Anterior Cruciate Ligament Reconstruction Research Articles

Effect of alendronate and platelet-rich plasma in tendon-bones integration in sheep anterior cruciate ligament surgery

Context: Anterior cruciate ligament (ACL) reconstruction often faces challenges due to poor integration of the tendon with bone. Aims: To evaluate the potential benefits of alendronate and platelet-rich plasma (PRP) in enhancing tendon-to-bone osteointegration in ACL surgery. Methods: This was a post-test only control group experimental study with Ovis aries Linnaeus sheep as experimental animals. The sample was divided into four groups: the control group ACL reconstruction with calcaneal tendons given NaCl, the group given PRP, alendronate, and PRP and alendronate. Bone healing biomarkers (NF-B, TNF-α, MMP-9, TGF-β1, and COL1A1) were examined through immunohistochemical analysis and histological studies to assess osteoblast counts and inflammatory tissue. Results: There was a statistically significant (p<0.05) increase in MMP-9 and osteoblast count after alendronate and PRP administration. Administration of alendronate and PRP also increased other variables, namely TNF-α, COL1A1, and the level of inflammation, although not statistically significant (p>0.05). The intervention did not affect NF-B and TGF-β1 (p> 0.05). Conclusions: These results show that the administration of alendronate and PRP improves the healing of tendon-calcaneal ACL reconstruction surgery in sheep.

Rehabilitation and Return to Play Protocols After Anterior Cruciate Ligament Reconstruction in Soccer Players: A Systematic Review.

Rehabilitation after anterior cruciate ligament ACL reconstruction (ACLR) is crucial for safe return to play (RTP) and reducing the chances of a reinjury. Yet, there is no consensus on the ideal functional tests to assess rehabilitation progress in soccer players after ACLR. The primary objective was to highlight the existing gap in the literature concerning the most effective standardized rehabilitation protocols and testing for facilitating successful RTP among soccer players. Systematic review; Level of evidence, 4. A systematic review using PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) was conducted. Inclusion criteria encompassed original studies (level of evidence 1-4) that examined rehabilitation protocols, metrics of knee rehabilitation, and clinical outcomes after ACLR in soccer players. This review incorporated 23 studies, predominantly retrospective case series, with a total number of 874 soccer players who underwent ACLR and rehabiliation. 5 (21.7%) studies utilized an accelerated rehabilitation protocol, while 7 (30.4%) of studies utilized a criterion-based rehabilitation. A wide heterogeneity of data was extracted including functional tests of rehabilitation and RTP such as strength test batteries, hop test batteries, and movement quality assessments. Of the 23 selected studies, 2 (8.7%) used all 3 test batteries, 8 (34.8%) used 2 test batteries, 12 (52.2%) used 1 test battery, and 1 (4.3%) used 0 of the test batteries. The mean time between surgery and RTP ranged from 3 to 8 months with only 2 (8.7%) studies reporting complications after ACLR. Lastly, out of the total studies examined, 9 (39.1%) assessed patient-reported outcome measures (PROMs), all of which demonstrated significant improvement from the initial assessment to the final follow up. Soccer-specific rehabilitation after ACLR lacks standardization. Even though many studies have assessed protocols for optimal RTP and reduced secondary ACL injuries, there is a gap in the literature regarding the most effective protocols and RTP testing. The methodology reported by Kyritsis et al could serve as a foundation for future prospective randomized multicenter studies to establish a standard rehabilitation protocol and enable a successful return to soccer.

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.

Comparison of genicular nerve block with adductor canal block for postoperative pain management in patients undergoing arthroscopic knee ligament reconstruction: A randomised controlled trial

Background and Aims: Genicular nerve block (GNB) is beneficial in early ambulation and faster patient discharge since it selectively blocks articular branches and is motor-sparing. This study aimed to compare the analgesic efficacy of ultrasound (US)-guided GNB with adductor canal block (ACB) in patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR). Methods: This randomised, double-blind study was conducted on 38 adults undergoing arthroscopic ACLR. Patients in Group GNB (n = 19) received US-guided GNB with 3 ml of 0.25% bupivacaine and 2 mg dexamethasone. Patients in Group ACB (n = 19) received US-guided ACB with 20 ml of 0.25% bupivacaine with 6 mg dexamethasone. Postoperative rescue analgesia was provided by intravenous Patient Controlled Analgesia (PCA) with morphine. The primary outcome was Numerical Rating Scale (NRS) pain scores over 24 h. The secondary outcome was the duration of analgesia and 24-h morphine consumption. The Chi-square test was used to test the statistical significance between categorical variables. Independent t-test or Mann–Whitney U test was used to compare continuous variables. Results: NRS scores at rest and physical activity at 24 h were similar in both the groups (P = 0.429 and P = 0.101, respectively). The mean time to rescue analgesia was comparable in both groups (Group GNB: 820.79 [483.65] min [95% confidence interval {CI}: 603.31–1038.27] and Group ACB: 858.95 [460.06] min [95% CI: 652.08, 1065.82], P = 0.805), and the mean 24-h morphine consumption was also comparable in both groups (P = 1.000). Conclusion: US-guided GNB has an analgesic efficacy similar to US-guided ACB for patients undergoing arthroscopic ACLR.

Anterior Cruciate Ligament Reconstruction in Tibial Eminence Avulsion Fracture: A Case Series

Introduction: Ruptures of the anterior cruciate ligament (ACL) are common orthopedic injuries, especially among patients participating in sports. Anterior cruciate ligament (ACL) avulsion fracture or tibial eminence avulsion fracture is a type of avulsion fracture of the knee. This article describes several cases of ACL rupture management with eminence avulsion. Case report: This case series describes 3 cases of ACL tear with eminence avulsion. The first patient was a 31-year-old female with right knee pain since 6 months ago after a traumatic fall from a motorcycle. The second patient, a 16-year-old girl with a history of bending her legs inward during exercise. The third patient is a 49-year-old female with a history of accidents and complaints of knee pain. All three patients found ACL tear accompanied by an avulsion fracture on the tibial eminence and then undergo ACL reconstruction. Discussion: The most common mechanism of trauma, which leads to a disruption of ACL, is a trauma forcing the knee in hyperextension combined with valgus-external rotation. At times, these lesions can occur in adults; in this instance, the main cause is high-energy trauma, such as road accidents. Based on case reports and previous research, the management approach in this case is still debatable in children and adults and requires a specific approach in each case. Conclusion: The management of ACL reconstruction in patients with tibial eminence avulsion involvement is still a challenge for orthopedic surgeon. Given the rarer cases, a different approach is needed in young and adult cases. Each case requires proper management to improve the patient's functional outcome and their quality of life. Keywords: anterior cruciate ligament reconstruction, avulsion fracture, tibial eminence avulsion

Vitamin D as an intervention for improving quadriceps muscle strength in patients after anterior cruciate ligament reconstruction: study protocol for a randomized double-blinded, placebo-controlled clinical trial

BackgroundThe goal of anterior cruciate ligament reconstruction (ACLR) is to restore the preinjury level of knee function to return to play (RTP). However, even after completing the rehabilitation programme, some patients may have persistent quadriceps muscle weakness affecting knee function which ultimately leads to a failure in returning to play. Vitamin D has been long recognized for its musculoskeletal effects. Vitamin D deficiency may impair muscle strength recovery after ACLR. Correcting vitamin D levels may improve muscle strength.MethodsThis is a double-blinded, randomized controlled trial to investigate the effects of vitamin D supplementation during the post-operative period on quadriceps muscle strength in anterior cruciate ligament (ACL)-injured patients. Patients aged 18–50 with serum vitamin D < 20 ng/ml, unilateral ACL injury, > 90% deficit in total quadriceps muscle volume on the involved leg compared with uninvolved leg, Tegner score 7 + , and no previous knee injury/surgery will be recruited. To assess patient improvement, we will perform isokinetic and isometric muscle assessments, ultrasound imaging for quadriceps thickness, self-reported outcomes, KT-1000 for knee laxity, biomechanical analysis, and Xtreme CT for bone mineral density. To investigate the effect of vitamin D status on quadriceps strength, blood serum samples will be taken before and after intervention.DiscussionPatients with low vitamin D levels had greater quadriceps fibre cross-sectional area loss and impaired muscle strength recovery after ACL. The proposed study will provide scientific support for using vitamin D supplementation to improve quadriceps strength recovery after ACLR.Trial registrationClinicalTrials.gov NCT05174611. Registered on 28 November 2021.

Associations between Body Mass Index, Gait Mechanics and Trochlear Cartilage Thickness in those with ACL Reconstruction.

High body mass index (BMI) is a strong predictor of post-traumatic osteoarthritis (OA) after anterior cruciate ligament reconstruction (ACLR). Altered gait mechanics are independently affected by BMI and ACLR, and influence OA risk. Yet, evidence directly assessing the impact of high BMI on gait or cartilage characteristics after ACLR are limited. Here, we evaluated if high BMI moderates associations between gait and trochlear cartilage structure in individuals with ACLR. Treadmill walking biomechanics were evaluated in forty normal BMI and twenty-four high BMI participants with ACLR at self-selected speeds. Normalized and absolute peak and cumulative loads (i.e., impulse) were extracted for peak knee flexion and adduction moments (KFM, KAM) and vertical ground reaction force (GRF). Medial and lateral femoral cartilage thickness and medial: lateral thickness ratios were assessed via ultrasound. Those with ACLR and high BMI walked with reduced normalized peak vertical GRFs, and greater absolute peak and cumulative loads compared to normal BMI individuals with ACLR. Those with ACLR and high BMI also exhibited thinner cartilage and greater medial: lateral ratios in ACLR limbs compared to contralateral limbs whereas normal BMI individuals with ACLR exhibited thicker ACLR limb cartilage. Lastly, greater peak KAM and KAM cumulative load were associated with thicker lateral cartilage and lesser medial: lateral thickness ratios, but only in the high BMI group. We observed those with high BMI after ACLR exhibited trochlear cartilage structural alterations not observed in normal BMI patients, while differential associations between loading outcomes and cartilage thickness in ACLR knees were observed between groups. Those with high BMI after ACLR may require different therapeutic strategies to optimize joint health in this subset of patients.

Italian research on anterior cruciate ligament: a bibliometric analysis.

This study analysed thetrend of publications on anterior cruciate ligament(ACL) in Italy. It was hypothesised that publications on this topic have quickly increased in recent years due to increased knowledge of both clinical and radiological pathology. PubMed and Scopus were accessed on 29/11/2023. This retrieved 838 articles from PubMed and 1050 from Scopus. We analysed the top 10 authors, and journals in publication numbers, citation numbers, and citations per year. We have also looked at the top 10 institutions publishing on anterior cruciate ligament from Scopus as PubMed does not give this information in the output. Data mining was performed using the Orange software, Mac version 3.32.0 ( https://orangedatamining.com/ ) from the titles of all articles. A word cloud analysis of titles, authors, journals and universities was performed. The peak of citations was in 2017 with 1529, whilst the peak of publications was in 2019 with 59 articles published. Analysing the number of publications and citations for the journal, the most impacted journal is Knee Surgery, Sports Traumatology, Arthroscopy with 5472 citations and 183 articles, followed by The American Journal of Sports Medicine, with 2722 citations and 56 articles and Arthroscopy with 1990 citations and 62 articles. Considering also international collaborations, the most cited author is Della Villa F. in 2020 with 43.67 citationsper year.The Italian author with the major number of publications is Zaffagnini S. with 39 articles, whilst the author with the higher number of citations is Aglietti P. with 1612 citations. ACL reconstruction has gained growing interest amongst the scientific community. Publications and citations presented a rising trend, the majority of the highly cited papers were contributed by few centres, and clinical trials were the most cited study designs. The long-term outcomes of ACL lesions have attracted interest. The authors hypothesised that shortly there will be an increase in articles analysing the results of ACL revisions, the use of lateral extra-articular tenodesis, and meniscus transplants. Cross-Sectional Study.

Advancements in Anterior Cruciate Ligament Repair—Current State of the Art

While anterior cruciate ligament reconstruction (ACL-R) has been considered the gold standard for ACL tears, renewed interest in ACL repair has emerged. This review aims to examine the current knowledge regarding ACL repair. A comprehensive literature search was conducted on the PubMed, Web of Science, Scopus, and Embase databases, focusing on the most recent studies up to January 2024. Arthroscopic ACL repair has several advantages, such as resulting in a natural ligament with proprioceptive properties, preservation, and donor graft comorbidity absence. Several ACL repair surgical procedures have been developed thanks to the advancement in new fixation devices. The current literature showed that when performed on a suitable patient with the appropriate lesion type, corresponding to the proximal third with good tissue quality, ACL repair leads to satisfactory outcomes. Despite the benefits of ACL repair with promising results, ACL-R remains the gold standard for ACL lesions. There is still a lack of literature analyzing long-term outcomes; large series with homogenous populations and types of lesions are lacking. Based on the current evidence, further research and higher-quality studies investigating ACL repair will be necessary.

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

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

Comparison of Cross-Pin Versus Cortical Button Femoral Fixation in Anterior Cruciate Ligament Reconstruction With Hamstrings Autograft: A Long-Term Clinical Study and Review of the Literature

Comparison of Cross-Pin Versus Cortical Button Femoral Fixation in Anterior Cruciate Ligament Reconstruction With Hamstrings Autograft: A Long-Term Clinical Study and Review of the Literature

A Single-Leg Vertical Hop Test Is an Effective Tool to Measure Functional Performance after Anterior Cruciate Ligament (ACL) Reconstruction

This study evaluated the single-leg vertical hop test (SLVHT), using digital sensor technology, for the functional assessment of rehabilitation progress in patients after ACL reconstruction (ACL-R). Between January 2019 and June 2022, 143 patients (26.6 (8.9) years, m/f 66/34%) completed return-to-sport testing at 3 and 6 months after ACL-R. The jump height during SLVHT was quantified with a digital motion sensor, containing a three-axis acceleration gyroscope sensor, and the limb symmetry index (LSI) (injured/non-injured leg ratio) was calculated. Three months postoperatively, the jump height of the injured leg was 59.6% (13.5 (5.5) cm) that of the non-injured leg (22.9 (6.2) cm; p &lt; 0.01). After 6 months, the jump height of the injured leg (18.4 (6.9) cm) improved by 44.1% compared to that at the 3-month follow-up but was still lower than the non-injured leg jump height (23.2 (7.0) cm, p &lt; 0.001; LSI = 79.6%). Men jumped higher than women, but their LSI was not different at 3 (59.6 vs. 59.5%) and 6 months (80.6 vs. 77.8%). Regression analysis identified the non-injured leg jump height as the primary independent predictor of the jump height of the injured leg (β = 0.776, T = 51.506, p &lt; 0.001). SLVHT, using digital sensor technology, is a simple and cost-effective functional test to assess rehabilitation progress after ACL-R, with the potential for multi-centre data analysis.

[Subtuberosity anterior closing wedge osteotomy to correct the increased posterior slope of the tibial plateau].

Reduction of increased reclination of the tibial plateau (posterior slope) to improve the anterior stability of the knee joint. Increased posterior reclination of the tibial plateau greater than 12° in combination with recurrent instability after anterior cruciate ligament (ACL) reconstruction. Hyperextension of more than 15° (relative). Anterior skin incision approximately 8-10 cm above the tibial tuberosity. Insertion of two converging guidewires directly below the patellar tendon ending obliquely in the area of the posterior cruciate ligament (PCL) insertion. Control of the wire position with the image intensifier core. Oscillating saw osteotomy. Removal of the wedge and closure of the osteotomy. Osteosynthesis with interfragmentary screw and medial angle-stable plate. Partial load with 10-20 kg for 2 weeks, then step by step increase in load. Mobility: free. To date we have operated on 36patients with recurrent instability after ACL reconstruction (20men, 16women, average age 34.4 years) in the manner described in this article. In 25cases, enlarged bone tunnels were filled with allogeneic bone at the same time. The posterior slope of the tibial plateau could be reduced from an average of 14.5° to8.8°. In 28cases another ACL reconstruction was performed after an interval of 4-12months. The Lysholm score significantly increased from 76.3 points to 89.2 points.

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

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

Clinical Outcomes in Patients Undergoing Anterior Cruciate Ligament Reconstruction With Controlled Accelerated Rehabilitation

Clinical Outcomes in Patients Undergoing Anterior Cruciate Ligament Reconstruction With Controlled Accelerated Rehabilitation

A novel practical method to predict anterior cruciate ligament hamstring graft size using preoperative MRI

BackgroundPredicting hamstring graft size preoperatively for anterior cruciate ligament (ACL) reconstruction is important for preempting an insufficient diameter in graft size intraoperatively, possibly leading to graft failure. While there are multiple published methods using magnetic resonance imaging (MRI) picture archiving and communication systems (PACS), most are not feasible and practical. Our study aims to (1) practically predict the ACL hamstring graft size in a numerically continuous manner using the preoperative MRI from any native MRI PACS system, (2) determine the degree of correlation between the predicted and actual graft size, and (3) determine the performance of our prediction method if we define an adequate actual graft size as ≥ 8 mm.MethodsA retrospective review of 112 patients who underwent primary ACL reconstruction with quadrupled hamstring semitendinosus-gracilis grafts at a tertiary institution was conducted between January 2018 and December 2018. Graft diameter can be predicted in a numerically continuous manner as √[2*(AB + CD)], where A and B are the semitendinosus cross-sectional length and breath, respectively, and C and D are the gracilis cross-sectional length and breath, respectively.ResultsA moderately positive correlation exists between the predicted and actual graft diameter (r = 0.661 and p < .001). Our method yields a high specificity of 92.6% and a moderate sensitivity of 67.2% if we define an adequate actual graft size as ≥ 8 mm. An area under receiver-operating characteristic curve shows good discrimination (AUC = 0.856).ConclusionsWe present a practical method to predict the ACL hamstring graft size with high specificity using preoperative MRI measurements.

Young men undergoing anterior cruciate ligament reconstruction with patellar tendon autograft and anteromedial drilling outperform at 5 to10-year follow-up in terms of graft stability and activity levels compared to those undergoing reconstruction with hamstring autograft and transtibial drilling

ObjectiveTo compare 5 to 10-year outcomes of anterior cruciate ligament (ACL) reconstruction in young men performed with bone-patellar tendon bone (BPTB) autograft and anteromedial portal to reconstruction with hamstring autograft and transtibial technique. It was hypothesized that in young adult men, at 5 to 10-year follow-up, superior restoration of knee laxity and activity levels would be demonstrated using BPTB autograft and anteromedial portal technique. MethodsNinety-four men who had ACL reconstruction with BPTB autograft and anteromedial portal were eligible for comparison to 106 men who had reconstruction with hamstring autograft and transtibial technique. Inclusion criteria were: (1) age 18-35 years, (2) ACL tear caused by sports trauma only, (3) no concomitant ligament reconstruction, and (4) 5 to 10-year follow-up. Outcome measures compared between the two groups included Lachman and pivot shift tests, KT side-to-side difference, Tegner and Marx scores, International Knee Documentation Committee (IKDC)-subjective score, Knee Osteoarthritis Outcome Scale (KOOS), Short Form (SF)-36, and single hop test for distance. P value < 0.05 indicated statistical significance. ResultsForty-five patients with BPTB and 55 patients with hamstring ACL reconstruction were available for in-person assessment at 5 to 10 years after surgery. Outcomes in the BPTB group compared to the hamstring group showed KT difference 1.4±1.9-mm vs. 2.8±2.3-mm (p < 0.01), pivot shift grade 2-3 in 4% vs. 34% (p < 0.01), return to preinjury Tegner level in 51% vs. 36% (p < 0.01) and to preinjury Marx score in 29% vs. 11% (p < 0.01), and IKDC-subjective 88±10 vs. 82±13 vs. (p < 0.01), respectively. Statistically significant inter-relationships were found between KT side-to-side difference and the Tegner, Marx, and IKDC-subjective scores at follow-up (r = -0.314, p < 0.01; r = -0.263, p < 0.01; r = -0.218, p = 0.03, respectively). ConclusionYoung men undergoing ACL reconstruction with patellar tendon autograft and anteromedial drilling outperform at 5 to10-year follow-up in terms of graft stability and activity levels compared to young men undergoing reconstruction with hamstring autograft and transtibial drilling. Level of evidenceIII (Retrospective cross-sectional comparative study).

Influence of female sex and double-quadruple semitendinosus-gracilis graft on the incidence of postoperative symptomatic cyclops lesions after ACL reconstruction.

Risk factors for the development of symptomatic cyclops lesion after anterior cruciate ligament reconstruction (ACLR) surgery are not entirely identified yet. This study aimed to investigate whether the choice of hamstring graft (semitendinosus-gracilis; STG vs. semitendinosus; ST) affects the risk of developing a symptomatic cyclops lesion after ACLR. This retrospective cohort study included 1416 patients receiving either an ST graft (n = 1209) or an STG graft (n = 207) ACLR with a follow-up of at least 2 years. A persisting extension limitation was clinically determined, and cyclops lesions were confirmed by magnetic resonance imaging (MRI) and second-look arthroscopy. Graft-specific incidence of cyclops lesions was examined with χ2 test and combined with the factors number of graft bundles, graft diameter and sex evaluated with a binominal logistic regression model. In total, 46 patients developed symptomatic cyclops lesions (3.2%), with 36 having ACLR with an ST graft (3.0%) and 10 with an STG graft (4.8%) (n.s). The mean time from ACLR to the second-look arthroscopy for cyclops removal was 1.1 ± 0.6 years. Female patients were 2.5 times more likely to develop a cyclops lesion than male patients. Patients with an STG graft and larger graft diameters did not have a higher risk of developing cyclops lesions. Patients who received an STG graft with both tendons folded four times (double-quadruple) had significantly higher risk of developing a cyclops compared with all other numbers of graft bundles combined (8.3%, respectively 3.0%; p = 0.014). This study could not prove an increased risk of developing a symptomatic cyclops lesion for patients with an STG graft compared with an ST graft used for ACLR. However, patients with a double-quadruple ACLR had a higher percentage of cyclops lesions compared with all other numbers of graft bundles. Female sex was associated with an increased risk of developing cyclops lesions. Level III.

Combined Anterior Cruciate Ligament Reconstruction (ACLR) and Lateral Extra-articular Tenodesis through the Modified Lemaire Technique versus Isolated ACLR: A Meta-analysis of Clinical Outcomes.

Objective  Lateral extra-articular tenodesis (LET) has been proposed to resolve rotatory instability following anterior cruciate ligament reconstruction (ACLR). The present meta-analysis aimed to compare the clinical outcomes of ACLR and ACLR with LET using the modified Lemaire technique. Materials and Methods  We performed a meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) staement. The literature search was performed on the PubMed, EBSCOHost, Scopus, ScienceDirect, and WileyOnline databases. The data extracted from the studies included were the study characteristics, the failure rate (graft or clinical failure) as the primary outcome, and the functional score as the secondary outcome. Comparisons were made between the patients who underwent isolated ACLR (ACLR group) and those submitted to ACLR and LET through the modified Lemaire technique (ACLR + LET group). Results  A total of 5 studies including 797 patients were evaluated. The ACLR + LET group presented a lower risk of failure and lower rate of rerupture than the ACLR group (risk ratio [RR] = 0.44; 95% confidence interval [95%CI]: 0.26 to 0.75; I 2  = 9%; p  = 0.003). The ACLR + LET group presented higher scores on the Knee Injury and Osteoarthritis Outcome Score (KOOS) regarding the following outcomes: pain, activities of daily living (ADL), sports, and quality of life (QOL), with mean differences of 0.20 (95%CI: 0.10 to 0.30; I 2  = 0%; p  < 0.0001), -0.20 (95%CI: -0.26 to -0.13; I 2  = 0%; p  < 0.00001), 0.20 (95%CI: 0.02 to 0.38; I 2  = 0%; p  = 0.03), and 0.50 (95%CI: 0.29 to 0.71; I 2  = 0%; p  < 0.00001) respectively when compared with the ACLR group. Conclusion  Adding LET through the modified Lemaire technique to ACLR may improve knee stability because of the lower rate of graft rerupture and the superiority in terms of clinical outcomes. Level of Evidence  I.

Evaluation of Failed ACL Reconstruction: An Updated Review.

Failure rates among primary Anterior Cruciate Ligament Reconstruction (ACLR) range from 3.2% to 11.1%. Recently, there has been increased focus on surgical and anatomic considerations which predispose patients to failure, including excessive posterior tibial slope (PTS), unaddressed high-grade pivot shift, and improper tunnel placement. The purpose of this review was to provide a current summary and analysis of the literature regarding patient-related and technical factors surrounding revision ACLR, rehabilitation considerations, overall outcomes and return to sport (RTS) for patients who undergo revision ACLR. There is a convincingly higher re-tear and revision rate in patients who undergo ACLR with allograft than autograft, especially amongst the young, athletic population. Unrecognized Posterior Cruciate Ligament (PLC) injury is a common cause of ACLR failure and current literature suggests concurrent operative management of high-grade PLC injuries. Given the high rates of revision surgery in young active patients who return to pivoting sports, the authors recommend strong consideration of a combined ACLR + Anterolateral Ligament (ALL) or Lateral extra-articular tenodesis (LET) procedure in this population. Excessive PTS has been identified as an independent risk factor for ACL graft failure. Careful consideration of patient-specific factors such as age and activity level may influence the success of ACL reconstruction. Additional technical considerations including graft choice and fixation method, tunnel position, evaluation of concomitant posterolateral corner and high-grade pivot shift injuries, and the role of excessive posterior tibial slope may play a significant role in preventing failure.