lateral tears.

There is one word that defines athletes who pursue ultra endurance sport events and that is “passion.” The participants themselves are not defined by age, sex, morphology, or even talent. Ultra endurance sporting events attract and welcome all measures of human abilities and performance. What does unite these individuals is the passion for the experience and the determination to accomplish what may be thought of as an insurmountable goal. The papers included within this issue of Sports Medicine and Arthroscopy Review are scholarly reviews of the various medical aspects of a category of sport that has exploded in popularity and participation over the past decade. For anyone interested in ultra endurance events, either as a participant or involved in the medical care of these athletes, the papers included within this issue will be a valuable resource of information. Enjoy. And for those not personally familiar with the “experience” of ultra running in particular, let me relate a piece of my journey as an example. But I must also emphasize that we should be aware that each and every runner has his or her own unique experiences to share that can be mystical and epic. This is but one example. The Western States 100, June 26/27, 2004 Life in a Parallel Universe (on the way to the Rucky Chucky river crossing) Well, it has taken me a lot longer this time to muster up my thoughts and impressions of my latest attempt at the Western States 100 Mile Endurance Run. In years past, I have been in a state of emotion so extreme that the words just flowed while at 35,000 feet on my way home. Not this time. I would say a state of mellowness would more aptly have applied to my ride home in 2004. But now, one week to the day later, I seem to have regained my emotional state of labiality and am ready to relate. This quest, to complete the WS 100, has been a 5-year journey. It began when I came upon an issue of Marathon and Beyond from the late 1990s, which was devoted to the history and personalities of the WS. I was fascinated; captured; and inspired. I am no veteran ultra marathoner and at that time was just learning about the sport from my son Sean. He had taken me on my first trail run while he was living in Tucson and I still have the “prickly pear” needles embedded in my right knee to prove it! But one thing led to another and soon not only me, but my wife Sue Ellen and my daughter Shannon were also on the trails of ultras from Arizona to Maryland. I suppose our family has a record of extrapolating success at one level into assumptions of success at other, much higher levels “Sure, since we have mastered the five mile climbs of the Allegany State Park on our bicycles, of course we can cycle ourselves and 8 of your high school friends across 1500 miles of western outback from Montana to Kansas!” So the fact that my modest successes of a 50K in Arizona led to my determination to complete the “Boston” of ultra marathoning through the Sierra Nevada mountains from Squaw Valley to Auburn, California, was no surprise to me or anyone in my family. Boy was I naïve! I remember a quotation (from: G. K. Chesterton) that could be aptly applied to my trail running experience. “A man must love a thing very much if he not only practices it without any hope of fame and money, but even practices it without any hope of doing it well.” And so, my attempt at the WS in 2001, which ended at Deep Canyon, 37 miles into the run, and my “success” of completing the Rucky Chucky river crossing at mile 78 in 2002, only to be pulled off the course 2 miles later at Green Gate (79+ miles); my blistered ending last year after 83 miles of the Wasatch Front 100 mile endurance run gave hope, but no guarantee for my third attempt at WS in 2004. But that said, it was great to be here in 2004! I had the best Spring training for me, ever. Sue Ellen had given me a Father’s Day gift of attending the Memorial Weekend training runs on the WS course and my support crew for the race was great. Sean would help crew the first 55 to 62 miles and then pace me the rest of the way (to the finish). And so on the morning of June 26, 2004, I and about 400 of my “best friends” took off from Squaw Valley at 5 am and made the climb to and over Emigrant Pass and into the “high country” portion of the Western States Trail. I fell early and skinned a knee, but my sturdy if not tank-like New Balance 1100’s protected my previously broken big toe and the fall served as a wake-up call for me to pick up my feet! The first 30+ miles of the course are truly beautiful with many vistas overlooking spectacular deep canyons and endless forest. Sue Ellen had been preaching to me (repeatedly!) over the Spring that I could not be content with keeping within the 30-hour pace, but I had to maintain a pace at least 1 hour below the 30-hour pace. Of course she was not only right, but prophetic. I was able to maintain “check point” times that were 45 to 60 minutes ahead of 30-hour pace through the first 62 miles! I even avoided crashing at my nemesis, Devil’s Thumb, and moved through the canyons ahead of schedule and into Forest Hill, where Sean was waiting to make the transition of Jack Andrish, solo runner, to the Jack and Sean team that would hopefully traverse the next 38 miles into the Placer County High School track and stadium finish. But the best laid plans of mice and men….or whatever….sort of fell apart at Forest Hill. The very efficient aid station visits that I had been having succumbed to stumbling and bumbling at Forest Hill. It was now dark and after finally successfully completing a change of shirts and reattaching of all of my paraphernalia (camel-back, fanny pack, water bottles, etc) Sean and I took off down California Street to reenter the WS trail and move on to the 17-mile stretch of mostly downhill (with the exception of 4 modest climbs) to the Rucky Chucky crossing of the American River. We were not on the trail for 100 yards and my stomach upset became an urge for #2! Sean told me to take the time now to “go” and it would more than be rewarded afterward. And so I made a detour off to the side of the trail and “prepared to go.” I got out my Kleenex; took off my “paraphernalia”; and proceeded to “squat.” The problem was, I could not squat! After 62+ miles of climbs and downhills, my quads would not permit it. So now I have a dilemma that I had not prepared for; what to do? I tried to “go” standing up; ever try it? Not easy and I at least had no success. Then I spotted a tree stump (and oh yes, it was pitch dark at this point and only my flashlight could give me a clue of where I was). I had the inspiration to sort of back into the tree and then lower myself down against it, like the “wall squats” that I used to practice with my friend Gordon Bell while waiting for our patients to return from having x-rays. Well, it worked for a millisecond and then I found myself lying on my side; with my pants down; in the dark; with my fanny amidst leaves and critters; and I gave up. So be it. If I were to have diarrhea, I would have it while in the up-right position; while running; and on the trail to Rucky Chucky! After redressing I rejoined Sean on the trail and spent the next few miles picking sticks and who knows what else out of my pants while traversing, slowly, down the trail. And so it should have been no surprise that when we got to an aid station check-in point, we were told that we were only 15 minutes under the 30-hour pace! “A man must love a thing very much if he not only practices it without any hope of fame and money, but even practices it without any hope of doing it well.” OK. I had lived those words long enough now! The warning that we received at the Cal 2 aid station scared me! A 15-minute cushion was not enough to get me through the next 30+ miles. And this is where the parallel universe enters. As Sean and I left Cal 2, he gave me his headlamp, which was working much better than mine. I could see the trail. I started to run. I kept running, even on the uphill sections. I ran the downhill; I ran the traverses; and I ran the uphills. I started passing groups of runners and their pacers. And they did not catch up! I had no pain. It was mystical. Sean and I arrived at the Rucky Chucky river crossing at 3 am; now fully 1.5 hours under the 30-hour pace. In the last 7 miles we had gained an hour and 15 minutes of “cushion.” We thought that it was a mistake; a misprint of sorts; an aberration! To this moment, I do not know how we did it. It was mystical. For the next 5 miles, we maintained the pace and led a pack of obviously superior runners (to me). We passed and were not passed. But then came a section, still in the dark, that entered a series of switchbacks uphill. With heads down and determined pacing we kept ahead of the pack; the trouble was that after about 20 minutes of serious climbing, Sean recognized that it was “too quiet.” I was in denial and swore I had seen a yellow ribbon just a few feet back, about 30 feet above us in a tree (I wonder how they tied it there?). I even saw a small black bear just ahead of us in the trail and scared him away with my flashlight (only to find out from Sean that it was no bear; it was a skunk!). And so we slowly reversed ourselves back downhill and sadly found out that we had missed a trail cut-off and had gone about 30 minutes out of our way (uphill, no less) and all of the “superior runners” we had been leading were far, far away. I think this was more of a psychological than a physical let down for me, but then at that point it is hard to separate the two. But we trudged on and Sean now was invaluable in maintaining my spirits and my pace. Night became day and downhills became uphills. We made it to No Hands Bridge with a 45-minute “cushion” for the last 3+ miles and I let myself believe that this time I just might make it all the way. “A man must love a thing very much if he not only practices it without any hope of fame and money, but even practices it without any hope of doing it well.” After the last climb on the trail to get us out of the river valley and into the town of Auburn, we celebrated the last mile into the Placer High School stadium. I admit to having trouble seeing everything and everyone as I broke through the entry onto the track. Tears have a way of doing that. Five years; more than a few DNFs; many hours of hill repeats in the Metro Parks of Cleveland; and now I had only 300 yards to go. With Sean by my side and what seemed like “thousands” of Virginia Happy Trails Running Club runners and crew yelling encouragement, 300 yards soon became 100 yards, then 100 feet; and then it was over. Twenty-nine hours, 26 minutes, and 26 seconds and I had finished. I was now Jack Andrish, 60 years old, and a FINISHER of the Western States 100.

Purpose: Multiple studies have shown patients are susceptible to post-traumatic knee osteoarthritis (OA) development after anterior cruciate ligament (ACL) injury even with ACL reconstruction (ACLR). Prospective studies using multivariate analysis to identify risk factors for OA are lacking. This study aims to identify baseline predictors of radiographic post-traumatic OA after ACLR at an early timepoint and hypothesizes that meniscal injury and cartilage lesions will be associated with worse radiographic OA. Methods: 421 patients who underwent ACLR returned onsite for standardized posteroanterior metatarsophalangeal radiographs a minimum of 2 years after surgery. At baseline, collection of demographics, graft type, meniscal status/treatment, and cartilage status was performed. Osteoarthritis Research Society International (OARSI) atlas criteria were used to grade all knee radiographs. Multivariate ordinal regression models identified baseline predictors of radiographic OARSI grades at follow-up. Results: The cohort's mean age was 19.8 years old with 51.3% females. Higher age (odds ratio (OR) 1.06) and BMI (OR 1.05) were statistically significantly associated with higher OARSI grade in the medial compartment. Patients with a meniscal repair and a partial meniscectomy had statistically significantly higher OARSI grades in the medial compartment (meniscal repair OR 1.92 and meniscectomy OR 2.11) and in the lateral compartment (meniscal repair OR 1.96 and meniscectomy OR 2.97). Graft type, cartilage lesion, sex, and Marx activity scales had no significant association with radiographic OA (Table 1). Conclusions: Older patients with a higher BMI who have an ACL tear with concurrent meniscal tear requiring partial meniscectomy or meniscal repair should be advised of their increased risk of developing radiographic OA. Alternatively, patients with an ACL tear with an articular cartilage lesion or with a meniscal tear not requiring treatment can be reassured that they are not at increased risk of developing knee OA.

BACKGROUND:Injuries to the posterolateral corner (PLC) may occur concurrently with anterior cruciate ligament (ACL) injury. PURPOSE/HYPOTHESIS:This study evaluated the outcomes of patients who underwent operative management of PLC injuries concurrently with ACL reconstruction in a prospective multicenter cohort. We hypothesized that there would be no differences in outcomes between patients who were treated with PLC repair and PLC reconstruction. STUDY DESIGN:Cohort study; Level of evidence, 3. METHODS:Patients undergoing ACL reconstruction were enrolled into a prospective longitudinal multicenter cohort between 2002 and 2008. Those with complete 6-year follow-up data (patient-reported outcomes and subsequent surgery information) were identified. Excluded from the study were patients with posterior cruciate ligament injuries. Patients who underwent PLC repair were compared with those who underwent PLC reconstruction with regard to interval from injury to surgery, need for revision surgery, and long-term outcomes at 6 years. RESULTS:During the identified time frame, 3026 identified patients underwent primary ACL reconstruction; 34 (1.1%) also underwent concurrent PLC surgery (15 repairs, 19 reconstructions [18 allografts, 1 autograft]). With the numbers available, we did not detect significant differences between groups regarding the rate of meniscal or chondral injuries. Median time to PLC reconstruction was 121 days as compared with 19 days for concurrent ACL reconstruction and PLC repair (P = .01). There were no between-group differences in Marx activity scores prior to surgery (P = .4). At 6-year follow-up, there were no between-group differences in Knee injury and Osteoarthritis Outcome Score (P = .36-.83) or International Knee Documentation Committee score (P = .84); however, patients treated with PLC reconstructions had lower Marx activity scores (4.1 vs 9.4; P = .02). There was 1 ACL revision in the PLC reconstruction group, and 1 of the PLC repairs was revised to a reconstruction during the follow-up period. CONCLUSION:Good outcomes were achieved at 6-year follow-up with both repair and reconstruction of PLC injuries treated concurrently with ACL reconstruction. The PLC reconstruction group had lower activity levels 6 years after surgery. The present data suggest that, for appropriately selected patients undergoing acute surgical treatment of combined ACL and PLC injuries, PCL repair can achieve good long-term outcomes.

Background: Anterior cruciate ligament (ACL) revision cohorts continually report lower outcome scores on validated knee questionnaires than primary ACL cohorts at similar time points after surgery. It is unclear how these outcomes are associated with physical activity after physician clearance for return to recreational or competitive sports after ACL revision surgery. Hypotheses: Participants who return to either multiple sports or a singular sport after revision ACL surgery will report decreased knee symptoms, increased activity level, and improved knee function as measured by validated patient-reported outcome measures (PROMs) and compared with no sports participation. Multisport participation as compared with singular sport participation will result in similar increased PROMs and activity level. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 1205 patients who underwent revision ACL reconstruction were enrolled by 83 surgeons at 52 clinical sites. At the time of revision, baseline data collected included the following: demographics, surgical characteristics, previous knee treatment and PROMs, the International Knee Documentation Committee (IKDC) questionnaire, Marx activity score, Knee injury and Osteoarthritis Outcome Score (KOOS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A series of multivariate regression models were used to evaluate the association of IKDC, KOOS, WOMAC, and Marx Activity Rating Scale scores at 2 years after revision surgery by sports participation category, controlling for known significant covariates. Results: Two-year follow-up was obtained on 82% (986 of 1205) of the original cohort. Patients who reported not participating in sports after revision surgery had lower median PROMs both at baseline and at 2 years as compared with patients who participated in either a single sport or multiple sports. Significant differences were found in the change of scores among groups on the IKDC (P < .0001), KOOS-Symptoms (P = .01), KOOS-Sports and Recreation (P = .04), and KOOS-Quality of Life (P < .0001). Patients with no sports participation were 2.0 to 5.7 times more likely than multiple-sport participants to report significantly lower PROMs, depending on the specific outcome measure assessed, and 1.8 to 3.8 times more likely than single-sport participants (except for WOMAC-Stiffness, P = .18), after controlling for known covariates. Conclusion: Participation in either a single sport or multiple sports in the 2 years after ACL revision surgery was found to be significantly associated with higher PROMs across multiple validated self-reported assessment tools. During follow-up appointments, surgeons should continue to expect that patients who report returning to physical activity after surgery will self-report better functional outcomes, regardless of baseline activity levels.

Background: While a primary goal of anterior cruciate ligament (ACL) reconstruction is to reduce pathologically increased anterior and rotational knee laxity, the relationship between knee laxity after ACL reconstruction and patient-reported knee function remains unclear. Hypothesis: There would be no significant correlation between the degree of residual anterior and rotational knee laxity and patient-reported outcomes (PROs) 2 years after primary ACL reconstruction. Study Design: Cross-sectional study; Level of evidence, 3. Methods: From a prospective multicenter nested cohort of patients, 433 patients younger than 36 years of age injured in sports with no history of concomitant ligament surgery, revision ACL surgery, or surgery of the contralateral knee were identified and evaluated at a minimum 2 years after primary ACL reconstruction. Each patient underwent Lachman and pivot-shift evaluation as well as a KT-1000 arthrometer assessment along with Knee injury and Osteoarthritis Outcome Score and subjective International Knee Documentation Committee (IKDC) scores. A proportional odds logistic regression model was used to predict each 2-year PRO score, controlling for preoperative score, age, sex, body mass index, smoking, Marx activity score, education, subsequent surgery, meniscal and cartilage status, graft type, and range of motion asymmetry. Measures of knee laxity were independently added to each model to determine correlation with PROs. Results: Side-to-side manual Lachman differences were IKDC A in 246 (57%) patients, IKDC B in 183 (42%) patients, and IKDC C in 4 (<1%) patients. Pivot-shift was classified as IKDC A in 209 (48%) patients, IKDC B in 183 (42%) patients, and IKDC C in 11 (2.5%) patients. The mean side-to-side KT-1000 difference was 2.0 ± 2.6 mm. No significant correlations were noted between pivot-shift or anterior tibial translation as assessed by Lachman or KT-1000 and any PRO. All predicted differences in PROs based on IKDC A versus B pivot-shift and anterior tibial translation were less than 4 points. Conclusion: Neither the presence of IKDC A versus B pivot-shift nor increased anterior tibial translation of up to 6 mm is associated with clinically relevant decreases in PROs 2 years after ACL reconstruction.

Objectives The purpose of this cross-sectional study was to describe the rates of additional surgery and patient-reported outcomes in patients who underwent surgical irrigation and debridement (I&D) for infection following anterior cruciate ligament reconstruction (ACLR) and test the hypothesis that additional surgery is associated with worse patient-reported outcomes. Methods Patients diagnosed with a postoperative infection following ACLR (defined as one requiring surgical treatment with either a deep or superficial I&D) were identified from a prospective cohort. Both primary and revision ACLRs were included, as well as any graft type (autografts and allografts). Patient-reported outcomes (International Knee Documentation Committee [IKDC], Knee Injury and Osteoarthritis Outcome Score [KOOS] and Marx activity level) and subsequent surgeries were collected at 2-year and 6 year follow-up from the initial ACLR surgery. Baseline demographics and 2-year and 6-year outcomes (from initial ACLR) were compared between patients who did or did not undergo additional surgery subsequent to I&D using Wilcoxon rank-sum tests for continuous variables and Fisher’s exact tests for categorical variables. Results Twenty-one of 3210 ACLR patients (0.7%) had a postoperative infection requiring surgical I&D. This group consisted of 12 men and 9 women, mean (SD) age of 25.8 (11.3) years, 18 primary and 3 revision ACLRs and 16 autografts and 5 allografts. The mean time from ACLR to the surgical I&D was 39 days. In these patients, IKDC scores improved from 44±17 prior to initial ACLR to 83±16 at 6-year follow-up (p<0.001). While all KOOS scores improved from baseline to final follow-up, activity level decreased from 11±6 to 7±5 points (p<0.001). Follow-up related to subsequent surgery was obtained on 20 of 21 patients (95%). Forty per cent of the infection group (n=8 of 20) underwent additional surgery following their I&D, with three patients (15%) undergoing revision ACLR and one patient (5%) undergoing total knee arthroplasty. Patients who underwent additional surgery had lower Marx activity at 2 years compared with patients who had no subsequent surgeries (4±3vs 9±5 points, p=0.018). Conclusion Patients who undergo I&D for an infection following ACLR have a high rate of additional surgery but still attain reasonable clinical outcomes 6 years after ACLR. Level of evidence IV