Anterior Cruciate Ligament Graft Research Articles

IS PERCUTANEOUS MEDIAL COLLATERAL LIGAMENT (MCL) RELAXATION DURING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION A SAFE OPTION FOR GAINING ACCESS TO THE MEDIAL KNEE COMPARTMENT IN CHILDREN?

Introduction:With participation in youth sports anterior cruciate ligament (ACL) injuries are a common occurrence. Nearly 70% of ACL tears in children and adolescents have an associated meniscus tear. Percutaneous medial collateral ligament (MCL) relaxation has been described as utilitarian in accessing the medial meniscus for diagnostic assessment and treatment in the adult population to increase medial compartment working space in arthroscopic surgery. The technique has not been evaluated in the pediatric population. The purpose of this study was to compare the outcomes of children and adolescents that underwent anterior cruciate ligament reconstruction (ACLR) with and without percutaneous relaxation of the medial collateral ligament (MCL) for meniscal tear management.Methods:A retrospective review was performed of patients aged 8 to 19 years old that had undergone knee arthroscopy for an (ACLR) with meniscus pathology. Those that underwent MCL relaxation were grouped together and compared to a matched cohort that did not have MCL relaxation performed. Preoperative, operative and postoperative data was analyzed. The primary measurement was obtained using a validated patient reported outcome score (Pedi-IKDC), secondary outcome measures were defined as superficial or deep infection, saphenous nerve dysesthesias, ACL graft failure and return to the operating room. Statistical analysis of the two cohorts was performed.Results:Fifty-four patients were included in the study (27 in each group) with average age 15 years (range 10-19). Average follow-up for the MCL relaxation group was 22.4 months versus 58 months for the non-MCL relaxation group. The average Pedi-IKDC score was 93.3 for the MCL relaxation group and 91.4 for the non-MCL relaxation group (p=0.34). There was no difference in patient demographics, return to the operating room (p=0.49), saphenous nerve dysesthesia (p=0.49), superficial or deep infection (p=0.32).Conclusion:ACL reconstruction in children and adolescents with MCL relaxation for the management of medial meniscal tears appears to be a safe option. Equivocal patient reported outcome scores as compared to the control group were found with no increase in post-operative complications. In children with ACL tears, appropriate diagnosis and management of medial meniscal pathology is important to maintain secondary restraint to anterior tibial translation and prevent premature graft failure. Pediatric knees can have tight medial compartments, making access difficult, potentially leading to poor visualization and iatrogenic chondral damage. Percutaneous medial collateral ligament (MCL) relaxation has been described in the adult population to increase medial compartment working space without long term sequela. We report similar findings in an all pediatric cohort.

Effect of Modified Lemaire Anterolateral Extra-articular Tenodesis on the Magnetic Resonance Imaging Maturity Signal of Anterior Cruciate Ligament Hamstring Graft

Background: Lateral extra-articular tenodesis (LET) is one of the most widely used procedures to restore anterolateral stability. Clinical outcomes after the addition of LET to anterior cruciate ligament (ACL) reconstruction (ACLR) have been widely investigated; however, the potential influence of LET on the ACL ligamentization process has not been examined. Purpose/Hypothesis: The purpose was to use 10-month postoperative magnetic resonance imaging (MRI) scans to determine whether the maturity of grafts after hamstring autograft ACLR was affected by concomitant LET. The hypothesis was that when modified Lemaire lateral extra-articular tenodesis (MLLET) was performed, the MRI parameters of ACL graft maturity would be modified. Study Design: Cohort study; Level of evidence, 3. Methods: The study included patients treated between December 2017 and December 2018 who had undergone anatomic 3-strand hamstring tendon autograft ACLR, with or without concomitant MLLET, and had undergone MRI 10 months postoperatively. Thus, the study included 30 patients who had isolated ACLR and 22 patients who had ACLR plus MLLET. The 2 groups were comparable based on all criteria analyzed. To evaluate graft maturity, the signal-to-noise quotient (SNQ) was measured in 3 regions of interest of the proximal, midsubstance, and distal ACL graft. Lower SNQ ratios indicate less water content and, theoretically, better maturity and healing of the graft. Results: The mean ± SD for SNQ was 4.62 ± 4.29 (range, 3.12-6.19) in the isolated ACLR group and 7.59 ± 4.68 (range, 4.38-8.04) in the ACLR plus MLLET group (P = .012). Upon comparing the mean values of the 3 portions between the 2 groups, we found a significant difference between the 2 groups for the proximal and middle portions (P = .007 and P = .049, respectively) but no difference in the distal portion (P = .369). Conclusion: At the 10-month follow-up, hamstring tendon autografts for anatomic ACLR with MLLET did not show the same MRI signal intensity compared with isolated hamstring anatomic ACLR.

Predicting Anterior Cruciate Ligament Reinjury From Return-to-Activity Assessments at 6 Months Postsurgery: A Prospective Cohort Study.

Return-to-activity (RTA) assessments are commonly administered after anterior cruciate ligament reconstruction (ACLR) to manage the patient's postoperative progressions back to activity. To date, few data are available on the clinical utility of these assessments to predict patient outcomes such as secondary anterior cruciate ligament (ACL) injury once the athlete has returned to activity. To identify the measures of patient function at 6 months post-ACLR that best predict RTA and second ACL injury at a minimum of 2 years after ACLR. Prospective cohort study. Laboratory. A total of 234 patients with primary, unilateral ACLR completed functional assessments at approximately 6 months post-ACLR. Of these, 192 (82.1%) completed follow-up at ≥2 years post-ACLR. The 6-month functional assessments consisted of patient-reported outcomes, isokinetic knee-flexor and -extensor strength, and single-legged hopping. We collected RTA and secondary ACL injury data at ≥2 years after ACLR. Of the patients who were able to RTA (n = 155), 44 (28.4%) had a subsequent ACL injury, 24 (15.5%) to the ipsilateral graft ACL and 20 (12.9%) to the contralateral ACL. A greater proportion of females had a secondary injury to the contralateral ACL (15/24, 62.5%), whereas a greater proportion of males reinjured the ipsilateral ACL graft (15/20, 75.0%; P = .017). Greater knee-extension symmetry at 6 months increased the probability of reinjury (B = 0.016, P = .048). Among patients with RTA at <8 months, every 1% increase in quadriceps strength symmetry at 6 months increased the risk of reinjury by 2.1% (B = 0.021, P = .05). Among patients with RTA at >8 months, every month that RTA was delayed reduced the risk of reinjury by 28.4% (B = -0.284, P = .042). Descriptive statistics of patient function stratified between the early and delayed RTA groups can be found in the Supplemental Table (available online at http://dx.doi.org/10.4085/1062-6050-0407.20.S1). Patients with more symmetric quadriceps strength at 6 months post-ACLR were more likely to experience another ACL rupture, especially those who returned to sport at <8 months after the index surgery. Clinicians should be cognizant that returning high-functioning patients to activity at <8 months post-ACLR may place them at an increased risk for reinjury.

The outcomes of quadriceps tendon autograft for anterior cruciate ligament reconstruction in adolescent athletes: a retrospective case series.

Multiple graft options exist for anterior cruciate ligament (ACL) reconstruction in an adolescent athlete. Patellar tendon harvest can lead to anterior knee pain, while hamstring tendon harvest can affect knee flexion strength and alter mechanics. Allograft is less desirable in pediatric patients due to the higher failure rate and slight risk of disease transmission. Quadriceps tendon autograft has rarely been reported for adolescent ACL reconstruction in the USA, but is an excellent option due to its large size, low donor site morbidity, and versatility. The purpose of this study is to report the outcomes of adolescents who have undergone ACL reconstruction using quadriceps tendon autograft. Twenty-two ACL reconstructions using the quadriceps autograft were performed on 21 pediatric patients by the senior author between 2010 and 2017. The patient's demographics, injury characteristics, imaging, physical examination findings, operative findings, outcomes and sports were recorded. The average age at the time of surgery was 15years. Two patients had open physes; the remainder had closing physes. 64% of patients had additional meniscal tears and 76% had bony contusions. The average duration of follow-up was 2.8years (range 2-5years). At final follow-up, there were no angular deformities or leg length discrepancies. The average quadriceps atrophy of the operative leg was 4mm. The average Lysholm score was 98. 86% of patients returned to sports. No patients had re-rupture of their operative ACL. No incidences of infections, numbness, or anterior knee pain were reported. Two patients had a second arthroscopy for re-injury, revealing new meniscal tears but intact ACL grafts. Use of quadriceps tendon autograft for ACL reconstruction in adolescent patients allows reliable return to sport with minimal complications. Level IV, retrospective case series.

Evaluation of ACL Graft Remodeling and Prediction of Graft Insufficiency in Sequenced MRI—Two-Year Follow-Up

Background: Postoperative magnetic resonance imaging (MRI) evaluation of anterior cruciate ligament (ACL) graft maturity is a useful and practical tool that allows for assessment of graft status and remodeling stage. The purpose of this study was to evaluate and compare previously described methods of graft evaluation in MRI. We identify factors influencing the maturation and correlating graft appearance in MRI with indirect symptoms of graft insufficiency to identify patients at risk. Methods: Retrospective evaluation was performed in 44 patients who received bone patellar tendon bone (BPTB) ACL reconstruction with nine consecutive postoperative MRIs at 2, 6, 12, 18, 24, 36, 48, 72, and 96 weeks. Graft status was evaluated using signal-to-noise quotient (SNQ) methods in both sagittal and axial planes. We also assessed the homogeneity of the graft by standard deviation (SD) of signal intensity. SNQ was correlated with patient’s age, sex, postoperative weight-bearing, as well as indirect signs of graft insufficiency by MRI including graft appearance, posterior cruciate ligament (PCL) buckling, and measurement of anterior tibia subluxation. Results: We observed that the results of modelling SNQs from both sagittal and axial planes were similar. For both SNQs, the change over weeks quotient was nonlinear where the clinical parameter increased at week 36 and subsequently decreased. The SNQ at week 96 does not reach the levels from week 2. We observed that the model incorporating SNQ and relative SD (rSD) in the sagittal plane predicted the tibia anterior subluxation proportions better than the model with clinical parameters measured in the axial plane. Our results demonstrate that greater SD is associated with less graft homogeneity, which could indicate that this model is a good predictor of graft insufficiency. In addition, the proportion of PCL buckling increased over the course of the study. Conclusions: MRI graft evaluation is very useful for assessing graft ligamentization stage and to predict graft insufficiency.

High Rate of Initially Overlooked Kaplan Fiber Complex Injuries in Patients With Isolated Anterior Cruciate Ligament Injury

Background: Injuries to the Kaplan fiber complex (KFC) are not routinely assessed for in the anterior cruciate ligament (ACL)-deficient knee during preoperative magnetic resonance imaging (MRI). As injuries to the KFC lead to anterolateral rotatory instability (ALRI) in the ACL-deficient knee, preoperative detection of these injuries on MRI scans may help surgeons to individualize treatment and improve outcomes, as well as to reduce failure rates. Purpose: To retrospectively determine the rate of initially overlooked KFC injuries on routine MRI in knees with isolated primary ACL deficiency. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent isolated ACL reconstruction between August 2013 and December 2019 were identified. No patient had had Kaplan fiber (KF) injury identified on the initial reading of the MRI scan or at the time of surgery. Preoperative knee MRI scans (minimum 1.5 T) were reviewed and injuries to the proximal and distal KFs were recorded by 3 independent reviewers. KF length and distance to nearby anatomic landmarks (the lateral joint line and the lateral femoral epicondyle) were measured. Additional radiological findings, including bleeding, lateral femoral notch sign, and bone marrow edema (BME), were identified to detect correlations with KFC injury. Results: The intact KFC could reliably be identified by all 3 reviewers (85.9% agreement; Kappa, 0.716). Also, 53% to 56% of the patients with initially diagnosed isolated ACL ruptures showed initially overlooked injuries to the KFC. Injuries to the distal KFs were more frequent (48.1%, 53.8%, and 43.3% by the first, second, and third reviewers, respectively) than injuries to the proximal KFs (35.6%, 47.1%, and 45.2% by the first, second, and third reviewers, respectively). Bleeding in the lateral supracondylar region was associated with KFC injuries (P = .023). Additionally, there was a positive correlation between distal KF injuries and lateral tibial plateau BME (P = .035), but no associations were found with the lateral femoral notch sign or other patterns of BME, including pivot-shift BME. Conclusion: KF integrity and injury can be reliably detected on routine knee MRI scans. Also, 53% to 56% of the patients presenting with initially diagnosed isolated ACL ruptures had concomitant injuries to the KFC. This is of clinical relevance, as ACL injuries diagnosed by current routine MRI examination protocols may come with a high number of occult or hidden KFC injuries. As injuries to the KFC contribute to persistent ALRI, which may influence ACL graft failure or reoperation rates, significant improvements in preoperative diagnostic imaging are required to determine the exact injury pattern and to assist in surgical decision making.

No Difference in Ligamentous Strain or Knee Kinematics Between Rectangular or Cylindrical Femoral Tunnels During Anatomic ACL Reconstruction With a Bone-Patellar Tendon-Bone Graft.

Background:As our understanding of anterior cruciate ligament (ACL) anatomy has evolved, surgical techniques to better replicate the native anatomy have been developed. It has been proposed that the introduction of a rectangular socket ACL reconstruction to replace a ribbon-shaped ACL has the potential to improve knee kinematics after ACL reconstruction.Purpose:To compare a rectangular femoral tunnel (RFT) with a cylindrical femoral tunnel (CFT) in terms of replicating native ACL strain and knee kinematics in a time-zero biomechanical anatomic ACL reconstruction model using a bone–patellar tendon–bone (BTB) graft.Study Design:Controlled laboratory study.Methods:In total, 16 fresh-frozen, human cadaveric knees were tested in a 5 degrees of freedom, computed tomography–compatible joint motion simulator. Knees were tested with the ACL intact before randomization to RFT or CFT ACL reconstruction using a BTB graft. An anterior translation load and an internal rotation moment were each applied at 0°, 30°, 60°, and 90° of knee flexion. A simulated pivot shift was performed at 0° and 30° of knee flexion. Ligament strain and knee kinematics were assessed using computed tomography facilitated by insertion of zirconium dioxide beads placed within the substance of the native ACL and BTB grafts.Results:For the ACL-intact state, there were no differences between groups in terms of ACL strain or knee kinematics. After ACL reconstruction, there were no differences in ACL graft strain when comparing the RFT and CFT groups. At 60° of knee flexion with anterior translation load, there was significantly reduced strain in the reconstructed state ([mean ±standard deviation] CFT native, 2.82 ± 3.54 vs CFT reconstructed, 0.95 ± 2.69; RFT native, 2.77 ± 1.71 vs RFT reconstructed, 1.40 ± 1.76) independent of the femoral tunnel type. In terms of knee kinematics, there were no differences when comparing the RFT and CFT groups. Both reconstructive techniques were mostly effective in restoring native knee kinematics and ligament strain patterns as compared with the native ACL.Conclusion:In the time-zero biomechanical environment, similar graft strains and knee kinematics were achieved using RFT and CFT BTB ACL reconstructions. Both techniques appeared to be equally effective in restoring kinematics associated with the native ACL state.Clinical Relevance:These data suggest that in terms of knee kinematics and graft strain, there is no benefit in performing the more technically challenging RFT as compared with a CFT BTB ACL reconstruction.

Meniscal problems in the ACL deficient knee: What every ACL surgeon must be able to do!

Meniscal tears are common concomitant injuries seen in up to 65% of anterior cruciate ligament (ACL) deficient knees. The goal of ACL reconstruction (ACL-R) is to restore mechanical stability to the knee and to prevent further damage to the menisci, which act as secondary knee stabilizers for both anterior-posterior translation and rotational laxity. Delayed ACL-R and chronic ACL insufficiency have been associated with secondary meniscal tears that are more likely to be complex tears. Excluding graft failure, another common cause of reoperation in ACL reconstructed knees is meniscal surgery. Therefore, addressing meniscal tears at time of primary ACL-R is important to restore joint mechanics, protect the ACL graft for successful healing, and prevent long-term osteoarthritis. Current management options include leaving tears in-situ, meniscectomy, or meniscus repair. However, inconsistent findings have identified the need for well-defined treatment recommendations. Surgical decision making is reliant upon multiple factors such as adequate understanding of meniscal anatomy, biomechanics, tear pattern, and patient factors. This review focuses on the impact of meniscus injuries in ACL deficient knees and addresses current surgical indications and outcomes.

Emerging Topics in ACL Graft Selection: Best Evidence for the Use of Quadriceps Tendon Graft

Reconstruction of the anterior cruciate ligament (ACL) is one of the most common surgical procedures in orthopaedic sports medicine. Despite this, graft selection remains controversial with various regional, institutional, and individual preferences and trends. The traditional autograft options for reconstruction have been hamstring tendon and bone-patellar tendon-bone (BTB) autografts. Recently, quadriceps tendon (QT) autografts have garnered significant interest and appear promising because of their biomechanical properties and stability on clinical outcomes, and have less donor site morbidity compared with BTB. In this review, recent developments in QT autograft research are discussed and future directions which may clarify the appropriate role of quadriceps grafts in ACL reconstruction are explored.

Anterior Cruciate Ligament Reconstruction and Lateral Plasty in High-Risk Young Adolescents: Revisions, Subjective Evaluation, and the Role of Surgical Timing on Meniscal Preservation.

In adolescents, the rate of meniscal injury at the time of anterior cruciate ligament (ACL) reconstruction, the rate of ACL graft revision, and clinical outcomes has not yet been investigated. In patients younger than 16 years, the rate of meniscal injuries at the time of ACL reconstruction increases with time from injury. The mid-term revision rate and reoperation rate after ACL reconstruction with hamstrings and lateral tenodesis are lower than those reported in literature for isolate ACL reconstruction. Case series. Level 4. Patients younger than 16 years who underwent ACL reconstruction with hamstring and lateral tenodesis, with a follow-up ≥2 years were included. The number of meniscal lesions was stratified according to the delay between injury-to-surgery (<3, 3-12, >12 months). All reoperations, Lysholm score, Knee Injury and Osteoarthritis Outcome Score subscales for pain (at rest and during activity), and return to sport were collected. A total of 151 patients (mean age 14.8 ± 1.2 years) were included. Patients undergoing surgery at <3 months after injury had a lower meniscal injury rate (36%) than those treated at 3 to 12 months (55%) and >12 months (63%) after injury (P = 0.04). Medial meniscal lesions were more likely to be repaired when surgery was performed <3 months after injury (91%). Subjective follow-up data were available for 132 patients, and 19 were lost to follow-up. At 6.0 ± 2.6 years, 6% of patients underwent ACL revision; 1 of 20 (5%) patients with posterior tibial slope ≥12° and 4 of 45 (9%) patients with Tegner level ≥8. Nine new meniscal procedures were performed; 19% of repaired menisci underwent meniscectomy. Good or excellent Lysholm score was reported by 88% of patients; 56% of patients with concurrent lateral meniscectomy had pain during activity, 91% returned to sport, and 79% were still participating at final follow-up. Patients younger than 16 years undergoing ACL reconstruction within 3 months from injury had the lowest rate of meniscal injuries. ACL reconstruction with lateral tenodesis had low revision rate (6%) and good or excellent clinical outcomes in 88% of young adolescents. Sport physicians should be aware that adolescent patients undergoing ACL reconstruction within 3 months after injury have the lowest rate of meniscal injuries; the mid-term revision rate of ACL reconstruction with lateral plasty is lower than 10% and the patients' perceived outcomes are good with almost all patients returning to sport activity.

Non-anatomic tunnel position increases the risk of revision anterior cruciate ligament reconstruction.

Anterior cruciate ligament (ACL) graft failure is a complication that may require revision ACL reconstruction (ACL-R). Non-anatomic placement of the femoral tunnel is thought to be a frequent cause of graft failure; however, there is a lack of evidence to support this belief. The purpose of this study was to determine if non-anatomic femoral tunnel placement is associated with increased risk of revision ACL-R. After screening all 315 consecutive patients who underwent primary single-bundle ACL-R by a single senior orthopedic surgeon between January 2012 and January 2017, 58 patients were found to have both strict lateral radiographs and a minimum of 24months follow-up without revision. From a group of 456 consecutive revision ACL-R, patients were screened for strictly lateral radiographs and 59 patients were included in the revision group. Femoral tunnel placement for each patient was determined using a strict lateral radiograph taken after the primary ACL-R using the quadrant method. The center of the femoral tunnel was measured in both the posterior-anterior (PA) and proximal-distal (PD) dimensions and represented as a percentage of the total distance (normal center of anatomic footprint: PA 25% and PD 29%). In the PA dimension, the revision group had significantly more anterior femoral tunnel placement compared with the primary group (38% ± 11% vs. 28% ± 6%, p < 0.01). Among patients who underwent revision; those with non-traumatic chronic failure had statistically significant more anterior femoral tunnel placement than those who experienced traumatic failure (41% ± 13% vs. 35% ± 8%, p < 0.03). In the PD dimension, the revision group had significantly more proximal femoral tunnel placement compared with the primary group (30% ± 9% vs 38% ± 9%, p < 0.01). In this retrospective study of 58 patients with successful primary ACL-R compared with 59 patients with failed ACL-R, anterior and proximal (high) femoral tunnels for ACL-R were shown to be independent risk factors for ACL revision surgery. As revision ACL-R is associated with patient- and economic burden, particular attention should be given to achieving an individualized, anatomic primary ACL-R. Surgeons may reduce the risk of revision ACL-R by placing the center of the femoral tunnel within the anatomic ACL footprint. Level III.

Stable Lateral Meniscal Posterior Root Tears Left In Situ at Time of Anterior Cruciate Ligament Reconstruction Are of Minimal Long-Term Clinical Detriment

The purpose of this study was to compare long-term patient-reported outcomes in patients undergoing anterior cruciate ligament (ACL) reconstruction with untreated stable lateral meniscal posterior root (LMPR) tears to those with an intact meniscus. Four hundred ninety-two subjects were followed for a minimum of 15-years post-ACL reconstruction and evaluated by an International Knee Documentation Committee questionnaire. The integrity of the meniscus was classified at surgery. Patients were grouped as either untreated injury to LMPR "with stable tear" (WST) group (n= 52) or intact lateral meniscus "no tear" (NT) group (n= 440). WST group included tears where those with a root avulsion within 9 mm of insertion and parrot beak tears with the integrity of the root attachment maintained. Outcomes were compared between groups. ACL graft rupture occurred in 10% in the WST group and in 11% in the NT group (P= .78). For participants with an intact graft (n= 440), the mean International Knee Documentation Committee scores were 82, in the WST group, and 87, in the NT group (P= .03), with a small effect size of .32. The WST group had a worse mean pain severity score (P= .04) and higher frequency of pain (P= .03) than the NT group, but the effect size was small (P < 0.3). There was no difference in the overall knee function (P= .209) or International Knee Documentation Committee activity level (P= .882). There was no adverse clinical outcome to leaving a stable LMPR tear in situ at the time of ACL reconstruction. LMPR tears left in situ were of minimal clinically significant long-term detriment, with outcomes similar to having an intact meniscus. There is an innate desire to fix the broken, but posterior meniscal root avulsions and stable parrot beak tears within 9 mm of insertion may not require intervention. At 15 years postinjury, most patients with a stable tear left in situ continue to enjoy an active lifestyle with a pain-free knee. Level III, retrospective comparative study.

Vancomycin Presoaking of the Graft Appears to Prevent Infection After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis.

Background: Vancomycin presoaking of the graft has been shown to decrease infection rates in some case series of anterior cruciate ligament (ACL) reconstruction. Purpose: We sought to substantiate the efficacy of vancomycin presoaked grafts for the prevention of infection after ACL reconstruction. Methods: We performed a systematic review of Medline and OVID to assess the incidence of postoperative infection in studies comparing patients undergoing ACL reconstruction with the use of vancomycin presoaked ACL grafts and a control group of patients undergoing ACL reconstruction without the use of presoaked grafts. The efficacy of vancomycin presoaking was calculated using the Agresti-Coull confidence interval. Relative risk (RR) was calculated for every study and the total sample. Results: The 11 studies that met inclusion criteria comprised 24,298 patients. In patients with vancomycin presoaking of the graft, 1 infection was reported in 8764 cases (0.01% rate). In the studies with control groups that did not have vancomycin presoaked grafts, there were 125 infections in 15,534 ACL reconstructions (0.8% rate). The efficacy of vancomycin presoaking in preventing infection after ACL reconstruction was 99.9% (0.999%-1.000% CI). The overall RR obtained was 0.07 (0.03-0.16 CI). All included studies were retrospective cohort studies (level III). Conclusions: Vancomycin presoaking of the graft has been shown to decrease infection rates after ACL reconstruction in studies of low evidence level. This suggests the need for prospective randomized controlled trials addressing this issue so that recommendations on the routine use of vancomycin presoaking of ACL grafts can be made with confidence.

Comparison of the Sterilization Efficiency of 3 Disinfectants for Dropped Anterior Cruciate Ligament Grafts: A Systematic Review and Meta-analysis.

Background:The inadvertent contamination of anterior cruciate ligament (ACL) grafts can occur if they are accidentally dropped on the floor during ACL reconstruction. There has been no meta-analysis conducted to compare the sterilization efficiency of the different disinfectants used on dropped ACL grafts.Purpose:To compare the sterilization efficiency of 3 disinfectants to decontaminate ACL grafts as necessary.Study Design:Systematic review.Methods:A systematic literature review was performed using the MEDLINE, Embase, and Cochrane Library databases. All studies reporting the management of dropped or contaminated grafts were considered for this meta-analysis.Results:A total of 7 studies meeting inclusion criteria were identified from a literature search. The pooled results of this meta-analysis indicated that the rate of positive cultures of ACL grafts dropped on the operating room floor was 44.9% and that the commonly contaminated microbes were staphylococci and bacilli. The meta-analysis results indicated that the sterilization efficiency of a 4% chlorhexidine solution was superior to an antibiotic solution (odds ratio [OR], 0.17 [95% CI, 0.05-0.57]; P = .004) and a 10% povidone-iodine solution (OR, 0.04 [95% CI, 0.01-0.20]; P < .0001). Further, the antibiotic solution was superior to the 10% povidone-iodine solution (OR, 0.20 [95% CI, 0.07-0.55]; P = .002).Conclusion:The results of our meta-analysis demonstrated that staphylococci and bacilli were the most common contaminants on dropped ACL grafts and that decontamination using a 4% chlorhexidine solution more reliably disinfected ACL grafts. This information can help to guide surgeons as regards appropriate remedial measures.

A simple technique for imaging of anterior cruciate ligament graft after anterior cruciate ligament reconstruction surgery in the immediate post-operative period

A simple technique for imaging of anterior cruciate ligament graft after anterior cruciate ligament reconstruction surgery in the immediate post-operative period

Combined Anterior Cruciate Ligament Repair and Anterolateral Ligament Reconstruction With a Single-Strand Gracilis Graft

There has been renewed interest in anterior cruciate ligament (ACL) repair procedures in the past decade. Even though ACL reconstruction is still considered the gold standard, ACL repair is an alternative in selected patients. However, the risk of failure owing to isolated ACL repair remains a concern. Intra-articular augmentation has been proposed to protect the repair during the healing period. In the same way, the protective effect of anterolateral ligament reconstruction on the ACL graft is increasingly recognized. We describe a combined ACL repair and anterolateral ligament reconstruction technique with a single-strand gracilis for the intra-articular portion and as an anterolateral graft to protect the ACL repair during the healing phase.

Adolescents show a lower healing rate of anterolateral ligament injury and a higher rotational laxity than adults after anterior cruciate ligament reconstruction

BackgroundThis study aimed to compare anterolateral ligament (ALL) injuries in anterior cruciate ligament (ACL) ruptures, as well as ALL healing and clinical outcomes following ACL reconstruction between adolescents and adults. MethodsThis retrospective study involved 98 patients who underwent ACL reconstruction. They were divided into two groups according to age: group A (adolescents, 16–20 years of age; n = 49) and group B (adults, 21–45 years of age; n = 49). Subjective scores including ACL-Return to Sport after Injury (ACL-RSI) scale and objective tests were assessed. Follow up magnetic resonance imaging (MRI) and second-look arthroscopy was conducted at 1-year and 2-year follow up, respectively. ResultsGood healing rate of ALL was higher in adults than in adolescents (P = 0.048). Graft tension and synovial coverage showed no significant differences between two groups. Group A showed a higher rate of high-grade pivot shift and a lower ACL-RSI at last follow up than group B (P = 0.126 and P = 0.016). Poor healing of ALL was significantly associated with lower ACL-RSI and failure to return to sports (P < 0.001 and P = 0.001). Re-rupture of the ACL graft was found in four (8.2%) and one (2.0%) of group A and B, respectively. ConclusionsAdolescents showed a lower healing rate of ALL, a lower ACL-RSI, a higher rate of high-grade pivot shift than adults. Moreover, poor healing of ALL was significantly associated with a lower ACL-RSI and failure to return to sports. We suggest that adolescents need to pay more attention to the presence of ALL injury.

Maturation of Anterior Cruciate Ligament Graft—Possibilities of Surgical Enhancement: What Do We Know So Far?

The purpose of this study is to review the surgical methods of enhancing anterior cruciate ligament (ACL) graft maturation. Several methods of ACL maturation enhancement were identified through research of the literature available in the PubMed database. ACL remnant preservation was the most extensively investigated technique. ACL reconstruction with a pedunculated hamstring graft provides superior revascularization of the graft along with higher mechanical strength. The usage of a graft enveloped with a periosteum was proposed to enhance the tendon-bone unit formation, and consequently, to prevent the bone tunnel widening. The muscle tissue on the graft is a potential source of stem cells. However, an excessive amount may weaken whole graft strength despite its enhanced remodeling. Similarly, amniotic tissue may augment the ACL reconstruction with stem cells and growth factors. Despite the existence of several surgical techniques that utilize amnion, the outcomes of these augmentation methods are lacking. Lastly, the intra-articular transplantation of the synovium on the surface of an ACL was proposed to augment the graft with synovial tissue and blood vessels. In conclusion, diverse approaches are being developed in order to enhance the maturation of an ACL reconstruction graft. Although these approaches have their foundation in on well-established scientific research, their outcomes are still equivocal. Clinical trials of high quality are needed to evaluate their utility in clinical practice.

Isokinetic Strength After ACL Reconstruction: Influence of Concomitant Anterolateral Ligament Reconstruction.

To reduce the rate of anterior cruciate ligament (ACL) graft rupture, recent surgeries have involved anterolateral ligament reconstruction (ALLR). This reconstruction procedure harvests more knee flexor muscle tendons than isolated ACL reconstruction (ACLR), but its influence on knee muscle strength recovery remains unknown. This study aimed to assess the influence of ALLR with a gracilis graft on the strength of the knee extensor and flexor muscles at 6 months postoperatively. The additional amount of knee flexor harvest for ALLR would result in impairment in knee flexor muscle strength at 6 months postoperatively. Retrospective cohort study. Level 2. A total of 186 patients were assigned to 2 groups according to the type of surgery: ACL + ALLR (graft: semitendinosus + gracilis, n = 119) or isolated ACLR (graft: semitendinosus, n = 67). The strength of the knee extensor and flexor muscles was assessed using an isokinetic dynamometer at 90, 180, and 240 deg/s for concentric and 30 deg/s for eccentric contractions and compared between groups using analysis of variance statistical parametric mapping. Regardless of the surgery and the muscle, the injured leg produced significantly less strength than the uninjured leg throughout knee flexion and extension from 30° to 90° for each angular velocity (30, 90, 180, and 240 deg/s). However, the knee muscle strength was similar between the ACL + ALLR and ACLR groups. The addition of ALLR using the gracilis tendon during ACLR does not alter the muscle recovery observed at 6 months postoperatively. Although more knee flexor muscle tendons were harvested in ACL + ALLR, the postoperative strength recovery was similar to that of isolated ACLR.

Creating a Femoral Tunnel Aperture at the Anteromedial Footprint Versus the Central Footprint in ACL Reconstruction: Comparison of Contact Stress Patterns.

Background:It remains unclear whether an anteromedial (AM) footprint or a central footprint anterior cruciate ligament (ACL) graft exhibits less contact stress with the femoral tunnel aperture. This contact stress can generate graft attrition forces, which can lead to potential graft failure.Purpose/Hypothesis:The purpose of this study was to compare the difference in contact stress patterns of the graft around a femoral tunnel that is created at the anatomic AM footprint versus the central footprint. It was hypothesized that the difference in femoral tunnel positions would influence the contact stress at the interface between the reconstructed graft and the femoral tunnel orifice.Study Design:Controlled laboratory study.Methods:A total of 24 patients who underwent anatomic single-bundle ACL reconstruction were included in this study. In 12 patients, the femoral tunnels were created at the center of the native AM footprint (AM group), and in the remaining 12 patients the center of the femoral tunnel was placed in the anatomic central footprint (central group). Three-dimensional knee models were created and manipulated using several modeling programs, and the graft-tunnel angle (GTA) was determined using a special software program. The peak contact stresses generated on the virtual ACL graft around the femoral tunnel orifice were calculated using a finite element method.Results:The mean GTA was significantly more obtuse in the AM group than in the central group (124.2° ± 5.9° vs 112.6° ± 7.9°; P = .001). In general, both groups showed high stress distribution on the anterior surface of the graft, which came in contact with the anterior aspect of the femoral tunnel aperture. The degree of stress in the central group (5.3 ± 2.6 MPa) was significantly higher than that in the AM group (1.2 ± 1.1 MPa) (P < .001).Conclusion:Compared with the AM footprint ACL graft, the central footprint ACL graft developed significantly higher contact stress in the extended position, especially around the anterior aspect of the femoral tunnel orifice.Clinical Relevance:The contact stress of the ACL graft at the extended position of the knee may be minimized by creating the femoral tunnel at the AM-oriented footprint.