Next up, we're going to have Dr. Volker Musel come up and talk to us about hypermobility and risk of re-injury. Thank you, Rachel. Thanks, David. And thank you for the invitation to speak here. The first author is Balint Sidai. He is currently an intern in Sweden, so he cannot come. Thanks to all the co-authors, the disclosures are on the website. So, ACL reconstruction has a very high failure rate. Generalized joint hypermobility is like a specific phenotype we all dread, but there's hyperextensibility of the tissues in the joint, and it's assessed with a Batten score. So patients with hyperlaxity have inferior post-op outcomes. The purpose of this study was to determine the 12-month risk of second ACL injury in patients with and without hyperlaxity and assess return to sport after ACL. We hypothesized that there's a higher rate of second ACL injury within 12 months of return to sport and also a greater lifetime risk. So we included patients from 16 to 50, and they're all within the Swedish knee ligament register, and they had their ACL reconstruction done after 2014. They all had a Tegna 6 or higher, so they're recreational athletes. Exclusion was missing Batten score, no return to sport, or less than 12 months follow-up. And then we divided this at the number of five. Primary outcome is rate of second ACL injury within 12 months, and the secondary injury is either repeat ipsilateral ACL injury or contralateral ACL. Secondary outcomes are a second ACL injury beyond the 12-months point and also some POOs and psychological readiness. Here's a graph, and of course the initial cohort is quite large, and the main reason for a dropout is either that the age wasn't within 16 to 50 or that surgery wasn't between 2014 and 19 and the missing Batten score, which wasn't initially done in the registry. So the average age was no different between the two groups, relatively young, 22 versus 24. The majority of the cases were done with hamstring ACL reconstruction. They were all done without LAT. There was a longer time to return to sport in the non-hyperlaxed group, 9 versus 11 months. The incidence of second ACL injury was 7 patients or 14% in the hyperlaxity group, which 4 were ipsilateral and 3 contralateral, and then 5 patients or 3% in the without hyperlaxity group. Logistic regression also showed that hyperlaxity led to a 5.5-fold odds of second ACL injury, with ipsilateral only as 4-fold and contralateral more than 12-fold injury risk. So this graph here shows the survival probability up to 7 years. You can see there's a 4.24-fold increased lifetime hazard ratio of repeat ACL injury after return to sport in patients with hyperlaxity. For the PROs, the tegna level was 9 versus 8. There was no difference at return to sport, and the return to pre-injury tegna level was 76% with hyperlaxity and 67% without hyperlaxity. No difference in any of the other PROs. So in conclusion, hyperlaxity should really be assessed in all ACL-injured athletes because there's a 5 times higher risk. We suggest that if you start a registry, maybe include it into it. Patients with hyperlaxity may benefit from individualized ACL surgery. Graph choices, I don't really know which one, but I don't think it's the hamstring. LAT, question mark, right? Individualized return to sport, maybe more delayed. And laxity assessment, risk appraisal, and counseling is encouraged. So obviously there's some strength, there's long-term outcome, and there's this really longitudinal follow-up that's done to this project ACL in Sweden. And the limitations are it's a small sample and incomplete PRO data. So look out for stability 2 where this is a randomized controlled study. Thank you very much.

Dr. Volker Musel

hypermobility

ACL reconstruction

second ACL injury

return to sport