Anterior Cruciate Ligament Graft Research Articles

Smith machine squats pose high risk to ACL graft integrity after the ACL reconstruction and conventional squats are a safer alternative.

The purpose of this study was to evaluate the impact of squats after the anterior cruciate ligament (ACL) reconstruction on the ACL graft, considering new data on biomechanics, posterior tibial slope (PTS)and anterolateral ligament (ALL). Utilising finite element analysis on the new 14-component knee joint model, we have evaluated stresses on the knee elements separately for the knee with a native double-bundle ACL and with a single-bundle ACL graft for the 5° and 14° PTS variants during both conventional and Smith machine horizontal squats. Replacing a native ACL with a single-bundle graft causes an overstrain on the graft compared to the intact ACL under all conditions. Stresses on the ACL, ACL graftand ALL are much higher during the Smith machine squats compared to the conventional ones. The stress on the menisci is 3.6-4.9 times higher with conventional squats. PTS at the squats' lowest point minimally affects ACL stress but impacts menisci. The single-bundle ACL reconstruction (ACLR) does not reproduce the biomechanics of the native ACL and increases stresses in most knee joint elements, according to the current study. Conventional squats are relatively safe for the ACL graft at their lowest point. Passing the half-squat position is the most dangerous point. Smith machine horizontal squats produce stress on the ACL graft several times higher than its estimated breaking load and dangerous stress levels on the ALL. During the rehabilitation following ACLR, it is advisable to prioritise the conventional squats over Smith machine squats until ligamentisation is complete. Level III.

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.

The Efficacy of Anterior Cruciate Ligament Reconstruction with Peroneus Longus Tendon and its Impact on Ankle Joint Function.

Peroneus Longus Tendon (PLT), a viable anterior cruciate ligament (ACL) graft, shares similar biomechanics, making it suitable for reconstruction. Controversy exists over whether PLT transplants affects the donor ankle joint. The purpose of this study was to examine the recovery of knee joint function following arthroscopic ACL restoration using autologous PLT and its influence on the donor ankle joint. A retrospective analysis was conducted on 65 patients with ACL rupture who underwent PLT graft reconstruction in our hospital from January 2016 to December 2021. A three-dimensional gait analysis of the bilateral knee and ankle joints was performed postoperatively using an Opti_Knee three-dimensional motion measurement and analysis system-Yidong Medical Infrared Motion Gait Analyzer. Knee function scores and changes in the range of motion of the bilateral knee and ankle joints were collected. The analysis of preoperative and postoperative joint function scores, bilateral knee and ankle mobility was performed by t-tests. One year after surgery, the patients' International Knee Documentation Committee (IKDC) scores, Knee Injury and Osteoarthritis Outcome Scores (KOOSs), and Lysholm scores were significantly improved compared to preoperative scores, with statistically significant differences (p < 0.05). There was no statistical difference in the American Orthopedic Foot and Ankle Society (AOFAS) score of the donor ankle joint before and after surgery (p > 0.05). During different gait cycles, there was no statistical difference in knee joint mobility between the affected and healthy sides (p > 0.05), but there was a statistical difference in the inversion and eversion angle of the donor ankle joint during the support phase (p < 0.05). ACL reconstruction using the PLT can yield satisfactory knee joint function. However, it does affect inversion and eversion in the donor ankle joint, necessitating postoperative exercises. Similar subjective function ratings for both operated and non-operated feet, despite increased inversion-eversion motion in the operated foot, may be influenced by the subjective nature and margin of error in the AOFAS Ankle-hindfoot score, along with the relatively small variation in ankle inversion-eversion angles.

The Effect of Supplementary Staple Fixation on Biomechanical Properties of Soft Tissue Graft Tibial Fixation in Anterior Cruciate Ligament Reconstruction.

This study aimed to test and compare the biomechanical properties of three tibial fixation methods of anterior cruciate ligament (ACL) tendon grafts under cyclic load and load-to-failure testing in the bovine proximal tibiae, comprising (1) staple fixation alone, (2) interference screw fixation alone, and (3) interference screw fixation with a supplementary staple. Twenty-four bovine tibiae used in the study were divided into three groups (eight proximal tibiae in each group) based on tibial fixation methods of ACL tendon grafts: group A (a spiked ligament staple alone), group B (a cannulated interference screw alone), and group C (a cannulated interference screw with a supplementary staple). Each graft fixation was exposed to cyclic loading conditions. Significant differences were determined in failure load among the three groups (p = 0.008). The mean failure load was significantly higher in group B (717.04 ± 218.51 N) than in group A (308.03 ± 17.22 N) (p = 0.006). No significant differences were observed among the groups regarding axial stiffness (p = 0.442). Cyclic displacement differed significantly among the three groups (p = 0.005). In pairwise comparisons, the mean cyclic displacement was significantly higher in group A (8.22 ± 3.24 mm) compared with group C (1.49 ± 0.41 mm) (p = 0.005). Failure displacement varied considerably among the groups (p = 0.037). Although group B (15.53 ± 6.43 mm) exhibited a greater mean failure displacement than both group A (4.9 ± 0.75 mm) and group C (8.84 ± 4.65 mm), these differences did not reach statistical significance (p = 0.602 and p = 0.329, respectively). Interference screw fixation alone and supplementary staple fixation have biomechanically similar characteristics in terms of initial strength and stiffness of tibial ACL soft tissue graft fixation. Regardless of staple use, an interference screw with the same diameter as the tibial tunnel can ensure sufficient tensile strength in tibial ACL graft fixation.

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.

Clinico-radiological outcome of Arthroscopic Anterior Cruciate Ligament Reconstruction with Augmentation of Dehydrated Human Amnion Chorion Allograft Membrane using Peroneus Longus Autograft.

For many sportsmen, anterior cruciate ligament (ACL) tears are unfortunate but common injuries. Several growth factors, cytokine, chemokine, and protease inhibitors functions in stimulation of paracrine reactions in fibroblast, endothelial, and stem cells thereby promoting the tissue restorative processes. Augmented with dehydrated Human Amnion Chorion Membrane (dHACM) allograft reinforces the reconstructed ligament and aids in effective restoration. In this case control study 15 patients undertaking ACL reconstruction with tripled peroneus augmented dHACM (G1) were prospectively monitored up for a period of 8 months along with 15 control patients (G2) without dHACM augmentation. Clinical and radiological outcomes were analysed and assessed about effect of augmenting the peroneus longus graft using dHACM. Clinical analysis included pre-operative two, four, six, and eight months post-operative Tegnor-Lysholm score, and radiological analysis included the 6th month postoperative MRI signal-to-noise ratio (SNR) measurements by mean signal-value at femoral insertion, midsubstance and tibial insertion of ACL graft. Clinically, as a mean Lysholm score of all patients, they were revealed to be consecutively high in G1 than in Group 2 at four, six, and eight months. The signal-to-noise ratio from the MRI results showed majority having good healing in G1 group. Based on 6-month MRI, an effective ligamentization (SNR<75) was noticed in 53.33% of patients in the dHACM allograft enhanced group on comparison with 33% in the controls. The overall results show that the augmentation of dHACM allograft to ACL reconstruction yields in good patient outcomes at post-operative follow-up.

The Influence of Tibial Tubercle–Sparing Slope-Reducing Osteotomy on Patellar Height in Patients Undergoing Revision ACL Reconstruction

Background: A posterior tibial slope (PTS) >12° is an independent risk factor for anterior cruciate ligament (ACL) graft rupture, and a high tibial osteotomy (HTO) for slope correction can help avoid it. Management of patellar height is of major concern when performing HTO. Purpose: To evaluate the effect of tibial tubercle–sparing anterior closing-wedge osteotomy on patellar height in revision ACL reconstruction (ACLR). Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent arthroscopic revision ACLR combined with retro–tibial tubercle anterior closing-wedge HTO (ACW-HTO) between January 1, 2016, and March 31, 2021, were assessed for eligibility. Patellar height was measured on full weightbearing lateral radiographs according to the Insall-Salvati index (ISI) and Caton-Deschamps index (CDI) or frontal radiographs using the femoral patellar height index. The PTS was evaluated using the proximal anatomic axis of the tibia on standard short lateral radiographs. The delta (postoperative – preoperative) and the ratio (preoperative/postoperative) of the 3 patellar height indices and PTS were calculated. Preoperative and postoperative patellar heights were compared using independent t tests for each index. Also investigated was whether patients changed patellar height category (baja, normal, or alta) after slope osteotomy. Results: Among 475 revision ACLRs, 47 tibial tubercle–sparing ACW-HTOs were retained for analysis. No significant difference in patellar height was found between pre- and postoperative radiographs regardless of the index (preoperative – postoperative) (ISI: 1.0 ± 0.2 – 0.9 ± 0.2, P = .1729; CDI: 1.0 ± 0.2 – 1.0 ± 0.2, P = .4034; femoral patellar height index: 1.5 ± 0.2 – 1.5 ± 0.2; P = .5130). Fifteen patients (31.9%) exhibited a postoperative change in their patellar height category when measured by the ISI (6 moved up a category, 9 moved down one), and 18 patients (38.3%) changed category according to the CDI (10 moved up a category, 8 moved down one). No significant difference was found between pre- and postoperative patellar height among these patients (ISI: P = .2418; CDI: P = .3005). Conclusion: Changes in patellar height ratio are common after tibial tubercle–sparing ACW-HTO in patients undergoing revision ACLR. The clinical effect of these changes is unknown, and further study is needed to investigate whether they may result in patellofemoral symptoms.

The terror of athletes - Anterior Cruciate Ligament Reconstruction, grafts and moden techniques

Introduction&#x0D; The anterior cruciate ligament (ACL) is a prevalent sports-related injury, constituting nearly half of knee injuries. This narrative review explores the evolution of ACL reconstruction surgeries, emphasizing graft types and their pros and cons.&#x0D; Current state of knowledgeThe ideal ACL graft choice depends on factors like age, lifestyle, and demands. Autografts are the current standard, with the Quadriceps Tendon graft offering similar outcomes and fewer complications. Allografts are a secondary option for older, low-demand patients due to a shorter recovery period. Artificial grafts have limited use, lacking strong evidence for clinical advantages but may be considered for suturing torn ACL stumps and in cases were quick recovery is essential.&#x0D; Summary&#x0D; Contemporary orthopedic practitioners must possess comprehensive knowledge of various ACL reconstruction graft types to tailor interventions precisely to individual patient requirements. The selection of a graft should be rooted in a profound comprehension of patients' lifestyles, medical histories, and specific demands, thereby mitigating the subjective impact of any associated limitations for the patient.

Tobramycin and Vancomycin in an In Vitro Model of Anterior Cruciate Ligament Allograft Decontamination

Background: Approximately 100,000 anterior cruciate ligament (ACL) reconstructions (ACLRs) occur annually in the United States, and postoperative surgical-site infection is a relatively rare but devastating complication, often leading to graft failure or septic arthritis of the knee, necessitating repeat surgery. Wrapping allografts in vancomycin-soaked gauze has been adopted as a common sterilization technique in the operating room to reduce surgical-site infection; however, identifying effective alternatives to vancomycin has not been extensively pursued. Hypothesis: Tobramycin would be as effective as vancomycin in reducing the concentrations of Staphylococcus epidermidis bacteria on tendon allografts. Study Design: Controlled laboratory study. Methods: S. epidermidis strain ATCC 12228 was inoculated onto the human cadaveric gracilis tendon. The tendons were wrapped in sterile gauze saturated with tobramycin or vancomycin at various experimental concentrations. Bacteria remaining on the tendon were dislodged, serially diluted, and plated for colony counting. Statistical analysis was performed utilizing 2-way analysis of variance testing. Results were considered statistically significant when P < .05. Results: Vancomycin (P = .0001) and tobramycin (P < .0001) reduced bacterial concentration. Tobramycin was found to produce a statistically significant reduction in bacterial concentration at concentrations as low as 0.1 mg/mL (P < .0001 and P = .01 at 10 and 20 minutes), while vancomycin produced a statistically significant reduction at a concentration as low as 2.5 mg/mL (P < .0001 at both 10 and 20 minutes). Conclusion: This study demonstrates that tobramycin is as effective as vancomycin in bacterial concentration reduction but can achieve this reduction level at lower doses. Further studies clarifying the biomechanical and cytotoxic effects of tobramycin on tendon tissue are indicated to solidify its use as a clinical alternative to vancomycin in ACLR. Clinical Relevance: These results will begin establishing tobramycin as an alternative to vancomycin in ACL graft decontamination. Because of relatively frequent shortages of vancomycin, establishing tobramycin as an alternative agent is a useful option for the orthopaedic surgeon.

Patients with Bilateral ACL Reconstruction (ACLR) have 3x the Rate of Posterior Tibial Slope Greater than 12-Degrees Compared to Unilateral ACLR: MRI and Radiographic Evaluation

Objectives: Increased posterior tibial slope (PTS) is a risk factor for primary anterior cruciate ligament (ACL) tear and graft failure, but PTS has not been well-defined in those who have experienced bilateral ACL injuries. We aimed to compare PTS angles, as well as the rate of elevated PTS (&gt;12° on lateral radiograph; &gt;7° on MRI), between patients who underwent bilateral ACL reconstruction (ACLR) vs unilateral ACLR. A secondary purpose was to examine whether these associations remained consistent on both plain radiographs and MRIs. Methods: We retrospectively identified patients who underwent primary ACLR at our institution from the years 2012 to 2020. Patients with non-simultaneous bilateral ACLR (n=53) were propensity matched to those with unilateral ACLR (n=53) by age, sex, and BMI. Exclusion criteria were: rotated lateral radiographs, inadequate quality MRI, concomitant ligament injury or fracture. Unilateral ACLRs with less than 5-year follow-up were further excluded. Three blinded readers measured PTS on lateral radiographs, while medial (MPTS) and lateral PTS (LPTS) were measured on MRI. Bivariate regression was performed to determine correlation between radiograph and MRI measurements. Results: A final cohort of 106 patients was analyzed (mean age: 27.4 ± 10.5 years, 49.1% male, BMI: 25.5 ± 4.3). PTS in the bilateral ACLR cohort was significantly greater than the unilateral ACLR cohort on radiographs (11.26° vs 10.13°, p=0.044) and LPTS (7.32° vs 6.08°, p=0.012), but not MPTS (4.55° vs 4.17°, p=0.467). The percentage of bilateral patients with radiograph PTS &gt;12° was 41.0%, compared to 13.2% in unilateral cohort (p=0.012). The bilateral cohort had a significantly greater rate of LPTS &gt;7° compared to unilateral patients (53.8% vs 32.1%, p=0.016), but not MPTS (p=0.467). On MRI, LPTS (5.93° ± 3.20°) was significantly greater than MPTS (5.12° ± 2.78°, p&lt;0.001). There was weak correlation between MPTS-radiograph ( R=0.24, p=0.02) and LPTS-radiograph was not significantly correlated ( R=0.03, p=0.810). Conclusions: Patients who underwent bilateral ACLR had significantly greater PTS on radiographs and LPTS on MRI compared to those with unilateral ACLR. The rate of PTS &gt;12° was 3.1x greater among bilateral ACLR compared to unilateral ACLR. PTS measurements on radiographs demonstrated weak-to-negligible correlation with MRI measurements, suggesting future normative PTS values should be reported specific to the imaging modality.

Factors Associated With Residual Pivot Shift After ACL Reconstruction: A Quantitative Evaluation of the Pivot-Shift Test Preoperatively and at Minimum 12-Month Follow-up.

Postoperative residual rotatory laxity remains despite improvement in surgical techniques for anterior cruciate ligament (ACL) reconstruction (ACLR). To evaluate factors associated with residual pivot shift after ACLR by quantitative measurement of the pivot shift before and after surgery. Case-control study; Level of evidence, 3. A total of 97 patients who underwent primary double-bundle ACLR between June 2016 and March 2021 and underwent surgery to remove staples, with at least 12 months of follow-up evaluation, were enrolled. Quantitative measurements were performed under general anesthesia immediately before ACLR (preoperatively), after temporary fixation of the ACL graft (intraoperatively), and immediately before staple removal (postoperatively). The laxity of pivot shift was assessed using inertial sensors to measure acceleration and external rotational angular velocity (ERAV). Descriptive data were assessed for associations with postoperative acceleration and ERAV in a univariate analysis. A multiple linear regression analysis was performed to identify factors associated with postoperative acceleration and ERAV. Anterior tibial translation, acceleration, and ERAV increased from intra- to postoperatively (P < .05). Factors significantly associated with postoperative acceleration were age (β = -0.238; P = .021), lateral posterior tibial slope (PTS) (β = 0.194; P = .048), and preoperative acceleration (β = 0.261; P = .008). Factors significantly affecting postoperative ERAV were age (β = -0.222; P = .029), ramp lesions (β = 0.212; P = .027), and preoperative ERAV (β = 0.323; P = .001). Greater preoperative laxity in the pivot shift was the factor having the most significant association with residual pivot shift after ACLR using quantitative measurements under general anesthesia. Younger age, higher lateral PTS, and concomitant ramp lesions were significant predictors of residual pivot shift. These findings can help pre- and intraoperative decision-making regarding whether an anterolateral structure augmentation should be added.

Revision ACL reconstruction in female athletes: current concepts

The challenge of revision anterior cruciate ligament (ACL) reconstruction lies in its complexity, varied presentation, and technical intricacies. A successful ACL reconstruction should allow patients to safely return to preinjury activities. However, it is only sometimes simple, and many risk factors and concurrent pathologies come into play. Evaluating and analysing the cause of failure and associated conditions is paramount to addressing them effectively. Despite a plethora of research and improvements in knowledge and technology, e gaps exist in issues such as optimal techniques of revision surgery, graft options, fixation, concurrent procedures, rehabilitation and protocol for return to sports of high-level athletes. Female athletes need additional focus since they are at higher risk of re-injury, suboptimal clinical outcomes, and lower rates of return to sport following revision reconstruction. Our understanding about injury prevention and the protection of ACL grafts in female athletes needs to be improved. This review focuses on the current state of revision ACL surgery in female athletes and provides recommendations and future directions for optimising outcomes in this high-risk group.

Analysis of Graft Types Augmented With an Internal Brace for ACL Reconstruction: A Systematic Review.

New techniques are being developed to decrease the failure rate of anterior cruciate ligament (ACL) grafts and prevent revision surgery. One such technique involves high-strength suture tape (ST), also referred to as internal bracing. Recent literature has highlighted the use of ST for ACL reconstruction, but no study has compared ST augmentation between graft types. To compare the use of ST augmentation for ACL reconstruction based on the type of graft used (ie, bone-patellar tendon-bone [BPTB], quadriceps, hamstring). Systematic review; Level of evidence, 5. An online search of multiple databases was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and was completed April 2022 to identify studies related to ST augmentation of ACL grafts. Of 926 studies identified, 10 met inclusion criteria. Five studies (50%) used hamstring tendon (HT), 3 (30%) used quadriceps tendon (QT), 1 (10%) used BPTB, and 1 (10%) used both HT and QT grafts. HT autografts augmented with ST had decreased dynamic and peak elongation (15%-56%), increased load to failure, and increased initial and final dynamic stiffness compared with controls. There was no significant difference in postoperative physical examination findings (range of motion, Lachman, pivot shift), except that ST-augmented grafts had significantly less laxity after surgery compared with HT alone (0.8 vs 1.9 mm; P < .05). QT allografts with ST augmentation showed increased graft strength. Human QT autograft studies showed higher Knee injury and Osteoarthritis Outcome Score scores compared with controls. BPTB allografts with ST augmentation had decreased cyclic displacement by 31% (P = .015) and increased load (758 ± 128 N; P < .001) and stiffness (156 ± 23 N/mm; P = .003) compared with nonaugmented groups. The complication rate was low or showed no increase in the ST augmentation groups compared with control groups. HT, QT, and BPTB grafts augmented with ST demonstrate an effective method for ACL reconstruction. All graft types with ST augmentation showed no evidence of clinical disadvantage, with some studies indicating significant biomechanical or clinical advantages compared with conventional ACL reconstruction.

Correlation of muscle strength and reported knee function after Anterior Cruciate Ligament (ACL) graft, unrepaired ACL injury, and healthy knees

Correlation of muscle strength and reported knee function after Anterior Cruciate Ligament (ACL) graft, unrepaired ACL injury, and healthy knees

Hyperbaric oxygen therapy enhances graft healing and mechanical properties after anterior cruciate ligament reconstruction: An experimental study in rabbits.

Hyperbaric oxygen therapy (HBOT) has proven successful in wound healing. However, its potential effects on anterior cruciate ligament (ACL) injuries remain uncertain. This study aimed to investigate the impact of HBOT on graft healing following ACL reconstruction in rabbits. Male New Zealand rabbits underwent ACL reconstruction and were randomly divided into two groups: the HBOT group and the ambient air group. The HBOT group received 100% oxygen at 2.5 atmospheres absolute for 2 h daily for 5 consecutive days, starting from the first day after surgery. The ambient air group was maintained in normal room air throughout the entire period. After 12 weeks following the surgery, animals were euthanized, and their knees were harvested for analysis. The HBOT group demonstrated superior graft maturation and integration in comparison to the ambient air group, as evidenced by lower graft signal intensity on magnetic resonance imaging, decreased femoral and tibial tunnel size, and higher bone mineral density values on high-resolution peripheral quantitative computed tomography scans. Additionally, biomechanical testing indicated that the HBOT group had greater load to failure and stiffness values than the ambient air group. In conclusion, the adjuvant use of HBOT improved ACL graft maturation and integration, reduced tunnel widening, and enhanced the biomechanical properties of the graft. These results may provide important insights into the potential clinical application of HBOT as a therapeutic intervention to enhance graft healing after ACL reconstruction, paving the way for further research in this area.

Graft Reorientation and Lateral Extra-articular Tenodesis in Revision Surgery for Persistent Rotational Instability of a Verticalized Anterior Cruciate Ligament Graft

Persistent rotational instability after anterior cruciate ligament reconstruction is a relatively common postoperative complication, typically associated with graft verticalization due to improper femoral tunnel placement, especially with classic transtibial femoral tunnel techniques. This article describes a technique designed to reorient a verticalized anterior cruciate ligament graft at its femoral insertion to a more anatomic position in the coronal and sagittal planes, aiming to restore knee stability without the need for a complete revision operation. Additionally, a lateral extra-articular tenodesis with fascia lata is added to reinforce rotational stability.

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.

Association of Lateral Extra-Articular Tenodesis With Improved Graft Maturity on MRI 2 Years After ACL Reconstruction With Quadriceps Tendon Autograft in Skeletally Immature Athletes.

Quadriceps tendon autograft (QTA) has recently gained popularity in the treatment of anterior cruciate ligament (ACL) ruptures in pediatric patients. The addition of lateral extra-articular tenodesis (LET) to an ACL reconstruction (ACLR) has been found to reduce the risk of ACL retear in high-risk patients. To (1) compare ACL graft maturity using signal intensity ratios (SIRs) on magnetic resonance imaging (MRI) scans in skeletally immature patients undergoing ACLR with QTA either with or without concomitant LET and (2) evaluate LET safety by calculating the physeal disturbance-related reoperation rate in the ACLR+LET group. Cohort study; Level of evidence, 3. The records of patients aged ≤18 years who underwent ACLR between 2015 and 2021 were reviewed retrospectively. Patients undergoing ACLR with QTA who had open distal femoral and proximal tibial physes on MRI scans and a minimum 2-year follow-up data were included. SIR values were measured on sagittal MRI scans by averaging the signal at 3 regions of interest along the ACL graft and dividing by the signal of the posterior cruciate ligament at its insertion. Statistical analysis was performed to evaluate differences in SIR values at 6 months, 1 year, and 2 years postoperatively in patients who underwent ACLR alone versus ACLR+LET. Overall, 29 patients were included in the study: 16 patients in the ACLR+LET group and 13 patients in the ACLR-only group. There were no significant differences in SIR values between groups at the 6-month or 1-year postoperative timepoints. At 2 years postoperatively, the median SIR of the ACLR+LET group was significantly lower than that of the ACLR-only group on both univariate (1.33 vs 1.86, respectively, P = .0012) and multivariate regression analyses adjusting for both sex and surgical technique (β = -0.49 [95% CI, -0.91 to -0.05]; P = .029). There were no cases of reoperation for physeal disturbance in patients who underwent ACLR+LET. The addition of LET to an ACLR with QTA was associated with lower average SIR values and thus improved graft maturity at 2 years postoperatively compared with ACLR alone in skeletally immature patients. The addition of LET to an ACLR was found to be safe in skeletally immature patients.

Arthroscopic Physeal Sparing Anterior Cruciate Ligament Reconstruction and Lateral Extra-articular Tenodesis With Semitendinosus and Gracilis Tendons

Anterior cruciate ligament (ACL) injuries among young patients have increased in recent years. The purpose of this study was to present a physeal-sparing intra- and extra-articular reconstruction using semitendinosus and gracilis tendons autograft. In recent years, the management of these injuries in the pediatric population has become increasingly surgical to restore knee function and reduce the risk of meniscal and chondral injury due to persistent knee instability. However, this is a population at high risk for ACL graft rupture, but it can be lowered by an addition of lateral extra-articular tenodesis (LET). This study shows the pearls and pitfalls of an arthroscopic physeal-sparing ACL reconstruction combined with a concomitant LET using hamstrings autograft.