Anterior Cruciate Ligament Reconstruction Procedures Research Articles

Anterior Cruciate Ligament Reconstruction: Common Intraoperative Mistakes and Techniques for Error Recovery.

Anterior cruciate ligament (ACL) reconstruction is a commonly performed procedure among general orthopedists, and is a logged procedure required for graduation from accredited orthopaedic residency programs. ACL reconstruction surgery has a number of critical steps, and intraoperative errors can significantly impact the success rate and morbidity of this operation. Technical errors are frequently cited as some of the most common reasons for ACL reconstruction failure. This narrative review provides low-volume surgeons and trainees with an overview of the common errors that can be made during the critical steps of an ACL reconstruction procedure. We suggest technical points for avoiding commonly-encountered errors and provide a description of evidence-supported error recovery techniques to address these errors if they occur intraoperatively. These key steps include femoral tunnel creation, tibial tunnel creation, graft harvest and preparation, and graft fixation within the tunnels. We discuss a number of primary and backup fixation strategies as well as all commonly used autografts (bone-patellar tendon-bone, hamstring, and quadriceps tendon). Additionally, we provide a brief overview on address intra-operative graft contamination citing currently available evidence.

Evaluation of Clinical Outcomes in Sport Participants Undergoing Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament (ACL) injury is one of the most common musculoskeletal injuries. Evaluating the clinical outcomes of the ACL reconstruction (ACLR) procedure is essential to provide information regarding the benefits of this procedure. This study aimed to assess the clinical outcomes of patients who underwent ACLR at Prof. Dr. R. D. Kandou Hospital Manado. This was a retrospective study. Secondary data were collected from all athlete patients who underwent ACLR. The ACLR procedure was performed by a single operator following the standard arthroscopic procedure. All grafts used Hamstring grafts (gracilis and semitendinosus). Suspense fixation was done using a button, while tibial fixation was done with interference fixation (bioabsorbable screw). Patients were evaluated over a short period, specifically at three months, six months, and nine months. Outcome parameters were assessed using the Visual Analog Scale (VAS), Range of Motion (ROM), Lachman test, Anterior Drawer test, and Knee Functional Score (KFS). Any complications that arose were documented. The results showed that among 21 patients at Prof. Dr. R. D. Kandou Hospital Manado, it was found that ACL injuries were more common in physically active men, especially in the age group of 26-30 years. Most patients who underwent ACLR had serious injuries that required immediate treatment. Hamstring graft was the most common choice (85.7%). Knee stiffness was the most common complication and required special attention during the rehabilitation program. Based on KFS, most patients successfully achieved good knee function recovery. There was a decrease in the VAS score reflecting the effectiveness of the procedure in reducing postoperative pain. There was an increase in the KSS reflecting the success of ACLR in restoring knee stability and function to almost normal levels. In conclusion, anterior cruciate ligament reconstruction in sport participants showed significant improvements in knee mobility and pain reduction, with low complications. Keywords: anterior cruciate ligament injury; anterior cruciate ligament reconstruction; graft fixation

The single antegrade sling graft: a novel hamstring autograft technique for combined anterior cruciate ligament and anterolateral ligament reconstruction

IntroductionAs a result of increased incidence of anterior cruciate ligament (ACL) injury in young athletes, there is a rise in the indications surgical ACL reconstruction procedures. The value of anterolateral ligament (ALL) reconstruction emerges as a proposed solution to prevent graft failures and improve stability in this high demanding category of patients. The purpose of this study is to present our experience with a novel hamstring auto-grafting technique, the single antegrade sling graft (SASG), for combined reconstruction of both ACL and ALL using autologous gracilis (GR) and semitendinosus (ST) grafts utilizing a single femoral tunnel and double tibial tunnels.Materials and methodsFrom January 2020 to December 2021, 21 soccer players were operated utilizing the SASG technique, a modification of the technique of SANTI study group. Inclusion criteria were participating in pivoting sport, high-grade pivot shift examination (Grade 2–3), and evidence of a lateral femoral notch sign or Segond's fracture on preoperative imaging. Patients were assessed for 2 years postoperatively by Lachman’s test for anteroposterior laxity and pivot shift test for rotational laxity. The postoperative outcomes were assessed by Tegner-Lysholm and International knee documentation committee scores. Also, the postoperative complications such as stiffness, infection and graft failure were reported.Results21 male soccer players with a mean age 26.4 years were included in this study. After 2 years follow up there was a statistically significant improvement in the both post-operative functional scores, P value < 0.001. Fifteen patients (71.4%) could return to their preoperative sport activity level with no giving-way symptoms. Only one case of graft failure was reported in the follow up.ConclusionsThe single antegrade sling graft (SASG), for combined reconstruction of both ACL and ALL yielded good results in terms of stability and return to sports. The technique is reproducible, and results are comparable to the available published literature.

Preoperative Physical Therapy Is Protective From Construct Failure in Anterior Cruciate Ligament Reconstruction.

Risk factors for anterior cruciate ligament reconstruction (ACLR) construct failure have been studied extensively. However, while some studies account for variables such as activity level, construct types, preoperative physical therapy, or patient demographics individually, comprehensive studies that control for all these factors simultaneously are scarce. By utilizing a robust multivariable analysis, the factors associated with an increased risk of ACLR construct failure can be determined. A single-center, retrospective cohort study was conducted, encompassing patients who underwent primary ACLR between January 2015 and December 2021. Level 3. Eligible patients were identified using the current procedural terminology code 29888. Datapoints collected included demographics, body mass index, injury setting, graft type, graft size, fixation type, concomitant ligamentous injuries, notchplasty, operating surgeon, preoperative physical therapy, and instances of construct failure. The prevalence of construct failure was analyzed using chi-square tests, comparing across all graft and fixation type combinations in ACLR procedures. A mixed-effects logistic regression model was utilized to account for the potential influence of all relevant variables on construct failure. Out of 1245 patients, the construct failure rate was 5.62% (n = 70), with >95% of patients having >2 years of retrospective follow-up (95% CI [4.34-6.90]), with a median failure time of 502.5 days (interquartile range [265.5-1033.8]). The mixed-effect logistic model identified preoperative physical therapy (odds ratio, 0.404, 95% CI [0.193-0.844]) as the only significant factor in possibly preventing construct failure. Contrary to conventional focus on graft and fixation types, this study emphasizes the protective role of preoperative physical therapy in reducing ACLR construct failure. Our findings suggest the integration of preoperative physical therapy in clinical practices to mitigate ACLR construct failure risk, warranting further exploration in future studies.

Evaluation of Return to Military Activities after Combining Anterior Cruciate Ligament Reconstruction with Modified Lateral Extra-articular Tenodesis Versus Anterior Cruciate Ligament Reconstruction Alone in Primary Anterior Cruciate Ligament Tear in Soldiers. A Randomized Comparative Study

Abstract Background: This study aimed to assess the clinical result, complications, failure rate, and return to resuming military duty of a single-stage anterior cruciate ligament reconstruction (ACLR) procedure utilizing quadrupled semitendinosus tendon graft joint with modified lateral extra-articular tenodesis (LET). This study evaluates the potential impact of combined modified LET with ACLR versus ACLR alone on the rate of return to high-impact military activities, which we call return to sports (RTSs), and the subsequent rate of the anterior cruciate ligament (ACL) graft failure. Materials and Methods: A total of 198 soldiers with primary ACL tears with a high-grade pivot test (grade 3) were included and randomized using the simple randomized method and divided into two groups. A consecutive cohort of military personnel with an isolated ACL tear undergoing ACLR with modified LET (group A, n = 116) and ACLR alone (group B, n = 82) were analyzed between 2016 and 2021. Both groups were followed up for a minimum of 2 years. Soldiers underwent a survey evaluating knee function (knee injury and osteoarthritis outcome score [KOOS]), RTS criteria (RTS type), symptoms (International Knee Documentation Committee [IKDC] subjective), activity level (Tegner score), and fear of movement (Tampa Scale of Kinesiophobia-11) to assess psychological readiness for sport participation. Results: Among these, a mean age of 32 ± 2.93 years underwent primary ACLR with modified LET (n = 116) or without LET (n = 82) procedure. A total of 31 soldiers (15.6%) experienced ACL graft failure, including 26 (31.7%) reconstructions without LET and 5 (4.3%) with LET. Combined with LET during primary ACLR, it lowered the risk of graft failure by 2.8 times. Multivariable analysis revealed a significant reduction in graft rupture risk (relative risk = 0.325, P = 0.029) associated with LET compared to ACLR alone after adjusting for age, anthropometric factors, and tibial slopes. 105 out of 113 (90.5%) soldiers were able to return to military duty in group A (combined ACLR with modified LET), whereas 51 of 81 (62.9%) of the soldiers who underwent ACLR alone (group B) returned to military duty (P = 0.05). Conclusion: At 24 months postoperatively, combined ACLR plus LET showed a significantly higher RTS rate than ACLR alone. The combined ACLR with the modified LET group also showed a lower failure rate than the ACLR alone group. No marked differences were observed in KOOS sub-scores, IKDCsubjective, and Tegner activity scores.

Progression of Osteoarthritis After Double-Bundle Versus Single-Bundle Anterior Cruciate Ligament Reconstruction: A Systematic Review of Randomized Controlled Trial

Introduction: Recently, anterior cruciate ligament (ACL) reconstruction procedures are frequently performed both single-bundle (SB) and double-bundle (DB) techniques. Following anterior cruciate ligament (ACL) injury, the knee suffers from a high incidence of osteoarthritis (OA), which has been decreased by ACL reconstruction using DB and SB techniques. However, there is debate regarding the extent to which the DB and SB techniques work at preventing the progression of OA after an ACL reconstruction. Methods: The databases, which included Scopus, Embase, and PubMed, were searched up. A Randomized Controlled Trial (RCT) comparing SB and DB ACL reconstruction and reporting the clinical outcomes for OA progression was included in the study. Only studies with a minimum of two years of follow-up and a ten-year time frame were included. Result: The evaluation was conducted on seven RCTs that satisfied the eligibility requirements. Overall, the studies indicate that there was no statistically significant difference in the rate of radiological OA progression between the DB group and the SB group. Conclusion: When it came to OA changes in ACL reconstruction, the DB technique was not better than the SB technique. This necessitates further research with longer follow-up periods, a larger sample size, and improved study designs.

Autograft Choice and Jumping Performance After Anterior Cruciate Ligament Reconstruction: A Comparative Study on Professional Athletes.

The extensor apparatus of the knee is of paramount importance in generating the torque needed for a countermovement jump (CMJ), especially in jumping athletes. In anterior cruciate ligament reconstruction (ACLR) procedures, graft harvesting from the extensor apparatus may dramatically affect extensor strength and jumping performance. The focused jump training of professional jumping athletes would increase the likelihood of restoring jumping performance after ACLR, despite the graft choice (autologous bone-patellar tendon-bone [BPTB] or hamstring [HS] tendon). Cohort study; Level of evidence, 3. A retrospective evaluation of prospectively collected data was carried out. Only professional athletes were included, and all surgical procedures were performed by a single experienced surgeon. Data collection considered the type of surgery, sports activity, and functional evaluation at 3 months after surgery. From the functional evaluation, data on single-leg hop (SLH) test, triple hop (TH) test, and CMJ were extracted. Limb symmetry index (LSI) for maximal voluntary isometric contraction of the quadriceps and for each of the jumping tests was calculated. Multiple analysis of covariance (ANCOVA) models were used to assess mean differences among groups for the LSI in CMJ, SLH, and TH and estimate the effect of confounders. From a subsequent series of 208 athletes, 44 professional athletes were included for data collection. Of these, 26 were male and 18 were female. A jumping sport (basketball, volleyball) was played by 17 athletes, while a running sport (soccer, judo, rugby, tennis, ski) was performed by 27 athletes. The mean time from injury to surgery was 17.8 ± 14.5 days. At 90 days from surgery, the overall mean LSI for CMJ was 85.3% ± 8.9%, for SLH was 92.2% ± 6.4%, and for TH was 90.8% ± 6.1%. When ANCOVA was fitted using the interaction term with BPTB autograft and jumping sport, a nonsignificant effect on LSI for CMJ (P = .56), SLH (P = .72), and TH (P = .98) was observed. The results of the present investigation on professional athletes showed that no difference occurred within the study cohort in overall jumping performance between jumping and running athletes undergoing ACLR either with BPTB or with HS tendon grafts. Although some evidence suggests that quadriceps strength may be dramatically affected by the harvesting of BPTB, the overall performance of the jump was not compromised.

The Development and Execution of An Orthopaedic Sports Medicine Fellowship Surgical Skills Assessment

Background: Assessment of orthopaedic surgery trainees is traditionally based on subjective evaluation by faculty. The recent push for value-based health care has placed a premium on improving patient outcomes. As a result, surgical training evaluations for orthopaedic trainees are evolving to include more objective measures to evaluate competency. Purpose: To develop and subsequently demonstrate the efficacy of a novel surgical skills assessment for orthopaedic sports medicine fellows. Study Design: Case series; Level of evidence, 4. Methods: A team of 14 fellowship-trained orthopaedic sports medicine surgeons developed objective scoring rubrics for anterior cruciate ligament reconstruction (ACLR) and rotator cuff repair (RCR) using a modified Delphi process. Rubrics were designed based on 10 surgical steps with a grading scale (1-5) based on core competencies with a maximum summative score of 50. Fourteen orthopaedic fellows across a regionally diverse group of sports medicine–accredited fellowship programs were invited to complete both an ACLR and RCR in a surgical skills laboratory at the beginning and end of their fellowship year. Individual surgical steps, overall performance, and total procedure time were evaluated by a single sports medicine surgeon for both sessions. Results: Thirteen of 14 fellows completed both pre- and post-fellowship assessments. For the ACLR procedure, the pre-fellowship mean summative score was 25.4 (SD, 4.4) and the post-fellowship mean summative score was 38.6 (SD, 4.1), which was a statistically significant improvement (P < .001). For the RCR procedure, the pre-fellowship mean summative score was 26.6 (SD, 5.4) and the post-fellowship mean summative score was 38.8 (SD, 4.3), which was also a statistically significant improvement (P < .001). The mean time to completion for the ACLR procedure was 82.3 minutes (SD, 4.3 minutes) pre-fellowship, which improved to 69.7 minutes (SD, 11.6 minutes) post-fellowship (P = .002). The mean time to completion for the RCR procedure was 85.5 minutes (SD, 5.0 minutes) pre-fellowship, which improved to 76.4 minutes (SD, 7.0 minutes) post-fellowship (P < .001). Conclusion: This surgical skills program represents the first standardized and reproducible instrument for the evaluation of 2 arthroscopic sports medicine procedures in the United States. Orthopaedic sports medicine fellows improved significantly in aggregate over their fellowship year with regard to the ACLR and RCR. The described program has the potential to serve as both a training tool and formal orthopaedic sports medicine fellow assessment.

The application of proximal tibial anterior closing wedge osteotomy in anterior cruciate ligament reconstruction

IntroductionPosterior tibial slope (PTS) plays a vital role in knee stability. PTS of more than 12° may be considered with increased strain on the native anterior cruciate ligament (ACL) fibers. To handle the instability caused by changes in PTS degree, Proximal Tibial Anterior Closing Wedge Osteotomy (PT-ACWO) is adopted by surgeons. MethodsBetween October 2015 and October 2019, our department conducted a retrospective analysis of patients who experienced anterior cruciate ligament reconstruction (ACLR) graft failures, with a particular focus on pathological PTS. The time from initial ACLR to revision ranged from 1 to 10 years, with a mean of 2.5 years. Radiological assessments of PTS were conducted, and outcomes were quantified using the International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity scale. The surgical technique and the use of 3D Patient-Specific Instrumentation (PSI) were outlined. Preoperative imaging included the use of Kirschner wires to establish tibial plateau reference points, and 3D-PSI was employed to guide the location and depth of the tibial osteotomy, which was performed obliquely. In a notable instance, a novel tibial tunnel was mapped out, and ortho-bridge system (OBS) fixation was utilized to ensure adequate space for the new tunnel. ResultsIn a cohort of seven patients with a mean follow-up of 28.1 months, a significant reduction in PTS was noted postoperatively (median [interquartile range, IQR], from 15.27° [13.46°, 16.60°] to 6.25° [5.89°, 6.78°]; P = 0.002). IKDC score improved to 85.10 (80.25, 88.10), P < 0.001; the Lysholm score to 88.00 (73.00, 90.50), P < 0.001; and the Tegner score to 8.00 (7.20, 8.05), P = 0.025 at final follow-up. Skin incision healing delays occurred in two instances, yet achieved closure by six weeks. Radiographs at three months demonstrated faster bone healing in oblique osteotomies than transverse ones. Knee joint stability was maintained, with no additional complications or evidence of instability noted. Magnetic resonance imaging (MRI) confirmed graft integrity in all patients, without signs of enlargement or mispositioning at last observation. ConclusionAn augmented PTS angle exceeding 12 may constitute a potential etiology for the failure of ACLR grafts. In such patients, the implementation of ACLR combined with PT-ACWO could mitigate the risk of surgical failure during initial ACLR or subsequent revision procedures.

Paper 02: Combined ACL Reconstruction and Lateral Extra-Articular Procedures Reduce Graft Ruptures in Patients Over the Age of 30 Years Old: A Matched-Pair Analysis of 1102 Patients

Objectives: Clinical studies have demonstrated significant advantages of combined anterior cruciate ligament (ACL) and Lateral Extra-Articular Procedures (LEAP) over isolated ACL reconstruction (ACLR), in terms of reducing graft rupture and reoperation rate. However, most of the published studies included young patients, and there are no studies focusing on population over 30 years old. The purpose of this study was to compare the outcomes of isolated ACLR versus ACLR + LEAP at mid-term follow-up in patients over the age of 30 years old. The hypothesis was that patients who underwent combined procedures would experience significantly lower rates of graft rupture. Methods: Patients older than 30 years old who underwent primary ACLR + LEAP between January 2003 and December 2020 were propensity matched in a 1:1 ratio to patients who underwent isolated ACLR. A retrospective analysis of prospectively collected data was achieved to determine whether patients had experienced any complications or reoperations. Graft survivorship was assessed using Kaplan-Meier method. Risk factors associated with the occurrence of graft failure were analyzed using a Cox proportional hazards model. Results: Two groups of 551 patients were included in the study with a mean follow-up of 97.19 ± 47.23 months. The mean age for both groups was 37 ± 6.14. The LEAP group was composed by 516 (93.6%) anterolateral ligament and 35 (6.4%) Lemaire. Overall, 19 (1.7%) patients had graft failure, 15 (2.7%) in the No LEAP group and 4 (0.7%) in the LEAP group (P = .0116). The risk of graft failure was significatively associated with the absence of LEAP (hazard ratio [HR], 3.309 [1.088; 10.065], P = 0.0350) and age between 30 to 35 years old (HR 4.533 [1.484; 13.841] P = .0080). A higher rate of reoperation for secondary meniscectomy were founded in the No LEAP group (5.6% vs 2.2%; P = .0031). Conclusions: Patients over 30 years old who underwent combined ACLR and LEAP experienced &gt; 3-fold lower risk of ACL graft failure compared to isolated ACLR. Furthermore, the group without LEAP also experienced a higher rate of reoperation for secondary meniscectomy.

Poster 346: The Statistical Fragility of Lateral Extra-articular Tenodesis Research: A Systematic Review

Objectives: With reinterest in lateral extra-articular tenodesis (LET), there is an imperative need to evaluate the rigor of clinical studies regarding LET with anterior cruciate ligament reconstruction (ACLR). This study aims to present a comprehensive picture of the robustness of evidence from comparative studies regarding LET and to inform evidence-based medical decision-making for current practitioners. We hypothesized that the results of these analyses will show statistical fragility, consistent with similar evidence across the orthopaedic literature. Methods: Using the PubMed database, comparative studies and randomized controlled trials (RCTs) related to LET as an augmentation procedure to ACLR or revision ACLR published between 2000 and 2022 were identified and collected. Studies on the topic were broadly queried for relevance, and after screening, they were included if they were (1) pertaining to LET as an augmentation to ACLR or revision ACLR, and (2) designed as comparative studies or RCTs. Exclusion criteria included (1) cadaveric, nonhuman, in vitro, laboratory, or surgical technique (without patient outcomes); (2) commentary, editorial, letter to the editor, conference reports, future study design/published protocol; (3) only abstract available; (4) non-English; or (5) lacked the statistical basis for a fragility analysis. Manuscripts were independently reviewed by three authors and variables of interest of interest were extracted, including both dichotomous and continuous variables relevant to clinical decision making. Discrepancies were resolved via paired discussions. For each dichotomous outcome, we calculated a Fragility Index (FI). FI was calculated using a 2-by-2 contingency table and the Fisher's exact test using the method outlined in Figure 1. For each continuous outcome, we calculated a Continuous Fragility Index (CFI). CFI was calculated using Welch's t-test and the method proposed by Caldwell et al to expand fragility analysis to continuous variables. The analysis for each outcome was conducted with n = 5 simulations using synthetic, representative data generated from the reported sample mean, standard deviation, and sample size for both the experimental and control arms. For both dichotomous and continuous outcomes, the statistical fragility was reported using median and interquartile range. Comparisons of mean statistical fragility were conducted using a nonparametric t test. Data were analyzed using Python 3.7. Results: Out of the 455 initially identified studies, 178 full texts were screened. Ultimately, 29 studies were included in the final analysis, including 20 comparative studies and 9 RCTs. 18 studies reported dichotomous outcomes and 27 studies reported continuous outcomes, which resulted in a cumulative total of 48 dichotomous outcomes and 265 continuous outcomes for analysis. Figure 4 reports the distribution of FI and CFI values for all dichotomous and continuous outcomes. The median FI was 9.0 (25-75th percentile, 7.0-13.25). The median CFI was 7.8 (25-75th percentile, 4.2-19.6). Commonly reported dichotomous outcomes included clinical failure, graft rupture, and return to sport. The number of outcomes in which loss to follow-up (LTF) exceeded the FI was 13 (27%). Reported significant dichotomous outcomes were significantly more fragile than outcomes that were not significant (fragility quotient [FQ] = 0.02 vs 0.11, Welch t test p &lt; 0.001); however, most dichotomous outcomes were reported insignificant (79.2%) (Table 1). Commonly reported continuous outcomes across different studies included KOOS, IKDC, and Lysholm scores. LTF exceeded the CFI for 20 outcomes (8%). In contrast to dichotomous outcomes, continuous outcomes from RCTs and comparative studies were equivalently robust (continuous fragility quotient [CFQ] = 0.12 vs 0.12). The CFQ of both significant and nonsignificant continuous outcomes were similarly equal (0.12 vs 0.12) (Table 2). Reports on fragility quotients from studies that focused on LET for either primary or revision ACLR clinically are presented in Table 3. These subgroups excluded translational research and imaging studies. The FQ and CFQ for studies focused on revision ACLR were larger (0.117 and 0.113) than those focused on primary ACLR (0.042 and 0.095). Conclusions: Research regarding the usage of LET as an augmentation procedure for ACLR and revision ACLR is more statistically robust than many other topics within orthopaedics. Studies regarding LET with primary ACLR are more fragile than those for revision ACLR. Given the resurgent interest in this procedure and the current mixed evidence regarding its effectiveness and indications, we recommend the future reporting of fragility quotients alongside p-values, to assist clinicians in assessing the robustness of new evidence to inform decision making.

Poster 331: No Difference in Anterior Knee Pain Between Bone-Patellar Tendon-Bone and Hamstring Autograft at Two-year Follow-up

Objectives: Anterior cruciate ligament reconstruction (ACLR) is one of the most common orthopaedic procedures performed in the United States each year. It has been shown to be an effective procedure with have relatively good surgical and patient-reported outcomes (PROs). Historically, there have been concerns that bone-patellar tendon-bone (BTB) autograft can be associated with more postoperative anterior knee pain compared to other graft types due to donor site morbidity. Many surgeons and patients elect to use hamstring autograft to mitigate this potential concern. Previous work has evaluated anterior knee pain with visual analog scales and other instruments; however, none have specifically used the Knee Injury and Osteoarthritis Outcome Score (KOOS) pain subscale. The incidence of anterior knee pain by graft type has yet to be fully evaluated. The primary aim of this study was to compare differences in anterior knee pain between patients undergoing primary ACLR with BTB or hamstring autograft at 2-year follow-up. Secondary aims include evaluating KOOS and Single Assessment Numeric Evaluation (SANE) differences between graft types. Methods: A retrospective review of a prospectively collected PRO database was conducted for patients who underwent primary ACLR between 2009 and 2021. Patients were excluded if they underwent any nonprimary ACLR procedures other than meniscal repair or meniscectomy, received a graft type besides BTB or hamstring autograft, had incomplete PROs, experienced reoperation or graft failure, or were not between the ages of 14 and 50. Demographic information including age, sex, body mass index (BMI) was collected, as well as surgical characteristics such as American Society of Anesthesiology (ASA) score, concomitant meniscal procedures, and graft type (BTB or hamstring autograft). Outcomes collected included 2-year KOOS, the KOOS pain subscale, and SANE. The KOOS pain subscale was used to evaluate any anterior knee pain differences between the graft types. Statistical analysis consisted of descriptive analyses (counts, means, ranges, etc.), independent sample t-tests, chi-squared tests, as well as analysis of variances (ANOVAs). The level of statistical significance was set at p≤0.05. Results: A total of 411 patients were included in the final analysis. Most patients were female (n=238, 57.9%), had an average age of 26.2±10.6, and a BMI of 25.5±4.5. 80.5% of patients (n=331) had an ASA of 1. There were 237 (57.7%) BTB and 174 (42.3%) hamstring autograft ACLRs. Approximately half of patients had a concurrent meniscus tear (49.9%, n=205). There were 176 patients who underwent a meniscus operation (43.8%) consisting of having a meniscectomy (27.7%, n=114) or undergoing a repair (19.2%, n=79). The average two-year change in KOOS, KOOS pain, and SANE were +17.8, +13.8, +26.0, respectively. Female sex was found to be associated with larger improvements in KOOS (p=0.044), and KOOS pain (p=0.003) (Table 1). There were no statistically significant differences between sex or ASA score between the graft types (p=0.172, p=0.069). BMI was found to be statistically different between BTB and hamstring patients, (25.1 vs. 26.2, p=0.017, respectively) although it was not associated with changes in KOOS, KOOS pain, or SANE. There were no differences in the proportion of concomitant meniscus tears or operations between the graft types (p≥0.087). The 2-year improvement in the KOOS pain subscale from preoperative baseline was not found to be significantly different between the groups (BTB: 12.5 vs. hamstring: 15.2, p=0.137). The 2-year KOOS pain value also did not differ by graft type (BTB: 91.6 vs. hamstring: 90.6, p=0.406). The 2-year change in SANE also did not differ between the grafts (p=0.815). The baseline overall KOOS and 2-year change in KOOS were higher in BTB autograft patients compared to hamstring autograft patients (68.2 vs. 63.3, p&lt;0.001; 16.4 vs.19.7, p=0.040, respectively). Overall KOOS at final follow-up did not differ between grafts (84.6 vs. 83.0, p=0.160, respectively). Conclusions: ACLR with BTB autograft was not found to be associated with worse anterior knee pain scores compared to hamstring autograft, with most patients achieving good outcomes in SANE, KOOS and KOOS pain at 2-year follow-up. Although patients who received hamstring grafts demonstrated larger improvements in KOOS at 2-years, they also started at a lower KOOS score on average compared to BTB patients. Patients in both groups achieved similar 2-year outcomes indicating that any differences may be due to ceiling effects of the PRO. During graft selection for ACLR, surgeons and patients can expect similar improvement in pain levels between BTB and hamstring autograft and should not choose one graft over the other based on concerns related to anterior knee pain differences.

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

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

Comparative Effectiveness of Supervised and Home-Based Rehabilitation after Anterior Cruciate Ligament Reconstruction in Competitive Athletes.

Background: After the increasingly common anterior cruciate ligament reconstruction (ACLR) procedure in competitive athletes, rehabilitation is crucial for facilitating a timely return to sports (RTS) and preventing re-injury. This pilot study investigates the patient-reported outcomes of postoperative rehabilitation in competitive athletes, comparing supervised rehabilitation (SVR) and home-based rehabilitation (HBR). Methods: After ACLR, 60 (out of 74 screened) athletes were recruited and equally divided into HBR and SVR groups using non-probability convenience sampling, with each group comprising 15 males and 15 females. The rehabilitation outcomes in the respective groups were evaluated at 8 months using measures (Tegner Activity Scale [TAS], International Knee Documentation Committee subjective knee form [IKDC-SKF], ACL Return to Sport after Injury [ACL-RSI]) and objective parameters (isometric muscle strength, hamstring/quadricep asymmetry). RTS was evaluated at 9 months, with ACL re-injury rates recorded approximately 6 months post-RTS. Results: Both groups exhibited decreased TAS scores (HBR: 8 to 6, SVR: 8 to 7), with the SVR group demonstrating superior postoperative IKDC-SKF scores (81.82 vs. 68.43) and lower ACL-RSI scores (49.46 vs. 55.25). Isometric and isokinetic muscle strength, along with asymmetry values, was higher in the SVR group 8 months post-ACLR (p < 0.05). The SVR group showed a higher RTS rate to the same level (76.6% vs. 53.3%), while the re-injury rate was the same in both the rehabilitation groups (3.3%). Conclusions: Although both rehabilitation approaches yielded comparable outcomes, SVR may demonstrate some superior biomechanical improvements in athletes, resulting in a higher RTS rate. However, the psychological outcomes and re-injury rates did not significantly differ between the groups, emphasizing the need to address individual psychological needs during rehabilitation. Further investigation is recommended with a larger sample size to address the differences of gender among competitive athletes.

Anterior Cruciate Ligament Reconstruction Surgery Outcomes: A Comparison Between Patients Who Underwent the Procedure During the COVID-19 Pandemic and a Cohort Treated Prior to the Pandemic.

Background and objective During the coronavirus disease 2019 (COVID-19) pandemic, many elective orthopedic surgeries, including anterior cruciate ligament reconstruction(ACLR), were temporarily postponed. The purpose of this study was to compare the outcomes of ACLR in patients who underwent surgery during the COVID-19pandemic with those in a cohort treated before the pandemic. Materials and methods This retrospective review compared patients who underwent primary ACLR during two periods: March to June 2020 (the pandemic group) and January to December 2018 (the pre-pandemic group). Matched cohorts (1:1) were created using propensity matching. Time from injury-to-first visit, injury-to-surgery, and first visit-to-surgery were calculated. Subjective and objective outcomes, minimal clinically important difference (MCID) achievement, and complication rates were recorded for up to two years postoperatively. Statistical analysis included 𝛘2 or Fisher's exact tests for categorical data, and t- or Wilcoxon signed-rank tests for continuous data with significance set at P< 0.05. Results The pandemic and pre-pandemic groups consisted of 33 and 217 patients, respectively.Matched cohorts consisted of 33 patients each. The time from injury-to-surgery and the first visit-to-surgery was prolonged in the pandemic group. When unmatched, visual analog scale (VAS) scores at three months postoperatively and Patient-Reported Outcomes Measurement Information System (PROMIS)-pain interference (PI) at six months postoperatively and at the final follow-up were higher in the pandemic group. When matched, PROMIS-PI at six months postoperatively was higher in the pandemic group, and VAS scores at one year postoperatively were higher in the pre-pandemic group. MCID achievement and complication rates did not significantly differ between the groups. Conclusions ACLR procedures were significantly delayed in the early months of the COVID-19 pandemic. While patients treated before and during the pandemic experienced varying pain levels during recovery, their functional outcomes, MCID achievement, and complication rates did not differ significantly.

Combining an Anterolateral Complex Procedure With Anterior Cruciate Ligament Reconstruction Reduces the Graft Reinjury Rate and Improves Clinical Outcomes: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background: Anterior cruciate ligament (ACL) reconstruction (ACLR) is a well-established surgical procedure, but it may not always restore complete rotational knee stability. Interest is increasing in anterolateral complex (ALC) procedures, lateral extra-articular tenodesis (LET) and anterolateral ligament reconstruction (ALLR), in association with ACLR to overcome this problem. The better ALC procedure, LET or ALLR, remains controversial to date. Purpose: To analyze the patient-reported outcome measures and ACL reinjury rate after ACLR with an ALC procedure compared with after isolated ACLR, as well as to analyze the clinical results and graft failure rate of the LET group versus the ALLR group. Study Design: Systematic review and meta-analysis; Level of evidence, 2. Methods: A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart was used to conduct a comprehensive search of 5 databases: Scopus, MEDLINE, Embase, PubMed, and the Cochrane Database of Systematic Reviews. Only randomized controlled trials were included. Eligible articles were classified according to the levels of evidence of the Oxford Centre for Evidence-Based Medicine. A methodological quality assessment of randomized controlled trials was performed using the Risk of Bias 2 tool. The present systematic review and meta-analysis was registered on PROSPERO. Results: A total of 14 clinical trials were included in the final analysis, with 1830 patients. Isolated ACLR or a combined procedure with LET or ALLR was performed, with several characteristics described, including the surgical technique, additional torn knee structures and their management, graft failure, complications, clinical outcomes, clinical and instrumental examinations to assess knee stability, and postoperative protocols. Regarding clinical outcomes, pivot-shift tests and reduced graft failure, a significant difference was found in the superiority of the combined ACLR associated with the ALC procedure compared with an isolated ACLR (P < .05). No statistically significant difference was found between the 2 ALC procedures. Conclusion: This systematic review and meta-analysis reported on the importance of combined ACLR and ALC procedures in patients with a high-grade rotational laxity, as both procedures, LET or ALLR, without superiority of one over the other, are associated with improved pivot-shift tests, patient-reported outcome measures, and reduced graft failure rates.

Association of Quadriceps Tendon Harvest for ACL Reconstruction With Development of Osteochondritis Dissecans of the Patella in Pediatric Patients.

There are various reported complications after primary anterior cruciate ligament reconstruction (ACLR) necessitating additional surgery in skeletally immature patients, regardless of technique and autograft type. To analyze the rate and type of complications encountered with soft tissue quadriceps tendon autograft (QTA) for ACLR in patients ≤18 years as well as the overall rate of second surgery, unrelated to the use of the QTA. Case series; Level of evidence, 4. A total of 141 patients ≤18 years who underwent ACLR with a QTA and had minimum 6-month follow-up were included. All patients underwent ACLR by utilizing a full-thickness soft tissue QTA. Complications associated with the QTA harvest site and use of QTA were reported. The mean age of the included cohort (84 men, 57 women) was 14.8 ± 1.6 years. The average follow-up was of 2.0 ± 1.2 years. A total of 30 (21%) patients had a subsequent complication that required surgical intervention; in 11 (8%) patients, the complication was specifically associated with the use of a QTA, whereas in 19 (13%) patients, the complication was related to the ACLR. In addition, 13 (9%) patients underwent a contralateral ACLR procedure. Of the QTA-related complications, 2 patients developed osteochondritis dissecans (OCD)-like lesions in the superior aspect of the patella, 2 patients had injured their quadriceps extensor mechanism and required surgical repair, and 8 patients had a subsequent procedure to remove nonabsorbable sutures used for donor site quadriceps tendon closure. One of the patients who underwent the removal of nonabsorbable sutures also had an arthroscopic debridement of patellar chondral damage. We reported complications encountered with soft tissue QTA for ACLR. The complication rate for QTA harvest was 8%. However, given that the removal of nonabsorbable sutures from the donor site was caused by the surgical technique used, the revised nonsuture-related complication rate for QTA graft harvest was 2%. Although the use of a QTA has recently gained popularity due to its high return-to-sport and low graft-failure rates, surgeons should be aware of the complications associated with using this graft type.

Clinical Outcomes of Anatomic, Anterior Cruciate Ligament Reconstruction through All-inside Technique in Armed Forces Personnel

Abstract Context: Reconstruction of the anterior cruciate ligament (ACL) allows patients to resume their sports activity and delay the onset of osteoarthritis associated with loss of meniscal function. The all-inside approach for ACL reconstruction (ACLR) is to increase the graft diameter by folding several strands when sufficient graft diameter is not secured. Aims: The aim of this study is to evaluate the clinical and functional outcomes in patients undergoing of anatomic, all-inside ACLR procedure. Settings and Design: This was a prospective clinical study conducted in a Tertiary Care Hospital for 12 months on patients undergoing all-inside anatomic arthroscopic ACLR with hamstring autograft using BUTTONFIX® fixation button with adjustable loop (Chetan Meditech Pvt. Ltd., Ahmedabad, Gujarat, India). Subjects and Methods: Patients were evaluated for functional status using Lysholm Knee Score, Knee Injury and Osteoarthritis Outcome Score (KOOS), and Tegner Activity Scale at 3-month, 6-month, and 12-month postsurgery. Statistical Analysis Used: All the statistical analyses were performed using SPSS version 23 (IBM 2013). Results: Forty patients were included in the study with a mean age of 29.38 ± 5.47. There was a gradual increase in the scores at the follow-up starting from baseline with a mean difference of Lysholm knee score from 43.58 ± 5.23 to 93.50 ± 3.00 at the 12-month follow-up period. Similarly, the KOOS at baseline showed a mean of 44.03 ± 5.20, which increased gradually up to 93.05 ± 2.83 at 12 months, and the Tegner activity score at baseline was 3.55 ± 0.6 and gradually increased to 7.28 ± 0.85 at 12-month period. Conclusions: All-inside surgical techniques for the anatomic ACLR showed favorable clinical and functional outcomes.

Research progress on preparation of lateral femoral tunnel and graft fixation in anterior cruciate ligament reconstruction.

Anterior cruciate ligament (ACL) injury is one of the most common types of sports injuries. People's need to participate in sports and desire for a high quality of life promotes the continuous development of ACL reconstruction technology. Arthroscopic ACL reconstruction has been recognized as an effective method for the treatment of ACL injuries. This review analyses and summarizes the advantages and limitations of each surgical procedure for arthroscopic ACL reconstruction reported in the relevant literature so as to promote the future development of more relevant techniques.

Outcomes of Slope-Reducing Proximal Tibial Osteotomy Combined With a Third Anterior Cruciate Ligament Reconstruction Procedure With a Focus on Return to Impact Sports

Background: An increased posterior tibial slope (PTS) is a proven risk factor for both native anterior cruciate ligament (ACL) and ACL graft insufficiency. Anterior closing wedge high tibial osteotomy (ACW-HTO) for PTS correction is a validated procedure in revision ACL reconstruction (ACLR). Purpose/Hypothesis: The aim of this study was to evaluate the effect of combined ACW-HTO and at least a second revision ACLR procedure on knee stability, function, and sports performance in a large series of patients. The hypothesis was that patients would return to impact sports after ACW-HTO combined with a second or third revision ACLR procedure. Study Design: Case series; Level of evidence, 4. Methods: A total of 64 patients who underwent a second (or more) revision ACLR procedure and ACW-HTO between June 1, 2015, and June 1, 2019, and had a PTS >12° were included. The mean age was 29.60 ± 6.31 years, and the mean preoperative PTS was 13.79°± 1.50°. The cases were analyzed at a mean follow-up of 2.96 ± 0.83 years (range, 2-5 years). At the last follow-up, the rate of patients returning to impact sports (based on the University of California, Los Angeles [UCLA], activity scale), ACL graft status (per magnetic resonance imaging), International Knee Documentation Committee (IKDC) scores, Lysholm scores, and laxity measurements using a knee arthrometer were recorded. Results: The total number of patients participating in impact sports and high-impact sports was as follows: 43 and 30, respectively, before the injury; 0 and 0, respectively, preoperatively; and 31 and 12, respectively, postoperatively. At the last follow-up, the UCLA score was ≥8 in 48.44% of the patients, and only 16 patients returned to their preinjury level of activity. At a minimum of 2 years of follow-up, there was clinical improvement in the IKDC score from 37.98 ± 12.48 preoperatively to 69.06 ± 12.30 postoperatively (P < .0001), in the Lysholm score from 51.94 ± 14.03 preoperatively to 74.45 ± 11.44 postoperatively (P < .001), and in the UCLA score. However, this clinical improvement did not equate to preinjury values for all outcome scores (P < .001). The preinjury IKDC and Lysholm scores were 76.98 ± 11.71 and 89.26 ± 8.91, respectively. The mean change in anterior knee laxity using a knee arthrometer at 134 and 250 N was −4.03 ± 0.18 mm and −3.63 ± 0.16, respectively. There were 3 cases of a rerupture with a severe pivot shift on the clinical examination. None of these patients underwent revision per the patient's preference. Increased knee recurvatum was observed in one-third of the patients, but all were asymptomatic. Conclusion: In the setting of chronic ACL-deficient knees, PTS reduction (ACW-HTO) with revision ACLR restored knee stability and improved function with an acceptable rate of specific complications. Increased knee recurvatum was observed in one-third of the patients, but all were asymptomatic. Also, approximately half of the patients were able to return to impact sports.