All-Inside Anterior Cruciate Ligament Reconstruction With Bone-Patellar Tendon-Bone Autograft

The type of graft for anterior cruciate ligament (ACL) reconstruction is still a topic of debate and there is still no clear consensus on the ideal graft for ACL reconstruction. This study was conducted to compare the outcome of ACL reconstruction surgery between hamstring tendon graft and bone-patellar tendon-bone (BPTB) graft. One hundred and sixty professional athletes were enrolled in the study. They were divided into two groups by computerized randomization. In Group I, ACL reconstruction was done using BPTB graft, and in Group II, ACL reconstruction was done using semitendinosus gracilis graft with preserved tibial insertion (STGPI). Postoperatively, patients were assessed for knee stability, Lysholm score, and WOMAC score. Mean KT-1000 side-to-side difference at 1year was 2.31 ± 1.68mm in BPTB cohort and 2.52 ± 1.6mm in STGPI cohort (P = 0.4); and at 2years, it was 1.98 ± 1.62mm in BPTB cohort and 2.23 ± 1.6mm in STGPI cohort (P = 0.4). Mean Lysholm score at 2years was 96.1 ± 5.81 in STGPI cohort and 97.3 ± 4.62 in BPTB cohort (P = 0.15). Mean WOMAC score at 2years was 3.3 ± 2.76 in STGPI cohort and 2.84 ± 2.21 in BPTB cohort (P = 0.25). Graft rupture rate was 3.75%; 3 patients in each group had graft rupture. Kneeling pain was present in 15% (12/80) of patients with BPTB graft whereas none of the patients in STGPI cohort had kneeling pain. There was no difference between two grafts in term of knee stability, visual analog scale score and functional outcome. However, hamstring tendon graft is associated with less donor site morbidity.

A Call for More Studies Evaluating Posttraumatic Knee Osteoarthritis in Patients Undergoing Combined Anterior Cruciate Ligament Reconstruction and Lateral Extra-Articular Stabilization

Anterior cruciate ligament reconstruction (ACLR) with bone–patellar tendon–bone (BPTB) graft is commonly performed. Fixation is traditionally performed with interference screws, which has certain disadvantages as the tendon can be damaged or cut during insertion or tension can be lost when inserting the tibial screw. For soft-tissue grafts, all-inside ACLR with blind sockets has gained increased interest over the past 2 decades and has several advantages over the use of full tunnels. Randomized trials have shown better patient-reported outcomes, less pain, and less tunnel widening with all-inside ACLR. Generally, all-inside ACLR is not considered with BPTB grafts because there is a fear of graft-tunnel mismatch, but this can be avoided by paying attention to patellar tendon length and patient height. In this article, we present an all-inside technique for BPTB ACLR using standard equipment that is reproducible with a low risk of graft-tunnel mismatch.

All-Inside Anterior Cruciate Ligament Reconstruction Using Quadrupled Semitendinosus: Comparable 2-Year Outcomes in Male and Female Patients

BackgroundAll-inside anterior cruciate ligament reconstruction (ACLR) is a novel technique that has gained attention due to its minimally invasive and graft-saving properties. However, studies comparing MRI-based graft maturity between all-inside and standard ACLR are lacking.PurposeThis study focused on the functional, knee laxity, and MRI-based graft maturity characteristics of all-inside and standard single-bundle ACLR.Study DesignRandomized controlled trial (RCT).MethodsFifty-four patients were randomly assigned to an all-inside reconstruction group (n = 27) or standard reconstruction group (n = 27). Using the same rehabilitation strategy. The Tegner, International Knee Documentation Committee, and Lysholm scores were recorded at postoperative months 3, 6, and 12 to assess functional recovery. MRI was conducted to measure the signal/noise quotient (SNQ) of the intra-articular graft to assess the maturity. A higher SNQ indicates lower graft maturity. Knee laxity was assessed using GNRB arthrometer at the postoperative month 12.ResultsThe graft SNQ of the all-inside group was significantly higher than that of the standard group at postoperative month 6 (p < 0.05). There was no statistical difference in graft SNQ between the two groups at postoperative months 3 and 12 (p > 0.05). Both groups exhibited the highest SNQ in the middle region of the graft, followed by the proximal region, and the distal region. Functional scores improved significantly for both groups and had no statistical difference (p > 0.05). The knee laxity was higher in the all-inside group (p < 0.05) at postoperative month 12. There was no correlation between the functional scores and graft maturity in both groups (p > 0.05).ConclusionsAll-inside and standard single-bundle ACLR show good functional outcomes; however, knee laxity was relatively higher in the all-inside ACLR group than in the standard ACLR group. Moreover, both techniques exhibited poor maturity in the middle graft region and the best in the distal region. Graft maturity with all-inside ACLR is inferior to that with standard ACLR in the early postoperative stages. There is no correlation between knee function and graft maturity.Trial registrationClinical trial registration numbers: ChiCTR1800018543.Date of registration: 09/23/2018.

The clinical outcomes of anterior cruciate ligament (ACL) reconstruction are typically evaluated at specific time points only. This study aimed to characterize the chronological changes in anterior knee stability after anatomical ACL reconstruction and to compare the anterior knee stability achieved with bone-patellar tendon-bone (BPTB) and hamstring tendon (HT) grafts. A total of 59 patients underwent anatomical rectangular tunnel ACL reconstruction using the BPTB graft and 23 patients underwent anatomical double-bundle ACL reconstruction using the HT graft. Anterior knee stability was quantitatively assessed using the KneeLax 3 arthrometer at 6 months, 1 year, and 2 years after surgery using side-to-side differences. The values for anterior knee stability using the BPTB graft were 0.3 mm after 6 months, 0.2 mm after 1 year, and 0.2 mm after 2 years, and no significant differences were observed during the postoperative study period. Meanwhile, the values for anterior knee stability using the HT graft were -0.3 mm after 6 months, 0.5 mm after 1 year, and 1.2 mm after 2 years, and anterior knee stability decreased chronologically from 6 months up to 2 years. Regarding anterior stability, the HT graft showed significant laxity compared with the BPTB graft only after 2 years. No chronological changes in anterior stability were observed from 6 months up to 2 years after ACL reconstruction using the BPTB graft, whereas anterior laxity developed during the same period after ACL reconstruction using the HT graft. This is a Level IV, therapeutic case series study.

Background: The optimal graft choice between the bone–patellar tendon–bone (BPTB) and the quadriceps tendon remains controversial. Studies evaluating the microscopic anatomy of the quadriceps tendon–patellar bone (QTB) and BPTB grafts for anterior cruciate ligament (ACL) reconstruction are currently lacking. Hypothesis: The relationship between post–ACL reconstruction graft bending angle (GBA) and the angle corresponding to the GBA (cGBA) would indicate that the BPTB can bend more than the QTB at the femoral tunnel aperture. Study Design: Controlled laboratory study. Methods: Twenty paired human cadaveric knees fixed at <10° of knee joint flexion (mean age, 82.5 years) underwent histological sectioning and staining with Masson trichrome and toluidine blue. The femoral ACL insertion, QTB graft, and BPTB graft were microscopically analyzed. The width of the direct insertion, thickness of the uncalcified fibrocartilage and calcified fibrocartilage, ligament attachment angle, and cGBA for each group were measured. Eighteen patients who underwent ACL reconstruction with QTB or BPTB autograft were included for the evaluation of GBA using computed tomography images at 1 week postoperatively. Results: The mean insertion widths of the femoral ACL, QTB, and BPTB were 7.81, 9.07, and 6.54 mm, respectively. The QTB was 16% wider than the ACL, while the BPTB was 16% narrower than the ACL. The mean insertion thicknesses of the femoral ACL, QTB, and BPTB were 0.53, 0.94, and 0.38 mm, respectively. The QTB was 77% thicker than the ACL (P < .001), while the BPTB was 28% thinner than the ACL (P = .017). The mean ligament attachment angles of the femoral ACL, QTB, and BPTB were 20.3°, 30.2°, and 33.3°, respectively, and the QTB and the BPTB were 49% and 64% larger, respectively, than the ACL. The mean cGBAs of the femoral ACL, QTB, and BPTB were 33.9°, 35.1°, and 12.3°, respectively. The BPTB was 64% smaller than the ACL, while there was no significant difference between the QTB and the ACL. The mean GBA was 57.7°. Conclusion: The insertion width and thickness were significantly greater and smaller in the QTB and BPTB grafts, respectively, than in the ACL. The relationship between GBA after ACL reconstruction and cGBA in knee extension indicates that at the femoral tunnel aperture, the BPTB can bend more than the QTB. Clinical Relevance: QTB graft may allow more anatomic ACL reconstruction to be performed.

The Adverse Effect of Femoral Nerve Blockade on Quadriceps Strength after ACL Reconstruction (SS-13)

BACKGROUNDMany studies have focused on the femoral tunnel technique and fixation method, but few studies have involved the tibial tunnel technique and fixation method. The all-inside technique is one of the new techniques that has been described in recent years. All-inside anterior cruciate ligament (ACL) reconstruction is based on a tibial socket instead of a full tunnel. This method has many potential advantages.AIMTo compare clinical outcomes of knee ACL autograft reconstruction using all-inside quadrupled semitendinosus (AIST) and traditional hamstring tendon (TBT) techniques.METHODSFrom January 2017 to October 2019, the clinical data of 80 patients with ACL reconstruction were retrospectively analyzed, including 67 males and 13 females. The patients had an average age of 24.3 ± 3.1 years (age range: 18-33 years). The AIST technique was used in 42 patients and the TBT technique was used in 38 patients. The time between operation and injury, operative duration, postoperative visual analogue scale (VAS) score and knee functional recovery were recorded and compared between the two groups. The International Knee Documentation Committee (IKDC) and Lysholm scoring system were used to comprehensively evaluate clinical efficacy.RESULTSEighty patients were followed for 24-36 mo, with an average follow-up duration of 27.5 ± 1.8 mo. There were no significant differences in the time between surgery and injury, operative duration, IKDC and Lysholm scores of the affected knee at the last follow-up evaluation between the two groups. There were significant differences in VAS scores 1 d, 3 d, 7 d, 2 wk and 1 mo after surgery (P < 0.05). There was no significant difference in VAS score at 3 mo, 6 mo and 1 year after operation.CONCLUSIONThe efficacy of the AIST ACL reconstruction technique was comparable to the TBT technique, but the postoperative pain was less with the AIST technique. Thus, the AIST technique is an ideal treatment choice for ACL reconstruction.

Objectives: Anterior cruciate ligament (ACL) reconstruction surgery has become popular with the advent of recent surgical techniques.With increasing sporting activities and active lifestyles, the need to travel makes the population “prone to ACL and multiligament injuries in the knee ”. As the number of ACL reconstruction surgeries rises, there is also a surge ACL failures due to re-injuries or various other reasons. The aim of this study is to evaluate the clinical outcomes, efficacy, and biomechanical stability of a single-stage novel method for treating ACL failure through revision ACL reconstruction using a bone-patellar tendon-bone (BTB) graft with suture disc and lateral extra-articular tenodesis (LET). Material and Methods: The use of a BTB graft for ACL failure surgery makes it more biological, and the suture disc ensures that the bone does not get crushed with the interference screw. Lateral extra-articular tenodesis reduces rotational stress on the knee and helps secure a stronger reconstruction of the ACL. Results: All of our patients recovered completely; there was no incidence of post-op infection, and the activity level reached normal within 8-10 weeks. The mean Lysholm score significantly improved from 25.4 ± 4.4 preoperatively to 87.1 ± 4.6 at 6months (p &lt; 0.0001), indicating substantial functional recovery. Sporting activities were allowed after 6 months of reconstruction. Conclusion: In a single-stage revision, an ACL reconstruction with BTB graft and extra-articular tenodesis proved superior and produced much more secure and stronger results. The time taken to return to sports is also reduced significantly.

Author Reply to “Regarding ‘Radiologic and Clinical Outcomes After Hamstring Anterior Cruciate Ligament Reconstruction Using an Adjustable-Loop Cortical Suspension Device With Retensioning and Knot Tying’”

Suture Tape Augmentation Improves the Biomechanical Performance of Bone-Patellar Tendon-Bone Grafts Used for Anterior Cruciate Ligament Reconstruction

Quadriceps tendon (QT) autograft represents an excellent option for anterior cruciate ligament (ACL) reconstruction (ACLR), with minimal donor site morbidity and failure rates comparable with bone-patellar tendon-bone (BPTB) autograft. This video aims to provide technical tips for ACLR using all-soft-tissue QT autograft. ACLR with QT autograft is indicated in young, active ACL-injured patients who desire a return to sport. It represents a viable option in both primary and revision ACLR, as well as in skeletally immature patients. It is particularly indicated in those who kneel frequently, such as wrestlers or laborers, due to the lower incidence of postoperative anterior knee pain. A vertical incision is used to harvest a 10 mm × 70 mm partial thickness, all-soft-tissue QT graft. Care is taken not to violate the capsule or musculature. If necessary, graft size is modified based on preoperative magnetic resonance imaging (MRI) measurement of the notch width. The graft is then prepared with continuous loop suspensory fixation on the femoral side and draw sutures on the tibial side. The lateral femoral notch is debrided to allow for visualization of the posterior wall to enable anatomic tunnel placement. When possible, the tibial stump is preserved. The femoral tunnel is drilled via an anteromedial portal and the tibial tunnel via a tibial guide. The graft is then passed through the tibial stump into the femur. It is fixed on the tibial side with a PEEK interference screw in full extension with application of a posterior drawer. Outcomes following ACLR with QT autograft are excellent, with laxity and patient-reported outcomes comparable with those following ACLR with BPTB and hamstring autograft. Furthermore, QT ACLR has been shown to result in less donor site morbidity than BPTB autograft, and lower rates of failure and infection compared with hamstring autograft. ACLR with QT autograft is a good option in young, active patients in both the primary and revision settings. Advantages of QT ACLR include less donor site morbidity than BPTB, and lower rates of failure compared with hamstring autograft in young patients. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

ObjectivesThis study aims to comparatively evaluate early to midterm clinical results of case-matched patient groups of primary repairs with dynamic intraligamentary stabilization (DIS) or all-inside anterior cruciate ligament (ACL) reconstruction (ACLR) by an independent group.Patients and methodsBetween March 2015 and September 2018, a total of 16 patients operated for ACL injuries with the repair technique were retrospectively identified. Cases were stratified by treatment: DIS technique versus all-inside ACLR and matched at a ratio of 1:2. The ACLR patients were selected from a patient group with an injury-tooperation time interval of fewer than three months. A total of 32 patients were included in the all inside ACLR group. Pre-injury and postoperative International Knee Documentation Committee (IKDC) subjective score, Tegner and Lysholm scores had been obtained. Additionally, ACLReturn to Sport after Injury (ACL-RSI) scale scores, clinical results, and complications were noted.ResultsOne (6%) patient in the DIS group and two (6%) patients in the ACLR group were lost-to-follow-up and, for a total of 45 patients, 15 in the DIS group and 30 in the ACLR group, were included in the study. The mean postoperative follow-up was 50.8±13.5 months and 48.2±11.4 months in the DIS and ACLR groups, respectively. The Tegner, Lysholm, and IKDC subjective scores were non-significantly different between the groups at any time points. The ACL-RSI scale scores were significantly higher at six (p<0.001) and 12 (p=0.01) months in the repair group. The pivot-shift test was negative in all cases postoperatively. One re-rupture occurred in each group. The reoperation rate at any cause was 25% for the repair and 10% for the ACLR group.ConclusionPrimary ACL repair using the DIS technique provides a similar clinical outcome to these by an all-inside ACLR technique in moderately active patients. The DIS technique is reliable and reproducible, and associated with an early and speedier psychological recovery in a carefully selected, non-athlete patient group as observed by an independent group.

Background: Anterior cruciate ligament (ACL) reconstruction in skeletally immature patients can result in growth disturbance due to iatrogenic physeal injury. Multiple physeal-sparing ACL reconstruction techniques have been described; however, few combine the benefits of anatomic reconstruction using sockets without violation of the femoral or tibial physis. Purpose: To utilize physeal-specific magnetic resonance imaging (MRI) to quantify the zone of physeal injury after all-inside ACL reconstruction in skeletally immature athletes. Study Design: Case series; Level of evidence, 4. Methods: Twenty-three skeletally immature patients (mean chronologic age 12.6 years; range, 10-15 years) were prospectively evaluated after all-inside ACL reconstruction. The mean bone age was 13.2 years. There were 8 females and 15 males. Fifteen patients underwent an all-epiphyseal (AE) ACL reconstruction and 8 patients had a partial transphyseal (PTP) ACL reconstruction, which spared the femoral physis but crossed the tibial physis. At 6 and 12 months postoperatively, MRI using 3-dimensional fat-suppressed spoiled gradient recalled echo sequences and full-length standing radiographs were performed to assess graft survival, growth arrest, physeal violation, angular deformity, and leg length discrepancy. Results: The mean follow-up for this cohort was 18.5 months (range, 12-39 months). Minimal tibial physeal violation was seen in 10 of 15 patients in the AE group and, by definition, all patients in the PTP group. The mean area of tibial physeal disturbance (±SD) was 57.8 ± 52.2 mm2 (mean 2.1% of total physeal area) in the AE group compared with 145.1 ± 100.6 mm2 (mean 5.4% of total physeal area) in the PTP group (P = .003). Minimal compromise of the femoral physis (1.5%) was observed in 1 case in the PTP group and no cases in the AE group. No cases of growth arrest, articular surface violation, or avascular necrosis were noted on MRI. No postoperative angular deformities or significant leg length discrepancies were observed. Conclusion: The study data suggest that all-inside ACL reconstruction is a safe technique for skeletally immature athletes at short-term follow-up. Physeal-specific MRI reveals minimal growth plate compromise that is significantly lower than published thresholds for growth arrest.