Anterior Cruciate Ligament Graft Failure Research Articles

Effect of Lateral Extra-Articular Procedures Combined With ACL Reconstruction on the Rate of Graft Rupture in Patients Aged Older Than 30 Years: A Matched-Pair Analysis of 1102 Patients From the SANTI Study Group

Background: Clinical studies have demonstrated significant advantages of combined anterior cruciate ligament (ACL) reconstruction (ACLR) and lateral extra-articular procedures (LEAPs) over isolated ACLR in terms of reducing graft rupture and reoperation rates. However, most of the published studies have included young patients, and no studies have focused on patients aged >30 years. Purpose/Hypothesis: The purpose of this study was to compare the outcomes of isolated ACLR versus ACLR + LEAP at midterm follow-up in patients aged >30 years. The hypothesis was that patients who underwent combined procedures would experience significantly lower rates of graft rupture. Study Design: Cohort study; Level of evidence, 3. Methods: Patients >30 years of age who underwent primary ACLR + LEAP between January 2003 and December 2020 were propensity matched at a 1:1 ratio to patients who underwent isolated ACLR. A retrospective analysis of prospectively collected data was performed to determine graft rupture rates, knee stability, reoperation rates, and complications. Graft survivorship was assessed using the Kaplan-Meier method. Risk factors associated with the occurrence of graft failure were analyzed using a Cox proportional hazards model. Results: Two groups of 551 patients each were included in the study, and the mean follow-up was 97.19 ± 47.23 months. The overall mean age was 37.01 ± 6.24 years. The LEAP group consisted of 503 (91.3%) patients who had anterolateral ligament reconstruction and 48 (8.7%) patients who had a Lemaire procedure. Overall, 19 (1.7%) patients had graft failure: 15 (2.7%) in the no-LEAP group and 4 (0.7%) in the LEAP group (P = .0116). The risk of graft failure was significantly associated with the absence of LEAP (31 vs 12; hazard ratio, 3.309; 95% CI, 1.088-10.065; P = .0350) and age between 30 and 35 years (hazard ratio, 4.533; 95% CI, 1.484-13.841; P = .0080). A higher rate of reoperation for secondary meniscectomy was found in the no-LEAP group (5.6% vs 2.2%; P = .0031). Conclusion: Patients aged >30 years who underwent combined ACLR and LEAP experienced a >3-fold lower risk of ACL graft failure compared with those who underwent isolated ACLR. Furthermore, the group without LEAP experienced a higher rate of secondary meniscectomy.

Association of Posterior Tibial Slope With Outcomes After Multiligamentous Knee Reconstruction for Knee Dislocation Grades 2 to 4.

Patients with isolated anterior cruciate ligament (ACL) reconstruction have demonstrated an increased risk of ACL graft failure and lower patient-reported outcome (PRO) scores when increased posterior tibial slope (PTS) is present. However, there is a paucity of literature evaluating the effect of PTS on outcomes after combined bicruciate multiligamentous knee reconstruction. To determine whether differences exist for graft failure rates or PRO scores based on PTS after combined bicruciate multiligamentous knee reconstruction. Cohort study; Level of evidence, 3. All patients who underwent combined ACL and posterior cruciate ligament (PCL) reconstruction between 2000 and 2020 at our institution were identified. Exclusion criteria were age <18 years, knee dislocation grade 5 injuries, concomitant osteotomy procedures, and <2 years of clinical follow-up. Demographic and outcomes data were collected from our prospectively gathered multiligamentous knee injury database. Lysholm and International Knee Documentation Committee (IKDC) scores were analyzed in relation to PTS. Outcomes were compared for patients with a PTS above and below the mean for the total cohort, PTS >12° versus <12°, positive versus negative Lachman test at follow-up, and positive versus negative posterior drawer test at follow-up. A total of 98 knees in 98 patients were included in the study, with a mean clinical follow-up of 5.1 years (median, 4.6 years; range, 2-16 years). The mean PTS was 8.7° (range, 0.4°-16.9°). Linear regression analysis showed no significant correlation between PTS and IKDC or Lysholm scores. Patients with a PTS above the mean of 8.7° trended toward lower IKDC (P = .08) and Lysholm (P = .06) scores. Four patients experienced ACL graft failure and 5 patients experienced PCL graft failure. There were no differences in graft failure rates or PRO scores for patients with a PTS >12°. Patients with a positive Lachman test trended toward higher PTS (9.6° vs 8.5°, P = .15). In this series of bicruciate multiligamentous knee reconstructions at midterm follow-up, no differences in graft failures, complications, reoperations, revisions, or PRO scores based on PTS were identified. Patients with a positive Lachman test were found to have a slightly higher PTS, although this did not reach statistical significance.

Clinical Outcomes of Different Management Techniques for Medial Meniscal Type 3 Ramp Lesions in Anterior Cruciate Ligament Reconstruction: A Comparative Analysis Between All-inside Repair, Suture Hook Repair, and Lesions Left In Situ.

There is ongoing debate about the best way to manage ramp lesions at the time of anterior cruciate ligament (ACL) reconstruction (ACLR). Type 3 lesions are not visible by the transnotch approach without superior debridement, making the management debate even more problematic. The purpose of this study was to evaluate the rate of secondary surgical interventions according to the management method of a type 3 ramp lesion concomitant with primary ACLR. The hypothesis was that the rate of secondary ACL or meniscal interventions would be higher in patients who underwent all-inside repair. Cohort study; Level of evidence, 3. A retrospective analysis of all patients who underwent primary ACLR with a type 3 ramp lesion between January 2012 and May 2020, regardless of the treatment method, was performed. The main criterion analyzed in this cohort was a secondary surgical intervention, defined as revision ACLR or a reintervention of the repaired meniscus. A survivorship analysis was performed to evaluate secondary surgical interventions in 3 groups: all-inside repair, suture hook repair, and left in situ. The following data were collected preoperatively and at the last follow-up: patient characteristics, time to surgery, side-to-side difference in laxity, pivot shift, Lysholm score, subjective International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, Tegner score, and meniscal repair failure rate. A total of 113 patients who underwent type 3 ramp lesion repair concomitant with ACLR were included: 52 (46.0%) in the all-inside repair group, 23 (20.4%) in the suture hook repair group, and 38 (33.6%) in the lesion left in situ group. There were 17 patients (15.0%) who underwent a secondary intervention because of ACL graft failure (n = 6) or meniscal repair failure (n = 15 [4 of whom underwent a concomitant ACL reintervention]). Overall, 62 patients (54.9%) underwent combined ACLR and anterolateral ligament reconstruction, while 51 patients (45.1%) underwent isolated ACLR. In the adjusted Cox model, the type of meniscal repair was not statistically significantly associated with secondary surgical interventions. The only risk factor for secondary surgical interventions in this cohort was isolated ACLR (hazard ratio, 8.077; P = .007). The rates of secondary surgical interventions after medial meniscal type 3 ramp lesion repair concomitant with ACLR were similar regardless of the management method of the meniscal lesion. Despite not being associated with meniscal treatment, this rate was 8 times higher for patients who underwent isolated ACLR in this cohort; this is probably because of the protection that lateral extra-articular procedures provide to the ACL graft.

A Novel Predictor of the Length and Size of ACL Grafts in Chinese Han Adults for ACL Reconstruction: An MRI Study.

Currently, there is no simple and valid method to predict the length and size of the native anterior cruciate ligament (ACL) in each adult patient who will undergo ACL reconstruction. This study aimed to develop an imaging prediction method that can predict the length and size of ACL grafts using the intact posterior cruciate ligament (PCL), in order to enhance the graft preparation individualized sizing. Three hundred and nineteen patients aged 18 years or older who underwent magnetic resonance imaging (MRI) of the knee at an orthopaedic clinic between September 9, 2021, and February 5, 2023, were included. The length, sagittal diameter, and coronal diameter of the ACL and PCL were measured in all patients, and F-test were performed to explore linear relationship between ligament measurements. Equations were established to predict a variable of the native ACL for the corresponding variable of the intact PCL (i.e., sagittal diameter of the ACL = 4.32 + 1.08 × sagittal diameter of the PCL, and coronal diameter of the ACL = 2.45 + 0.59 × coronal diameter of the PCL, length of the male ACL = 10.92 + 0.64 × length of the male PCL, length of the female ACL = 11.76 + 0.58 × length of the female PCL) (R2 = 0.532; R2 = 0.417; R2 = 0.488; R2 = 0.509; respectively). The length and size of the intact PCL in cases without PCL buckling are predictors of the length and size of the native ACL in adults, respectively. The use of this information to optimize graft diameter may lower the rates of ACL graft failure in the future.

Tibial Supra-Tubercular Deflexion Osteotomy During Revision Anterior Cruciate Ligament Reconstruction

Background: A deflexion osteotomy may reduce anterior translational forces imparted upon an anterior cruciate ligament (ACL) reconstruction (ACL-R) graft, thereby reducing risk of ACL graft failure in patients with excessive congenital posterior tibial slope. Indications: A 13-year-old female competitive soccer player with 13.7° of posterior tibial slope presented with failure of a prior ACL-R. Technique Description: A vertical incision is made along the medial border of the patellar tendon and the proximal tibia is exposed. The planned osteotomy is templated under fluoroscopic guidance by placement of 2.4-mm Steinmann pins. A supra-tubercular deflexion osteotomy is made with a sagittal saw and osteotomes, with care to maintain the posterior cortical hinge. Compression staples are utilized for fixation of the osteotomy site. Revision ACL-R is then performed. Results: There were no immediate complications following surgery. Surgical management led to radiographic improvement of the patient's posterior tibial slope and clinical resolution of anterior translational knee instability. Discussion/Conclusion: The senior author's preferred technique for a tibial supra-tubercular deflexion osteotomy in association with a revision ACL-R is presented. A deflexion osteotomy is a surgical option for patients with excessive (&gt;12°) posterior tibial slope in the setting of a prior failed ACL-R. This case demonstrates the efficacy of a tibial supra-tubercular deflexion osteotomy in the revision ACL-R setting by reducing posterior tibial slope, thereby lessening anterior translational forces on the ACL graft in a patient at high risk of graft failure. Patient Consent Disclosure Statement: 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.

Graft failure within 2years of isolated anterior cruciate ligament reconstruction is associated with increased risk of secondary meniscus tears.

A debilitating complication following anterior cruciate ligament reconstruction is a secondary meniscus tear. Currently, the literature is mixed regarding the risk factors associated with the incidence of secondary meniscus tears. The aim of this study was to investigate risk factors associated with meniscus tears following an isolated primary anterior cruciate ligament reconstruction. ACL graft failure was hypothesized to be the strongest risk factor for secondary meniscal injury occurrence. A retrospective cohort analysis was performed using the PearlDiver Database. Patients with a primary anterior cruciate ligament reconstruction were identified in the database. Patients with concomitant knee ligament injury or meniscus injury present at the time the index procedure were excluded. Patients were grouped to those who had a secondary meniscus tear within 2years following anterior cruciate ligament reconstruction and those who did not. Univariate analysis and multivariable regression analysis was conducted to identify significant risk factors for a secondary meniscus tear. There were 25,622 patients meeting criteria for inclusion in this study. Within 2years from the primary anterior cruciate ligament reconstruction, there were 1,781 patients (7.0%) that experienced a meniscus tear. Graft failure had the highest odds of having a postoperative meniscus tear within 2years (OR: 4.1; CI 3.5-4.8; p < 0.002). Additional significant risk factors included tobacco use (OR: 2.0; CI 1.0-3.1; p < 0.001), increased Charlson Comorbidity Index (OR: 1.2; CI 1.1-1.4), male gender (OR: 1.1; CI 1.1-1.2; p < 0.001), obesity (OR: 1.1; CI 1.1-1.2; p < 0.001), delayed surgery (OR:1.1; CI 1.1-1.2; p < 0.002), and patients age 30 and older (OR: 1.0; CI 1.0-1.0; p < 0.001). This study found that anterior cruciate ligament graft failure is the strongest predictor of post-operative meniscus tears. Other risk factors, including tobacco use, increased CCI, male gender, obesity, delayed surgery, and age 30 and older, were established, with several being modifiable. Therefore, targeted preoperative optimization of modifiable risk factors and postoperative protocols may reduce the risk of secondary meniscus tears. Level III, prognostic trial.

Revision Anterior Cruciate Ligament Reconstruction: Current Approaches to Preoperative Planning (Systematic Review)

Background. The number of primary anterior cruciate ligament (ACL) reconstructions increases every year, which causes an increase in revision interventions due to ACL graft failure. When studying the literature, we identify many factors that together influence the outcome of revision ACL reconstruction, but are not always taken into account by surgeons.&#x0D; Aim of the review — is to perform a systematic review of studies that evaluated the outcomes of revision anterior cruciate ligament reconstructions and to identify optimal solutions to the most common problems encountered in preoperative planning.&#x0D; Methods. Information search was performed in the eLIBRARY, PubMed, and Scopus databases for the period from 2013 to 2022. Studies describing the main aspects of revision ACL reconstruction were selected for analysis. Inclusion criteria were the following: mean patient follow-up period of no less than 12 months, number of observations of no less than 10 cases. After evaluation of 898 articles, 22 articles were included in the systematic review.&#x0D; Results. Five main factors that should be taken into account in preoperative planning of revision ACL reconstruction have been identified: choice of the graft, necessity of reconstruction of the anterolateral complex, correction of tibial plateau deformity in the sagittal plane, determination of indications for one- or two-stage intervention, method of bone defect replacement in two-stage surgical treatment.&#x0D; Conclusion. The patient’s autogenous tissues should be preferred when choosing a graft. Correction of excessive anteroposterior tibial plateau inclination angle is performed only at the second revision intervention if the inclination angle exceeds 12º. Reconstruction of the anterolateral complex should be performed in young, active patients who are involved in pivot sports and in case of severe anterior instability. When determining the possibility of performing revision ACL reconstruction in one or two stages, the canal diameter is not a crucial parameter, as it is necessary to take into account the possibility of fusion of the canals from the previous surgery with the newly created ones. If the canals have correct entry points, one-stage revision reconstruction can be performed with the canal width not exceeding 10 mm and depending on the expected diameter and type of the prepared tendon graft. Bone grafting of the secondary dilated canals in two-stage intervention can be carried out using any material, but allogenous bone or synthetic grafts have certain advantages.

A New Algorithm to Treat Chronic Combined ACL/MCL Injuries: Let's Come Back to the “Rotatory Instability Test”

Background: Chronic combined medial collateral ligament (MCL) and anterior cruciate ligament (ACL) injuries are frequent. Medial residual laxity is a risk factor for ACL rerupture. It should be treated at the same time as the ACL reconstruction (ACLR) if necessary, but there are still questions surrounding the indications for abstention or surgery of the medial plan, especially for grade 2 MCL injuries of the Fetto and Marshall classification. Indications: The purpose is to come back to a simple test, the “Rotatory Instability Test” as described by Slocum and Larson in 1968 for systematic clinical examination of the knee to improve the sensitivity and accuracy of the deep MCL (dMCL) and superficial MCL (sMCL) examination and to propose a decision-making algorithm for the treatment of the chronic combined ACL/MCL injuries based on the assessment of anteromedial rotatory instability (AMRI). Technique Description: Examination of the ACL with Lachman test, anterior drawer in neutral rotation, and pivot shift test confirm the ACL injury. Valgus laxity is tested in extension and at 20° of flexion. Then, an anterior drawer test at 90° of flexion with external rotation is done (the anterior drawer in external rotation [ADER] test) allowing to identify isolated dMCL, dMCL + sMCL, or MCL + posterior oblique ligament (POL) injuries. Discussion: As persistent medial laxity is a risk factor for ACL graft failure and there is no reliable method of instrumented laxity assessment, careful clinical examination remains essential. Systematic examination of the medial side with valgus laxity testing at 0° and 20° flexion combined with the ADER test assessment of AMRI can guide treatment of the MCL injury component. Where there is no valgus laxity and the ADER test is negative, isolated ACLR is indicated. If there is significant medial laxity at 0°, this suggests combining sMCL and POL reconstruction with ACLR. Where the knee is stable at 0° but there is valgus laxity at 20° and a positive ADER test, the dMCL can be reconstructed using a gracilis graft or a combined sMCL and dMCL reconstruction can be added to the ACLR depending on the degree of laxity. Patient Consent Disclosure Statement: 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.

Concurrent Repair of Medial Meniscal Ramp Lesions and Lateral Meniscus Root Tears in Patients Undergoing Anterior Cruciate Ligament Reconstruction: The “New Terrible Triad”

Recent studies have suggested that up to 8% of patients with anterior cruciate ligament (ACL) tears can present with a combined medial meniscal ramp lesion (MMRL) and lateral meniscus root tear (LMRT). MMRLs and LMRTs often are missed preoperatively and can increase the risk of ACL graft failure if left untreated. Given the potential synergistic biomechanical consequences and challenging repair techniques used for treatment, our group commonly refers to this presentation (MMRL-LMRT-ACL) as the “new terrible triad” of ACL pathology. This Technical Note aims to describe a systematic approach for arthroscopic assessment and our preferred inside-out and transtibial pull-out repair techniques to efficiently diagnose and treat a combined MMRL and LMRT at the time of ACL reconstruction surgery.

Biomechanical Analysis of Tibial Motion and ACL Graft Forces After ACLR With and Without LET at Varying Tibial Slopes.

Lateral extra-articular tenodesis (LET) is being performed more frequently with anterior cruciate ligament (ACL) reconstruction (ACLR) to decrease graft failure rates. The posterior tibial slope (PTS) affects ACL graft failure rates. The effect of ACLR + LET on tibial motion and graft forces with increasing PTS has not been elucidated. LET would decrease anterior tibial translation (ATT), tibial rotation, and ACL graft force versus ACLR alone with increasing tibial slope throughout knee range of motion. Controlled laboratory study. Twelve fresh-frozen cadaveric knees (mean donor age, 40.5 years; all female) were tested in 4 conditions (intact, ACL cut, ACLR, and ACLR + LET) with varying PTSs (5°, 10°, 15°, and 20°) at 3 flexion angles (0°, 30°, and 60°). Specimens were mounted to a load frame that applied a 500-N axial load with 1 N·m of internal rotation (IR) torque. The amount of tibial translation, IR, and graft force was measured. Increasing PTS revealed a linear and significant increase in graft force at all flexion angles. LET reduced graft force by 8.3% (-5.8 N) compared with ACLR alone at 30° of flexion. At the same position, slope reduction resulted in reduced graft force by 17% to 22% (-12.3 to -15.2 N) per 5° of slope correction, with a 46% (-40.7 N) reduction seen from 20° to 5° of slope correction. For ATT, ACLR returned tibial translation to preinjury levels, as did ACLR + LET at all flexion angles, except full extension, where ACLR + LET reduced ATT by 2.5 mm compared with the intact state (P = .019). Increased PTS was confirmed to increase graft forces linearly. Although ACLR + LET reduced graft force compared with ACLR alone, slope reduction had a larger effect across all testing conditions. No other clinically significant differences were noted between ACLR with versus without LET in regard to graft force, ATT, or IR. Many authors have proposed LET in the setting of ACLR, revision surgery, hyperlaxity, high-grade pivot shift, and elevated PTS, but the indications remain unclear. The biomechanical performance of ACLR + LET at varying PTSs may affect daily practice and provide clarity on these indications.

Influence of Staphylococcus epidermidis on Collagen Crimp Patterns of Soft Tissue Allograft

Background: Postoperative infections, commonly from Staphylococcus epidermidis, may result in anterior cruciate ligament graft failure and necessitate revision surgery. In biomechanical studies, S. epidermidis has been shown to establish biofilms on tendons and reduce graft strength. Purpose/Hypothesis: The goal of this study was to determine the effect of bacterial bioburden on the collagen structure of tendon. It was hypothesized that an increase in S. epidermidis biofilm would compromise tendon crimp, a pattern necessary for mechanical integrity, of soft tissue allografts. Study design: Controlled laboratory study. Methods: Cultures of S. epidermidis were used to inoculate tibialis anterior cadaveric tendons. Conditions assessed included 5 × 105 colony-forming units or concentrated spent media from culture (no living bacteria). Incubation times of 30 minutes, 3 hours, 6 hours, and 24 hours were utilized. Second-harmonic generation imaging allowed for visualization of collagen autofluorescence. Crimp lengths were determined using ImageJ and compared based on incubation time. Results: Incubation time positively correlated with increasing S. epidermidis bioburden. Both fine and coarse crimp patterns lengthened with increasing incubation time. Significant coarse crimp changes were observed after only 30-minute incubations (P < .029), whereas significant fine crimp lengthening occurred after 6 hours (P < .0001). No changes in crimp length were identified after incubation in media lacking living bacteria. Conclusion: The results of this study demonstrate that exposure to S. epidermidis negatively affects collagen crimp structure. Structural alterations at the collagen fiber level occur within 30 minutes of exposure to media containing S. epidermidis. Clinical Relevance: Our study highlights the need for antimicrobial precautions to prevent graft colonization and maximize graft mechanical strength.

Poster 318: CHANGE IN POSTERIOR TIBIAL SLOPE FOLLOWING DISPLACED PEDIATRIC TIBIAL TUBERCLE FRACTURES: A POTENTIAL MODEL FOR GROWTH MODULATION IN THE ACL DEFICIENT KNEE

Objectives: Increased posterior tibial slope angle (PTSA) increases the risk for anterior cruciate ligament (ACL) tear and ACL graft failure. Proximal tibial slope changing osteotomies are employed in the adult population; growth modulation procedures may present a treatment opportunity in the skeletally immature. This procedure has not been described in the context of ACL injuries, and the rate at which posterior tibial slope could be corrected is unknown. Our purpose was to quantify the rate of change in PTSA following operatively treated displaced tibial tubercle fractures in skeletally immature patients, and to determine how this rate is affected by skeletal age. We hypothesized that there would be a progressive loss of posterior tibial slope after injury, and that rate of change in PTSA would be highest during peak growth velocity Methods: We retrospectively reviewed skeletally immature patients with tibial tubercle fractures treated with ORIF. We measured posterior tibial slope angle (PTSA) at ˜3-, 6-, 12-months, and further postoperative time points if available. All subjects had a minimum of 6-months follow up. Bone age at the time of injury was determined. Negative PTSA was indicative of posteriorly directed slope, positive PTSA indicated anterior slope. Linear regression analysis was used to evaluate rate of change in PTSA (ΔPTSA) for individual patients and total cohort trend. Patient regression coefficients were averaged into bone age cohorts. The unit of analysis was the knee. Results: Twenty-two patients with 23 knees were included. 86% of patients were male. Average chronologic and bone age was 14 years at time of injury. Average follow-up was 17 months (range 6 to 52 months). Patients had a mean PTSA of -12˚ ± 2.4˚ at the time of injury. The overall mean ΔPTSA for the cohort was 0.30˚ ± 0.31˚ per month (range -0.27˚ to 0.97˚ per month). Linear regression revealed a significant relationship between months post-fixation and PTSA, demonstrating a ΔPTSA of +0.31˚ per month (CI 95% (0.24, 0.38); p&lt;.001) (Figure 1). The highest average ΔPTSA was seen at 14-years (0.58˚ ± 0.44˚ per month). The average overall absolute change in PTSA from injury to final follow-up was +4.1˚ (range -3.4˚ to 21˚) (Figure 2). Conclusions: Our data suggest progressively more anterior slope following ORIF. The greatest rate of change in PTSA corresponded with peak growth velocity. These findings may serve as a model for predicting the effect of anterior proximal tibia epiphysiodesis on tibial slope in ACL surgery.

Paper 24: Reliability of Posterior Tibial Slope Measurement on Magnetic Resonance Imaging Versus Computed Tomography

Objectives: Increased posterior tibial slope (PTS) has been linked to higher rates of anterior cruciate ligament (ACL) injury and ACL graft failure post-reconstruction. In recent years, more specific investigations have delineated distinct roles of the medial tibial plateau (MTP) and lateral tibial plateau (LTP) geometries on anteroposterior and rotatory stability of the knee. While the diagnostic workup of patients with ACL insufficiency typically consists of radiographs and magnetic resonance imaging (MRI), computed tomography (CT), which is the gold standard for evaluating the osseous geometry of the proximal tibia, is not routinely obtained. With increased understanding of the roles of the MTP and LTP geometries on tibiofemoral kinematics, accurate sagittal slope measurements of both the MTP and LTP will be crucial for further defining the treatment algorithm for ACL insufficiency. It is currently unknown whether traditional MRI can be used to accurately measure PTS and how well these measurements correlate to those on CT. Therefore, the purpose of this study was to compare PTS measurements of the MTP and LTP on MRI versus CT. Methods: After Institutional Review Board approval was obtained, an institutional picture archiving and communication system imaging database was retrospectively queried for patients that received concurrent MRI and CT imaging of the same knee within a one-year interval. Knees with significant arthrosis (Kellgren-Lawrence grade &gt;2), deformity, proximal tibia fracture, or artifact that obscured visualization of proximal tibia landmarks were excluded. On paired MRI and CT studies, PTS of the MTP and LTP were measured using a previously described, validated method (Hudek et al, Clin Orthop Relat Res, 2009) by two independent raters (Figure 1). Interrater reliability of PTS measurements was assessed using the intraclass correlation coefficient (ICC). Intermethod agreement between MRI and CT measurements was assessed using the ICC and Bland-Altman analysis. Results: A total of 41 knees in 40 patients (mean age, 37.9±13.4 years, 78.0% male) met final inclusion criteria. Interrater reliability was moderate for MRI measurements (ICC = 0.62-0.73) and high for CT measurements (ICC = 0.83-0.86). Mean measurements of PTS at the MTP were 3.3±2.8° (range, -4.7-8.4°) and 3.7±3.1° (range, -3.8-10.4°) on MRI and CT, respectively. Mean measurements of PTS at the LTP were 4.5±3.8° (range, -8.0-10.6°) and 5.2±3.6° (range, -3.6-15.7°) on MRI and CT, respectively. The mean absolute differences in PTS measurements between MRI and CT were 2.6±2.1° and 2.6±2.6° at the MTP and LTP, respectively. Poor intermethod agreement between MRI and CT was observed at the MTP (ICC = 0.31-0.41), while moderate intermethod agreement was observed at the LTP (ICC = 0.61-0.62). Bland-Altman plots demonstrated high variability and minimal bias of PTS measurements on MRI compared to CT (-0.9° [95% Limit of Agreement (LOA) -7.5-5.6°] for MTP; -1.0° [95% LOA -7.2-5.2°] for LTP) (Figure 2). Conclusions: With increased understanding of the roles of the medial and lateral tibial plateau geometries on tibiofemoral stability in the setting of ACL insufficiency, accurate measurements of PTS are necessary to guide treatment decisions. In this study, PTS measurements on MRI demonstrated lower interrater reliability compared to PTS measurements on CT. Poor-to-moderate agreement was observed for measurements of PTS of the MTP and LTP between paired MRI and CT studies, with high variability and minimal bias. Therefore, measurements of medial and lateral PTS may not be reliable on traditional MRI.

Association of Tibial Tubercle–Trochlear Groove Distance With Risk of ACL Graft Failure

Background: Limited evidence suggests a positive correlation between tibial tubercle–trochlear groove (TT-TG) distance and the risk of native anterior cruciate ligament (ACL) tear. The relationship between TT-TG distance and the risk of ACL graft failure is unknown. Hypothesis: TT-TG distance is independently associated with risk of ACL graft failure. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who underwent ACL revision surgery between 2010 and 2018 at a single institution were identified. A control cohort underwent primary ACL reconstruction (ACLR) between 2006 and 2015, with no evidence of graft failure at 8.1 ± 2.5 years postoperatively. Record review included anthropometrics, graft type, and estimated Tegner activity score at ≥6 months after primary ACLR. Magnetic resonance imaging (MRI) scans after native ACL tear (controls) or graft failure (revision cohort) were assessed for (1) TT-TG distance, (2) proximal tibial slopes, (3) depth of tibial plateau concavity, and (4) tunnel position (revision cohort). Associations between ACL graft failure and MRI measurements, surgical variables, and patient characteristics were evaluated with logistic regression analyses. Sensitivity analyses, excluding patients with tunnel malposition, were performed to confirm multivariable results in patients with “ideal” tunnel placement. Results: Participants included 153 patients who underwent revisions and 144 controls. Controls were older than the patients who underwent revision (26.6 ± 8.8 vs 20.6 ± 7.3 years; P &lt; .001). The mean TT-TG distance and lateral posterior tibial slope (PTS) were smaller for the control group than for the revision group (TT-TG: 9.3 ± 3.9 vs 11.2 ± 4.2 mm; P &lt; .001; lateral PTS: 6.2° ± 3.3° vs 7.2° ± 3.6°; P = .01). TT-TG distance, lateral PTS, and age were associated with risk of ACL graft failure by multivariable analysis (OR, 1.15; 95% CI, 1.07-1.23; P &lt; .001; OR, 1.13; 95% CI, 1.04-1.22; P = .004; and OR, 0.90; 95% CI, 0.87-0.94; P &lt; .001, respectively). With sensitivity analyses, TT-TG distance, lateral PTS, and age at index surgery remained significantly and independently associated with ACL graft failure. Conclusion: Increased TT-TG distance, increased lateral PTS, and younger age are independently associated with increased odds of ACL graft failure. Patients with these characteristics may require a more comprehensive strategy to reduce the risk of ACL reinjury.

Clinical Outcomes After ACL Reconstruction in Soccer (Football, Futbol) Players: A Systematic Review and Meta-Analysis.

The risk factors for anterior cruciate ligament (ACL) tear for athletes participating in pivoting sports includes young age and female sex. A previous meta-analysis has reported a reinjury rate of 15% after ACL reconstruction (ACLR) for athletes across all sports. To the best of the authors' knowledge, this is the first systematic review and meta-analysis of available literature reporting outcomes after ACLR in soccer players. To review and aggregate soccer-specific outcomes data after ACLR found in current literature to help guide a more tailored discussion regarding expectations and prognosis for soccer players seeking operative management of ACL injuries. A comprehensive search of publications was performed using PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and SPORTDiscus databases. Inclusion criteria consisted of original studies, level of evidence 1 to 4, studies reporting clinical and patient-reported outcomes (PROs) after primary ACLR in soccer players at all follow-up length. The primary outcomes of interest were graft failure/reoperation rates, ACL injury in contralateral knee, return to soccer time, and PROs. Level 4. Search of literature yielded 32 studies for inclusion that involved 3112 soccer players after ACLR. The overall graft failure/reoperation rate ranged between 3.0% and 24.8% (mean follow-up range, 2.3-10 years) and the combined ACL graft failure and contralateral ACL injury rate after initial ACLR was 1.0% to 16.7% (mean follow-up range, 3-10 years); a subgroup analysis for female and male players revealed a secondary ACL injury incidence rate of 27%, 95% CI (22%, 32%) and 10%, 95% CI (6%, 15%), respectively. Soccer players were able to return to play between 6.1 and 11.1 months and the majority of PROs showed favorable scores at medium-term follow-up. Soccer players experience high ACL injury rates after primary ACLR and demonstrated similar reinjury rates as found in previous literature of athletes who participate in high-demand pivoting sports.

A comparison of the outcomes of anterior curciate ligament reconstruction with large-size graft versus reconstruction with average-size graft combined with extraarticular tenodesis.

Many patients who have had anterior cruciate ligament (ACL) reconstruction (R) complain of instability, inability to return to previous levels of sports activity, and possible ACL graft failure. Graft size was discovered to be an important factor in lowering ACL failure rates. Also, extraarticular tenodesis decreases recurrent instability, A comparative study was done to compare the effect of graft size and lateral external tenodesis on the recurrence of instability after ACL-R. A Prospective Blinded Randomized Controlled study included 100 consecutive patients who underwent ACL-R with hamstring tendon grafts in our Hospital. The patients were allocated into two groups (Group A and B) with randomization; group A received ACL-R with a large-size ACL-graft diameter of 6 strands, and group B received ACL-R of 4 strands combined with lateral extraarticular tenodesis (LET) (Modified Lemaire). Each group had fifty patients. The follow-up time was two years. They were examined for graft failure, anterolateral rotatory instability with the pivot shift test, and clinical outcomes, which were evaluated with the International Knee Documentation Committee score (IKDC) both subjective and objective. In this study; group A, graft failure occurred in three (6.3%) patients, a positive pivot shift test grade I was detected in eight (17.8%) patients, grade II in three (6.7%) patients, and grade III in one (2.2%) patient. The subjective IKDC score was 87.9 (± 7.19) points. The objective IKDC score was normal or nearly normal in 43 (93.4%) patients. In group B, one (2.1%) patient had graft failure, five (10.9%) had a positive pivot shift test grade I, one (2.1%) had a grade II, and no patient had a grade III. The subjective IKDC score was 91.9 (± 8.9) points. The objective IKDC score was normal or nearly normal in 44 (95.6%) patients. As regard the subjective IKDC score, there was a non-significant difference between both groups (p value=0.465). Both groups showed a low ACL-graft failure rate, low anterolateral rotatory instability, and a good clinical outcome. Although there was no significant difference in subjective IKDC score between both groups, the failure rate and anterolateral rotatory instability were significantly lower in the ACL-R (4 strands) with LET combination group than in the group with the large-diameter (6 strands) graft. Level 1; Randomized Comparative Study.

Bone Marrow Aspirate Concentrate With Two-Staged-Revision ACL Reconstruction

Background: The incidence of anterior cruciate ligament (ACL) injuries, reconstructions, and re-ruptures has rapidly increased. Patients with failed ACL reconstructions have been reported to suffer from far worse outcomes as compared with those with primary reconstructions, prompting the advancement of surgical and biologic techniques. Effective treatment of re-tears has been shown to be achieved either utilizing a 1-stage or 2-staged approach, with the latter preferred if the patient presents with significant bone loss, previously malpositioned tunnels, or unacceptable tunnel expansion. Recent literature has shown the efficacy of bone marrow aspirate concentrate (BMAC) in improving clinical outcomes and graft integration as well as accelerated ligamentization. Indication: Patients are indicated for surgery when presenting with chronic ACL graft failure and objective insufficiency as well as concerns regarding tunnel overlap, enlargement, or interference. Contraindications for revision involve influences of concurrent injuries that may be secondary causes of the ACL injury. Technique Description: After bone marrow aspiration is performed, the tibial and femoral tunnel apertures are debrided of fibrous tissue with a combination of a shaver and curettes. A threaded guide wire is passed and the interference screws are removed, revealing the residual ruptured graft. A shaver and radiofrequency ablation device are utilized to clean off remaining graft remnants. Sequential debridement and reaming are performed to remove any residual fibrous tissue or sclerotic bone from the tunnel. The demineralized bone matrix is then combined with the prepared BMAC in a syringe with a cannula extension and subsequently injected into the tunnels. A freer elevate is used to tamp and smooth the graft to match the surrounding contour. A 12-mm cannulated allograft bone dowel is then passed up into the tibial tunnel and gently tamped into place. Results: Within 2 years postoperatively, patients are expected to have improved overall knee-specific quality of life, reduced pain, and a successful return to activities. No differences in outcomes have been noted in the literature between 1-staged and 2-staged ACL reconstructions. Discussion/Conclusion: Recent advancements in our understanding of the effects of BMAC in the setting of an ACL reconstruction should prompt surgeons to consider such treatments in indicated patients. Patient Consent Disclosure Statement: 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.

Elevated Posterior Tibial Slope Is Associated With Anterior Cruciate Ligament Reconstruction Failures: A Systematic Review and Meta-analysis

To evaluate the association of posterior tibial slope (PTS) with anterior cruciate ligament (ACL) reinjury following primary ACL reconstruction. PubMed, Scopus, Embase, and CINAHL databases were searched from inception through March 1, 2021, to retrieve relevant studies. Comparative studies reporting PTS measurements in a cohort of patients experiencing ACL graft failure versus patients with intact primary ACL reconstruction or studies comparing patients undergoing revision ACL reconstruction versus primary ACL reconstruction were included for analysis. A random-effects model was used to calculate the overall standardized mean difference (SMD) between groups. The following inclusion criteria were used: English language; full text available; Level I, II, or III evidence; studies in humans; and skeletally mature patients. After we systematically screened 1,912 studies, 15 studies met the inclusion/exclusion criteria. Radiographic measurements were used in 6 studies reporting medial PTS in 411 ACL failures versus 2808 controls. Patients with ACL failure had significantly greater medial PTS compared with controls (SMD 0.50; 95% confidence interval [CI] 0.23-0.77; P < .001). Magnetic resonance imaging (MRI) was used in 9 studies reporting lateral PTS measurements in 641 patients with a failed ACL reconstruction compared with 705 controls. Seven of the MRI studies also measured medial PTS in 552 failures versus 641 controls. Patients with ACL failure had significantly greater lateral PTS on MRI (SMD 0.58; 95% CI 0.13-1.03; P= .012) and medial PTS on MRI (SMD 0.59; 95% CI 0.23-0.96; P= .001) compared with controls. The present meta-analysis demonstrated that patients with elevated PTS on radiographs and MRI are at increased risk for ACL graft failure after primary ACL reconstruction. Level III, meta-analysis of Level III studies.

Comparative Study of ACL Reconstruction With Hamstring Versus Patellar Tendon Graft in Young Women: A Cohort Study From the New Zealand ACL Registry

Background: Young female athletes are a specific population that is at high risk of primary anterior cruciate ligament (ACL) rupture and subsequent graft failure. Despite large numbers of ACL reconstructions being carried out in young women, there is limited analysis of outcomes in this group, leading to low levels of evidence for graft choice. Purpose: To assess the effect of graft choice on ACL reconstruction failure rates among young women in New Zealand. Study Design: Cohort study; Level of evidence, 2. Methods: Prospective data captured by the New Zealand ACL Registry between April 2014 and March 2022 were reviewed. Young women aged 15 to 20 years were included. The primary outcome measure was ACL graft failure during the study period, with the key independent variable being graft type, either patellar or hamstring tendon autograft. This is presented as the rate per 100 patient-years and is compared between the 2 groups using the hazard ratio generated from a Cox proportional hazards regression. Secondary outcome measures were Marx activity scores and the Knee injury and Osteoarthritis and Outcome Score patient-reported outcome measure. Results: A total of 1261 primary ACL reconstructions in young women aged 15 to 20 years were reviewed. Hamstring tendon grafts were used in 797 (63%) reconstructions and patellar tendon graft in 464 (37%) reconstructions. Patients with a hamstring tendon graft had a graft failure rate of 7.7% compared with 1.1% in patients with a patellar tendon graft (hazard ratio, 6.1; 95% CI, 2.4-15.1; P < .001). The number of failures per 100 person-years was significantly higher in the hamstring group (2.05) compared with the patellar tendon group (0.37). No difference was noted at final follow-up between the hamstring tendon and patellar tendon groups when comparing patient-reported outcome measures during the follow-up period. Conclusion: In the young female population of this study, the use of a patellar tendon graft was associated with reduced risk of graft failure and was not associated with an increase in knee morbidity. This highlights the importance of informed decision-making in this high-risk population when considering ACL reconstruction graft type.

Closing-Wedge Posterior Tibial Slope-Reducing Osteotomy in Complex Revision ACL Reconstruction.

A posterior tibial slope (PTS) >12° has been shown to correlate with failure of anterior cruciate ligament (ACL) reconstruction (ACLR). PTS-reducing osteotomy has been described to correct the PTS in patients with a deficient ACL, mostly after failure of primary ACLR. To report radiologic indices, clinical outcomes, and postoperative complications after PTS-reducing osteotomy performed concurrently with revision ACLR (R-ACLR). Case series; Level of evidence, 4. A review of medical records at 3 institutions was performed of patients who had undergone PTS-reducing osteotomy concurrently with R-ACLR between August 2010 and October 2020. Radiologic parameters recorded included the PTS, patellar height according to the Caton-Deschamps Index (CDI), and anterior tibial translation (ATT). Patient-reported outcomes (International Knee Documentation Committee [IKDC] and Knee injury and Osteoarthritis Outcome Score [KOOS]), reoperations, and complications were evaluated. Included were 23 patients with a mean follow-up of 26.7 months (range, 6-84 months; median, 22.5 months). Statistically significant differences from preoperative to postoperative values were found in PTS (median [range], 14.0° [12°-18°] vs 4.0° [0°-15°], respectively; P < .001), CDI (median, 1.00 vs 1.10, respectively; P = .04) and ATT (median, 8.5 vs 3.6 mm, respectively; P = .001). At the final follow-up, the IKDC score was 52.4 ± 19.2 and the KOOS subscale scores were 81.5 ± 9.5 (Pain), 74 ± 21.6 (Symptoms), 88.5 ± 8 (Activities of Daily Living); 52.5 ± 21.6 (Sport and Recreation), and 48.8 ± 15.8 (Quality of Life). A traumatic ACL graft failure occurred in 2 patients (8.7%). Reoperations were necessary for 6 patients (26.1%) because of symptomatic hardware, and atraumatic recurrent knee instability was diagnosed in 1 patient (4.3%). Tibial slope-reducing osteotomy resulted in a significant decrease of ATT and can be considered in patients with a preoperative PTS ≥12° and ≥1 ACLR failure. In highly complex patients with multiple prior surgeries, the authors found a reasonably low graft failure rate (8.7%) when utilizing PTS-reducing osteotomy. Surgeons must be aware of potential complications in patients with multiple previous failed ACLRs.