Anterior Cruciate Ligament Reconstruction Graft Research Articles

Transepicondylar Distance Can Predict Graft and Tunnel Length for Different Pediatric Anterior Cruciate Ligament Reconstruction Techniques: A Magnetic Resonance Imaging Study

To find a correlation and mathematical formulas between a linear 2-dimensional (2D) magnetic resonance imaging (MRI) measurement around the knee and the length of the grafts and tunnels required for both all-inside-all-epiphyseal and Kocher-Micheli pediatric anterior cruciate ligament (ACL) reconstruction techniques. At time 0 and 30 days after, 2 observers measured: (1) on standard 2D knee MRI, 7 linear distances, representing morphologic measurements, such as transepicondylar distance (TD), and (2) on 3-dimensional (3D) MRI, 5 curved distances, corresponding to Kocher-Micheli and all-epiphyseal ACL reconstruction techniques. Intra- and interobserver reliability was tested for all measurements. The correlation between 2D and 3D measurements was tested. The 2D measurement with highest repeatability and reproducibility and with strongest correlation with 3D measurements was used to extract formulas to calculate the tunnel and graft length for the 2 techniques. Seventy-six MRIs were used. The intra- and interobserver reliability of 2D measurement was high, with TD showing the highest reproducibility and repeatability. 3D measurements also showed good intra and inter-observer reliability. A linear correlation was found between 2D and 3D measurements, with TD showing the strongest correlation. TD was used to extract formulas to calculate graft or tunnel length for Kocher-Micheli and all-epiphyseal ACL reconstruction. All formulas were proven to be accurate. A reference chart was also created to be used in the surgical setting. With specific formulas, TD can be used to calculate the length of the tunnels, intra-articular portion and graft length for an all-inside all-epiphyseal pediatric ACL reconstruction and the length of the iliotibial band required for the Kocher-Micheli technique. The surgeon can use these formulas in pediatric ACL reconstruction preoperative planning, graft harvesting and tunnel drilling.

Usage of Accessory Anteromedial Portal for Anatomical Placement of Femoral Tunnel in Transportal Anterior Cruciate Ligament Reconstruction: A Prospective Study.

Background and objectiveThe anterior cruciate ligament (ACL) has an essential role in preserving the function and stability of the knee joint. It acts primarily to prevent anterior tibial translation. Arthroscopic ACL reconstruction using quadrupled hamstring graft is the widely practiced modality for treating ACL injuries nowadays. The objective of this study was to assess the functional outcomes of ACL reconstruction using the transportal approach for a femoral tunnel through an accessory anteromedial portal (AAM).Materials and methodsThis prospective study included 35 patients who met the inclusion criteria. All patients underwent arthroscopic reconstruction of ACL using quadrupled hamstring tendon graft via transportal technique for femoral canal reaming through AAM. Patients were assessed for the functional outcome for a year using the Tegner-Lysholm knee scoring system.ResultsThe analysis of the studied cases revealed that the mean age of the patients was around 27 years. Males were affected more than females. The left side (77.14%) was affected more than the right side (22.86%); 54.28% of patients had a history of road traffic accidents (RTAs). Preoperatively, 19 (54.28%) patients had poor and 16 (45.72%) patients had fair Tegner-Lysholm scores. After one year of follow-up, 29 (82.85%) of the patients had an excellent score as per the Tegner-Lysholm scoring system. Three patients had knee pain and thigh muscle wasting (2-3 cm), and two of them also had a sense of giving away during follow-up.ConclusionAnatomical reattachment of tendon graft for ACL reconstruction at femoral and tibial footprints is indispensable for good functional outcome and knee kinematics, and the usage of the AAM provides good visualization of femoral footprint and ease to surgeons during ACL reconstruction for making a near-accurate femoral tunnel and thereby achieving better outcomes.

Association Between Graft Choice and 6-Year Outcomes of Revision Anterior Cruciate Ligament Reconstruction in the MARS Cohort

Background: Although graft choice may be limited in the revision setting based on previously used grafts, most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome. Hypothesis: In the ACL revision setting, there would be no difference between autograft and allograft in rerupture rate and patient-reported outcomes (PROs) at 6-year follow-up. Study Design: Cohort study; Level of evidence, 2. Methods: Patients who had revision surgery were identified and prospectively enrolled in this cohort study by 83 surgeons over 52 sites. Data collected included baseline characteristics, surgical technique and pathology, and a series of validated PRO measures. Patients were followed up at 6 years and asked to complete the identical set of PRO instruments. Incidence of additional surgery and reoperation because of graft failure were also recorded. Multivariable regression models were used to determine the predictors (risk factors) of PROs, graft rerupture, and reoperation at 6 years after revision surgery. Results: A total of 1234 patients including 716 (58%) men were enrolled. A total of 325 (26%) underwent revision using a bone-patellar tendon-bone (BTB) autograft; 251 (20%), soft tissue autograft; 289 (23%), BTB allograft; 302 (25%), soft tissue allograft; and 67 (5%), other graft. Questionnaires and telephone follow-up for subsequent surgery information were obtained for 809 (66%) patients, while telephone follow-up was only obtained for an additional 128 patients for the total follow-up on 949 (77%) patients. Graft choice was a significant predictor of 6-year Marx Activity Rating Scale scores (P = .024). Specifically, patients who received a BTB autograft for revision reconstruction had higher activity levels than did patients who received a BTB allograft (odds ratio [OR], 1.92; 95% CI, 1.25-2.94). Graft rerupture was reported in 5.8% (55/949) of patients by their 6-year follow-up: 3.5% (16/455) of patients with autografts and 8.4% (37/441) of patients with allografts. Use of a BTB autograft for revision resulted in patients being 4.2 times less likely to sustain a subsequent graft rupture than if a BTB allograft were utilized (P = .011; 95% CI, 1.56-11.27). No significant differences were found in graft rerupture rates between BTB autograft and soft tissue autografts (P = .87) or between BTB autografts and soft tissue allografts (P = .36). Use of an autograft was found to be a significant predictor of having fewer reoperations within 6 years compared with using an allograft (P = .010; OR, 0.56; 95% CI, 0.36-0.87). Conclusion: BTB and soft tissue autografts had a decreased risk in graft rerupture compared with BTB allografts. BTB autografts were associated with higher activity level than were BTB allografts at 6 years after revision reconstruction. Surgeons and patients should consider this information when choosing a graft for revision ACL reconstruction.

Increased Posterior Tibial Slope is Associated with Revision Anterior Cruciate Ligament Reconstruction Graft Re-Rupture

Objectives:Anterior cruciate ligament reconstruction (ACLR) graft failure continues to be a problem with failure rates reported up to 11%. Following revision ACLR, 3.3 – 4.3% of these patients suffer re-tear of the revision ACL graft. The purpose of this study was to evaluate the influence of posterior tibial slope (PTS) on ACL graft re-tear after revision ACLR. It was hypothesized that increased posterior tibial slope (PTS) is associated with an increased risk of ACL graft re-tear following revision ACLR.Methods:Retrospective chart review identified patients who underwent revision ACLR between 2005 and 2016 at a single institution. Patients who suffered an ACL re-tear following revision surgery were matched by age, sex, and graft type to controls who had intact revision ACLR grafts at a minimum of 2 years follow-up. Medial posterior tibial slope (MPTS) and lateral posterior tibial slope (LPTS) were measured on lateral radiographs and sagittal magnetic resonance imaging (MRI). Tibial slope was then compared between groups using independent sample t-tests.Results:Twenty-nine patients with a graft failure after revision ACLR were included and compared to 29 matched controls with a mean follow-up of 5.8 years (range: 2 to 11.3 years). Each group included 16 males and 13 females. Average age was 26 +/- 8.3 years at time of revision ACLR. Both x-ray and MRI demonstrated increased LPTS in the failure group versus controls (12.7 ± 3.2 degrees vs. 10.6 ± 3.6 degrees, p = 0.02 and 8.1 ± 3.4 degrees vs. 5.0 ± 3.5 degrees, p = 0.001, respectively). There was no significant difference in MPTS between the failure and control groups on x-ray (11.9 ± 2.9 degrees vs. 11.1 ± 3.6 degrees, p = 0.3772) nor MRI (4.3 ± 3.5 degrees vs. 3.3 ± 3.0 degrees, p = 0.2486).Conclusions:Matching for age, sex, and graft type, increased LPTS measured on both x-ray and MRI is associated with increased risk of a subsequent ACL injury following revision ACLR. Identification of at-risk patients may guide pre-operative discussions regarding revision ACL graft failure risk.

Peroneus Longus Tendon Autograft: A Promising Graft for ACL Reconstruction

Background: With the increasing use of hamstring tendon as an autograft in anterior cruciate ligament (ACL) reconstruction, some shortcomings have been found on the donor site. Therefore, an alternative autograft option with adequate strength and less donor site morbidity will be very valuable. Peroneus longus tendon has been found to be a promising option. Indication: Primary ACL reconstruction. Technique Description: Peroneus longus tendon graft is harvested with a longitudinal skin incision at 2 to 3 cm (2 finger-breadths) above and 1 cm (1 finger-breadth) behind the lateral malleolus, followed by superficial fascia incision in line with skin incision. The peroneus longus and peroneus brevis tendons were then identified. The tendon division location was marked at 2 to 3 cm above the level of the lateral malleolus. After that, an end-to-side suture was performed between the distal part of the peroneus longus tendon and peroneus brevis tendon. The peroneus longus tendon was stripped proximally with a tendon stripper to at least 5 cm from the fibular head to prevent peroneal nerve injury. Graft preparation was performed with a standard procedure to obtain the suitable graft size. In routine arthroscopic ACL reconstruction, peroneus longus tendon graft fixation can be performed with a cortical suspension device, bioabsorbable screws, or a combined technique. Results: Recent studies showed that peroneus longus autograft had a comparable outcome with hamstring tendon autograft in primary ACL reconstruction at a 1-year follow-up. The use of peroneus longus tendon autograft resulted in larger graft diameter and less thigh hypotrophy. The mean (±SD) for the AOFAS-Hindfoot Score in the peroneus longus group was 97.3 ± 4.2, while the mean FADI score was 98 ± 3.4, both of which were considered excellent results. Discussion/Conclusion: The use of peroneus longus autograft in primary ACL reconstruction is a safe procedure with an excellent outcome. Peroneus longus tendon autograft can be recommended as an alternative graft in single-bundle ACL reconstruction. Further study of the functional outcome and knee stability evaluation is recommended.

Comparing Knee Laxity After Anatomic Anterior Cruciate Ligament Reconstruction Using Quadriceps Tendon Versus Semitendinosus Tendon Graft.

Background:The choice of graft in anterior cruciate ligament (ACL) reconstruction is still under discussion. The hamstrings are currently the most used grafts for primary ACL reconstruction in Europe. However, increased interest has arisen in the quadriceps tendon (QT) as an alternative autologous graft option for primary ACL reconstruction.Purpose:To evaluate knee stability and the subjective outcome after ACL reconstruction using either autologous QT graft in implant-free femoral press-fit fixation technique or semitendinosus tendon (ST) graft.Study Design:Cohort study; Level of evidence, 2.Methods:We evaluated 50 patients who underwent ACL reconstruction, including 25 patients who received autologous ipsilateral QT graft (QT group) and 25 patients who received the ipsilateral ST graft (ST group). The follow-up for this prospective comparative study was at least 2 years after surgery, comprising KT-1000 arthrometer testing, pivot-shift test, Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm score, and rerupture rate.Results:The mean patient age was 31.72 years (9 women, 16 men) in the QT group and 32.08 years (13 women, 12 men) in the ST group. The mean ± standard deviation postoperative side-to-side difference assessed using KT-1000 arthrometer was 1.56 ± 1.56 mm for the QT group and 1.64 ± 1.41 mm for the ST group, with no significant difference. No significant difference was found on any of the KOOS subscale scores (P = .694) or the Lysholm score (P = .682). No rerupture or positive pivot-shift test occurred during follow-up. No difference was found in donor-site morbidity between the study groups.Conclusion:Clinical outcomes were not significantly different between QT and ST grafts in the current study. Thus, the QT may serve as a good alternative graft for primary ACL reconstruction.

Quadrupled Hamstring Graft Diameter Adequacy in Anterior Cruciate Ligament Reconstruction Using Patient Anthropometry: A Prospective Cohort Study in Indian Males

Background and aimThe diameter of the graft used for the reconstruction of the anterior cruciate ligament (ACL) is an important determinant for the overall strength and future outcome of the operative procedure. Preoperative prediction of quadrupled hamstrings autograft (QHAG) diameter can prove to be of help in forecasting the need for augmentation or alternative grafts like quadriceps, bone-patellar tendon-bone autograft, and synthetic grafts. The relationship between the preoperatively assessed anthropometric parameters and the obtained quadrupled hamstrings graft diameter has not been extensively studied, especially in the population of Indian origin. This study aimed at investigating whether a correlation exists between the measured anthropometric parameters like age, weight, height, thigh circumference, and body mass index (BMI) and the intraoperatively obtained diameter of hamstring graft for ACL reconstruction in the study population of Indian male subjects.Study designA prospective cohort study conducted in a tertiary care center and teaching hospital in a district in central Uttar Pradesh, India.MethodsThe preoperative anthropometric data (age, height, weight, BMI, and thigh circumference of the injured side) of 73 Indian male subjects undergoing primary ACL reconstructive surgeries between May 2018 and August 2020 were prospectively collected, and their respective intraoperative QHAG diameters measured and recorded. Pearson’s correlation test was employed to determine the correlation between the preoperative demographic and anthropometric data and the obtained corresponding graft diameters. Simple linear regression was performed to obtain the graphical plots and determine the relationship between the dependent and independent variables. Of these, the variables showing significant association were subjected to stepwise linear regression to identify and exclude the confounder(s) and obtain the predicted equation.ResultsThe study comprised 73 male participants. The study participants' mean age was found to be 33.7 years, mean height was 173.1 cm, mean weight was 71.2 kg, mean BMI was 23.7 kg/m2, mean thigh circumference was 50.4 cm, and the obtained mean graft diameter was 8.0 mm. A strongly positive correlation was observed between height and the graft diameter (r=0.940, P=0.000) and thigh circumference and the graft diameter (r=0.769, P=0.000). In contrast, weight showed a moderately positive correlation with the graft diameter (r=0.514, P=0.000). A very weakly positive correlation was observed between the BMI of the subjects and the obtained graft diameters (r=0.236, P=0.045). However, no correlation was observed between the age and the final graft diameters (r=0.140, P=0.238). Subsequent linear regression analysis indicates that only height (R2=0.883, P=0.000; strong) and the thigh circumference (R2=0.591, P=0.000; moderate) share a significant predictive value for the obtained QHAG. Both height and thigh circumference together were good predictors for graft diameter as determined by multiple regression (F (2,70)=272.372, P<0.001), with an R2 of 0.886.ConclusionCertain anthropometric parameters depict a positive correlation with the QHAG diameter and can assist in preoperative planning, predicting the possible harvested graft diameter and the need for alternative grafts or augmentation during ACL reconstructive surgeries.

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.

Clinical Reliability of Adjustable Femoral Cortical Suspensory Fixation in Anterior Cruciate Ligament Reconstruction and Correlation of Clinical Outcomes With Demographic and Perioperative Factors.

Background and objectiveThe primary goal of anterior cruciate ligament reconstruction (ACLR) is to protect the initial graft fixation against heavy loads encountered during the rehabilitation phase. The purpose of this study was to evaluate the functional outcomes (Lysholm score) and laxity [anterior tibial translation (ATT), anterior drawer test, Lachman test, and pivot shift test] of ACLR with adjustable-loop femoral cortical suspensory fixation (CSF) and tibial interferences crew fixation.MethodsThis study included 100 patients who underwent primary ACL reconstruction using quadruple hamstring grafts secured with TightRope® (Arthrex Inc, Naples, FL) femoral fixation and an interference screw on the tibial end. Six patients were excluded from the final analysis (four lost to follow-up, one suffered re-injury, and one had septic arthritis). The remaining 94 patients were evaluated for laxity and functional outcomes preoperatively, as well as at one, six, and 12 months postoperatively. Regression analysis was performed to determine the association between outcomes and 11 independent variables. This was designed as a prospective cohort study (level of evidence: II).ResultsThe mean age of the participants was 28.46 ± 7.01 years. The median preoperative Lysholm knee score of 49 (mean ± SD: 48.2 ± 5.42) improved to 93 (92.7 ± 2.1) at six months and 98 (97.6 ± 2.1) at the one-year follow-up. The improvement was found to be statistically significant (p<0.01). The median ATT was 10 mm preoperatively, which decreased to 2 mm at one month, remained the same at six months, and rose to 3 mm at the one-year follow-up. ATT was found significantly reduced at one month postoperatively (p<.001) and did not show any significant further changes at subsequent follow-ups (p>0.05). Multiple linear regression revealed that one-year postoperative ATT (Rolimeter, Aircast Europa, Stephanskirchen, Germany) was independent of all demographic and perioperative variables tested.ConclusionQuadrupled hamstring graft ACLR with adjustable-loop fixation showed excellent subjective and objective outcomes with no residual laxity or failure of graft over mid-term follow-up. Postoperative laxity was not correlated with graft and tunnel dimensions.

Peroneus longus tendon graft for anterior cruciate ligament reconstruction: A case report and review of literature.

IntroductionThe anterior cruciate ligament (ACL) is one of the most frequently injured structures of the knee joint. Anterior cruciate ligament reconstruction (ACLR) provides surgical restoration of the injured ACL using the placement of graft material. The choice of graft is principal in providing optimal knee stability after surgery. Peroneus longus tendon (PLT) is an autograft modality that offers unique benefits for ACL reconstruction cases.Presentation of caseWe present a case of ACL reconstruction surgery using PLT graft in a patient with a confirmed ACL rupture. Assessment of post-surgical pain, knee stability, and ankle function were performed to determine functional outcome and donor site morbidity. The follow-up results revealed favorable recovery and improvement in all objective parameters.DiscussionPost-operative biomechanical outcomes were evaluated using the International Knee Documentation Committee (IKDC) and the American Orthopedic Foot and Ankle Score (AOFAS) score. The use of PLT in ACL reconstruction established an excellent potential for its satisfactory result and comparable to other graft modalities in widely used evidence-based findings.ConclusionPeroneus longus tendon may be considered the first-option graft in ACL reconstruction as it indicated the absence of significant post-operative morbidity.

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

The purpose of this study was to investigate the time-zero biomechanical properties (stiffness, displacement, and load at failure) of bone-patellar tendon-bone (BTB) grafts used for anterior cruciate ligament (ACL) reconstruction with and without suture tape augmentation as a means to determine the potential clinical benefit of this technique. Eight juvenile porcine knees underwent ACL reconstruction with a human cadaveric BTB graft (control). These were compared to 8 juvenile porcine knees that underwent ACL reconstruction with a BTB graft augmented with suture tape. All knees underwent biomechanical testing utilizing a dynamic tensile testing machine. Cyclic loading between 50-250N was performed for 500 cycles at 1 Hz to simulate invivo ACL loads during the early rehabilitation phase. The grafts were displaced during load-at-failure tensile testing at 20 mm/min. Differences in graft displacement, stiffness, and load at failure for the control and suture tape augmented groups were compared with the Student t-test with a significance level of P < .05. There was no difference in graft displacement between the 2 groups. A 104% higher postcyclic stiffness was noted in the augmented group compared to the controls (augmentation: 261 ± 76 N/mm versus control 128 ± 28 N/mm, P= .002). The mean ultimate load at failure was 57% higher in the augmented group compared to controls (744 ± 219 N vs postcyclic 473 ± 169 N, respectively [P= .015]). There was no difference in mode of failure between the control knees and those augmented with suture tape, with approximately half failing from pull off of the tendon from the bone plug and half with pull out of the bone plug from the tunnel. Independent suture tape augmentation of a BTB ACL reconstruction grafts was associated with a 104% increase in graft stiffness and a 57% increase in load at failure compared to nonaugmented BTB grafts. Invivo suture tape augmentation of a BTB ACL reconstruction increases graft construct strength and stiffness, which may reduce graft failure in the clinical setting.

306 Anterior Cruciate Ligament Graft Rupture: Analysis of Anteromedial Versus Trans-Tibial Portal Technique for Femoral Tunnel Placement in 473 Patients

Abstract Introduction Correct femoral tunnel position in anterior cruciate ligament reconstruction (ACLR) is critical in obtaining good clinical outcomes. We aimed to delineate whether any difference exists between the anteromedial and trans-tibial portal femoral tunnel placement techniques on the primary outcome of ACLR, graft rupture. Method Adult patients (&amp;gt;18 years old) who underwent primary ACLR between January 2011 - January 2018 were identified and divided based on portal technique (anteromedial v trans-tibail). The primary outcome measure was graft rupture. Univariate analysis was used to delineate association between independent variables and outcome. Binary logistic regression was utilised to delineate odds ratios of significant variables. Results 473 patients were analysed. Median age at surgery was 27 years old (range 18-70). 152/473 (32.1%) patients were anteromedial group compared to 321/473 (67.9%) trans-tibial. 25/473 (5.3%) patients sustained graft rupture. Median time to graft rupture was 12 months (IQR 9). A higher odd for graft rupture was associated with the anteromedial group, which trended towards significance (OR 2.03; 95% CI 0.90 - 4.56, p = 0.081). Conclusions There is no statistically significant difference in ACLR graft rupture rates when comparing anteromedial and trans-tibial portal technique for femoral tunnel placement. There was a trend towards higher rupture rates in the anteromedial portal group.

Same knee, different goals: patients and surgeons have different priorities related to ACL reconstruction.

The priorities of patients should be shared by those treating them. Patients and surgeons are likely to have different priorities surrounding anterior cruciate ligament reconstruction (ACLR), with implications for shared decision-making and patient education. The optimal surgical approach for ACLR is constantly evolving, and the magnitude of treatment effect necessary for evidence to change surgical practice is unknown. The aim of this study was to determine (1) the priorities of surgeons and patients when making decisions regarding ACLR and (2) the magnitude of reduction in ACLR graft failure risk that orthopaedic surgeons require before changing practice. This study followed a cross-sectional survey design. Three distinct electronic surveys were administered to pre-operative ACLR patients, post-operative ACLR patients, and orthopaedic surgeons. Patients and surgeons were asked about the importance of various outcomes and considerations pertaining to ACLR. Surgeons were asked scenario-based questions regarding changing practice for ACLR based on new research. Surgeons were more likely to prioritize outcomes related to the surgical knee itself, whereas patients were more likely to prioritize outcomes related to their daily lifestyle and activities. Knee instability and risk of re-injury were unanimous top priorities among all three groups. A mean relative risk reduction in ACLR graft failure of about 50% was required by orthopaedic surgeons to change practice regardless of the type of change, or patient risk profile. There are discrepancies between the priorities of surgeons and patients, and orthopaedic surgeons appear resistant to changing practice for ACLR. IV.

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.

Quadriceps Tendon-Bone Full-Thickness Autograft: Reproducible and Easy Harvesting Technique Using Simple Surgical Tools

Autogenous quadriceps tendon-bone graft is a great choice for knee reconstruction procedures, including primary and revision reconstructions of both anterior cruciate ligament (ACL) and posterior cruciate ligament. In primary ACL reconstruction, one of the most frequently performed procedures in orthopaedic surgery, it is gaining more and more popularity owing to improved or similar biomechanical, anatomic, and histological properties than bone-patellar tendon-bone graft. The clinical outcomes of quadriceps tendon-bone graft in ACL reconstruction are similar to bone-patellar tendon-bone graft, however, lowering the inconvenience associated with donor-site morbidity and making it possible to adjust graft length and diameter. This Technical Note describes a surgical technique for harvesting a full-thickness quadriceps tendon graft with a bone block using simple surgical tools.

Anatomic Double-Bundle ACL Reconstruction With Extra-articular Anterolateral Ligament Reconstruction and Internal Brace

Anterior cruciate ligament reconstruction (ACLR) with additional procedures could be necessary for patients with increased preoperative pivot shift. Double-bundle (DB) ACLR provides more footprint coverage and recreates the 2 functional anteromedial (AM) and posterolateral (PL) bundles, which are believed to give better joint function and stability than single-bundle (SB) ACLR. Internal brace augmentation with suture tape is proposed along with tendon graft in ACLR to protect the newly reconstructed ligament during rehabilitation. Additional reconstruction with anterolateral ligament (ALL) during ACLR has shown significant reduction in the level of persistent pivot shift. In Technical Note we present a modified surgical technique of combined anatomic DB ACLR and ALLR with hamstring autograft and internal brace, using button suspensory fixation device and aperture screws. The objective of this technique is to decrease residual anterior and rotational instability after ACLR and ALLR.

Radiological outcome of hamstring graft after anterior cruciate ligament reconstruction with augmentation of bone marrow aspirate concentrate

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Anterior cruciate ligament (ACL) tears are common injuries in the athletic population. Surgical intervention is required for ACL tears as it restores the knee function and it prevents early osteoarthritis. In the recent research there is increasing use of bone marrow aspirate concentrate in orthopaedics. Bone marrow aspirate concentrate (BMAC) provides mesenchymal stem cells progenitor cells and growth factors which has potential benefits in hamstring graft healing after ACL reconstruction.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This was a prospective randomized case control study carried out between May 2017 and June 2020. 30 patients between age group of 18 to 40 years with complete ACL tear were divided into two groups which consisted of the control group in which only ACL reconstruction was done and second group in which ACL reconstruction was done augmenting it with bone marrow aspirate concentrate. For the BMAC group, 3 ml of BMAC was obtained in the operation theatre itself and was injected into femoral tunnel and the tibia tunnel just before portal suturing. MRI was obtained post operatively at 6 months and at 1 year. Graft healing was seen as the time taken for the graft to reach ligamentization phase when the graft became hyper intense or was visualized similar to PCL or the remnant which was preserved during reconstruction in all cases.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Most of the patients in which augmentation (86%) was done healed at 6 month as compared to those who were not augmented (13%).&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; BMAC showed faster and better healing of the graft in ACL reconstruction.&lt;/p&gt;

Predictive Value of the Magnetic Resonance Imaging–Based Coronal Lateral Collateral Ligament Sign on Adolescent Anterior Cruciate Ligament Reconstruction Graft Failure

Background: The coronal lateral collateral ligament (LCL) sign is the presence of the full length of the LCL visualized on a single coronal magnetic resonance imaging (MRI) slice at the posterolateral corner of the knee. The coronal LCL sign has been shown to be associated with elevated measures of anterior tibial translation and internal rotation in the setting of anterior cruciate ligament (ACL) tear. Hypothesis: The coronal LCL sign (with greater anterior translation, internal rotation, and posterior slope of the tibia) will indicate a greater risk for graft failure after ACL reconstructive surgery. Study Design: Cohort study; Level of evidence, 3. Methods: Retrospective review was performed of adolescent patients with ACL reconstruction: a cohort without graft failure and a cohort with graft failure. MRI was utilized to measure tibial translation and femorotibial rotation and to identify the coronal LCL sign. The posterior tibial slope was measured on lateral radiographs. Patient-reported outcomes were collected. Results: We identified 114 patients with no graft failure and 39 patients with graft failure who met all criteria, with a mean follow-up time of 3.5 years (range, 2-9.4 years). Anterior tibial translation was associated with anterolateral complex injury (P < .001) but not graft failure (P = .06). Internal tibial rotation was associated with anterolateral complex injury (P < .001) and graft failure (P = .042). Posterior tibial slope was associated with graft failure (P = .044). The coronal LCL sign was associated with anterolateral complex injury (P < .001) and graft failure (P = .013), with an odds ratio of 4.3 for graft failure (95% CI, 1.6-11.6; P = .003). Subjective patient-reported outcomes and return to previous level of sport were not associated with failure. Comparison of MRI before and after ACL reconstruction in the graft failure cohort demonstrated a reduced value in internal rotation (P = .003) but no change in coronal LCL sign (P = .922). Conclusion: Our study demonstrates that tibial internal rotation and posterior slope are independent predictors of ACL graft failure in adolescents. Although the value of internal rotation could be improved with ACL reconstruction, the presence of the coronal LCL sign persisted over time and was predictive of graft rupture (without the need to make measurements or memorize values of significant risk). Together, these factors indicate that greater initial knee deformity after initial ACL tear predicts greater risk for future graft failure.

Posterior Lateral Meniscal Root Tears Increase Strain on the Reconstructed Anterior Cruciate Ligament: A Cadaveric Study

PurposeTo quantify the amount of strain across an anterior cruciate ligament reconstruction (ACLR) before and after a lateral meniscus (LM) posterior root complex tear and determine whether a meniscal root repair effectively protects the ACLR against excessive strain.MethodsFresh-frozen cadaveric knees were tested with an 88-N anterior drawer force and an internal and external torque of 5-Nm applied at 0°, 15°, 30°, 60°, and 90° of flexion. A simulated pivot shift was also applied at 0, 15, and 30° of flexion. Rotation and translation of the tibia, and strain across the ACL graft were recorded. Testing was repeated for the following four conditions: ACL-intact, ACLR with intact LM, ACLR with LM posterior root complex tear, and ACLR with root repair.ResultsThe kinematic data from 12 fresh frozen cadaveric knees underwent analysis. Only 11 specimens had usable strain data. Sectioning the meniscofemoral ligaments and the LM posterior root increased rotational and translational laxity at 30° of knee flexion. ACLR graft strain significantly increased when an anterior load and internal torque were applied. Repair of the LM posterior root reduced strain when the knee was internally rotated but was unable to normalize strain when an anterior force was applied.ConclusionsThis cadaveric biomechanical study suggests injury to the LM posterior root complex increases rotational and anterior laxity of the knee and places increased strain across reconstructed ACL grafts. Subsequent root repair did not result in a statistically significant reduction in strain.Clinical RelevanceThis study provides quantitative data on the implications of a LM posterior root injury in the setting of an ACL reconstruction to help guide clinical decision-making.