Bone-patellar Tendon-bone Autograft Research Articles

The Influence of Platelet-Rich Fibrin on the Healing of Bone Defects after Harvesting Bone-Patellar Tendon-Bone Grafts.

Background and Objectives: A bone-patellar tendon-bone (BTB) autograft in anterior cruciate ligament reconstruction (ACLR) is still considered the gold standard among many orthopedic surgeons, despite anterior knee pain and kneeling pain being associated with bone defects at the harvest site. Bioregenerative products could be used to treat these defects, perhaps improving both the postoperative discomfort and the overall reconstruction. Materials and methods: During a year-long period, 40 patients were enrolled in a pilot study and divided into a study group, in which bone defects were filled with Vivostat® PRF (platelet-rich fibrin), and a standard group, in which bone defects were not filled. The main outcome was a decrease in the height and width of the bone defects, as determined by magnetic resonance imaging on the control exams during the one-year follow-up. The secondary outcomes included an evaluation of kneeling pain, measured with a visual analog scale (VAS), and an evaluation of the subjective knee scores. Results: The application of Vivostat® PRF resulted in a more statistically significant reduction in the width of the defect compared with that of the standard group, especially at 8 and 12 months post operation (p < 0.05). Eight months following the surgery, the study group's anterior knee pain intensity during kneeling was statistically considerably lower than that of the standard group (p < 0.05), and the statistical difference was even more obvious (p < 0.01) at the last follow-up. Each control examination saw a significant decrease in pain intensity in both the groups, with the values at each exam being lower than those from the prior exam (p < 0.01). A comparison of subjective functional test results 12 months post operation with the preoperative ones did not prove a statistically significant difference between the groups. Conclusions: The use of Vivostat® PRF reduces kneeling pain and accelerates the narrowing of bone defects after ACLR with a BTB graft, but without confirmation of its influence on the subjective knee score.

An Isolated Midsubstance ACL Tear Repaired With the BEAR System

Background: Anterior cruciate ligament (ACL) repairs, once widely abandoned due to historically high failure rates, have recently regained interest with the development of the bridge-enhanced ACL repair (BEAR) implant, a novel arthroscopic technique that uses a resorbable protein-based implant combined with autologous blood to primarily repair a midsubstance ACL tear. This technical note presents a step-by-step surgical method for performing an isolated midsubstance ACL repair using the BEAR implant. Indications: The BEAR implant is indicated for skeletally mature patients at least 14 years of age with a complete rupture of the ACL, confirmed by magnetic resonance imaging. The complete ACL tear must have an attached stump to the tibia. Technique Description: A diagnostic arthroscopy is used to confirm complete rupture of the ACL and presence of residual tibial stump. A self-retrieving suture passage device is used to whipstitch a total of 6 passes with #2 Vicryl suture from distal to proximal through the residual stump. A notchplasty followed by femoral and tibial tunnels is created in a standard fashion. An Endobutton, soaked in a bacitracin solution, is then loaded with the sutures that were previously passed through the residual ACL stump and then through the femoral tunnel and cinched down to bone. The 4 suture ends that are coming from the Endobutton are then passed through the BEAR implant with the use of a Keith needle and shuttled through the tibial tunnel. The BEAR implant is hydrated with 15 cc of the patient's blood and is shuttled through the anteromedial portal with the knee in full extension. The 4 tibial sutures passed through the graft and tibial tunnel are passed, and tensioned to the proximal tibial with a second Endobutton. Standard closure and dressings are applied. Results: This new surgical implant and technique have shown noninferiority to ACL autograft reconstruction with respect to the International Knee Documentation Committee and anteroposterior laxity, with improved hamstring strength and decreased incidence of contralateral ACL tears at 2 years postoperative. Discussion/Conclusion: While initial data remain promising, future long-term designed studies are needed to determine the clinical efficacy of the BEAR technique, particularly comparing itself with bone-patellar tendon-bone autograft ACL reconstruction. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Patellar Fracture Forces Are Not Affected by Proximal Versus Distal Bone Block Anterior Cruciate Ligament Reconstruction Harvest Sites in a Cadaveric Model

To quantify the maximum load to fracture in patellae from which bone-patellar tendon-bone (BPTB) and bone-quadriceps tendon (BQT) autografts have been harvested for anterior cruciate ligament reconstruction in a cadaveric model. Forty-six fresh-frozen patellae were isolated and divided into the BPTB harvest and BQT harvest groups with matching based on donor age and sex. Computed tomography scans were obtained to calculate bone mineral density (BMD) and patellar height, width, and thickness. BPTB and BQT grafts were harvested from the inferior patella and superior patella, respectively, and then ramped to failure in a 3-point bend test configuration to simulate a postoperative fracture produced by a direct impact after a fall. The presence of fracture, fracture pattern, and maximum load to fracture were recorded. Donor demographic characteristics; patellar height, width, and thickness; and maximum load were compared by the Student t test. Pearson correlations were used to determine whether maximum load was affected by BMD or patellar morphology. The level of significance was set at P < .05. Maximum load to fracture was not significantly different (P= .91) between the BPTB (5.0 ± 2.3 kN) and BQT (5.1 ± 2.6 kN) groups. Maximum loadto fracture in the BPTB group did not correlate with BMD (P= .57) or patellar measurements (P= .57 for thickness, P= .43 for width, and P= .45 for height). Maximum load to fracture in the BQT group positively correlated with BMD and negatively correlated with patellar height. Maximum load to fracture in the BQT group did not correlate with patellar thickness or width. Fracture through the harvest site was observed in 87% of BPTB specimens and 78% of BQT specimens. The location of the BPTB or BQT autograft harvest site did not significantly affect patellar load to fracture in a cadaveric model. It is important to understand patellar morphology and the effect of BPTB and BQT graft harvest-site locations on the biomechanical strength of the patella after anterior cruciate ligament reconstruction.

Outcomes of bone-patellar tendon-bone autograft and quadriceps tendon autograft for ACL reconstruction in an all-female soccer player cohort with mean 4.8-year follow up

ObjectiveThe purpose is to compare functional outcomes, return to soccer rates, and revision rates in an all-female soccer player cohort undergoing quadriceps tendon (QT) autograft ACLR versus bone-patellar tendon-bone (BPTB) autograft ACLR. MethodsFemale soccer players who sustained an ACL rupture and underwent primary anatomic, single-bundle ACLR with BPTB autograft or QT autograft were included. Demographic and surgical characteristics were collected. Outcomes of interest included Tegner score, International Knee Documentation Committee (IKDC) score, Marx score, return to soccer rates, and failure rates. ResultsData on 23 patients undergoing BPTB autograft ACLR and 14 undergoing QT autograft ACLR was available. Average age was 18.7 years, and average follow up was 4.8 years. Overall, 76 ​% (28/37) returned to soccer and 5.4 ​% (2/37) underwent revision ACLR. No major significant differences were found in demographic or surgical characteristics. No differences were found in postoperative IKDC scores, preoperative, postoperative, or change from pre-to postoperative Marx activity scores, or pre-and postoperative Tegner scores between the groups. QT autograft ACLR patients had significantly less change in Tegner scores pre-to postoperatively compared to the BTPB autograft ACLR group (0.6 ​± ​1.2 versus 2.1 ​± ​1.8; p ​= ​0.02). Both groups had similar rates of return to soccer [78 ​% (18/23) BPTB autograft ACLR versus 71 ​% (10/14) QT autograft ACLR; p ​= ​0.64] and rates of revision (8.7 % (2/23) BPTB autograft ACLR; 0 % (0/14) QT autograft ACLR. ConclusionResults of this study suggest that BPTB autograft ACLR and QT autograft ACLR produce comparable, successful functional and return to soccer outcomes in this all-female soccer player cohort study. Larger, prospective studies are needed to improve the strength of conclusions and provide more information on the optimal graft choice for female soccer players. Surgeons can use the results of this study to counsel female soccer players on expected outcomes after ACLR. Level of EvidenceIII.

Time to treat the tendon rupture induced by surgery: early hypertrophy of the patellar tendon graft site predicts strong quadriceps after ACLR with bone-patellar tendon-bone autograft.

Quadriceps dysfunction is ubiquitous after anterior cruciate ligament reconstruction, especially when using bone-patellar tendon-bone (BPTB) autografts. The role of patellar tendon hypertrophy after graft harvest on knee extensor strength is unknown. The purpose of this study was to determine the predictive ability of patellar tendon (PT) and quadriceps muscle (Quad) cross-sectional area (CSA) on knee extensor strength 1-2months after ACLR using BPTB autografts. This is a cross-sectional analysis of a cohort 1-2months after ACLR using BPTB autograft. Peak knee extensor torque, and PT and Quad CSA measured using ultrasound imaging, were collected in 13 males and 14 females. Simple linear regressions compared quadriceps strength index (QI) against limb symmetry index (LSI) in PT and Quad CSA. Multiple linear regressions with sequential model comparisons predicting peak knee extensor torque were performed for each limb. The base model included demographics. Quad CSA was added in the first model, then PT CSA was added in the second model. Both PT (p < 0.001, R2 = 0.693) and Quadriceps CSA (p = 0.013, R2 = 0.223) LSI had a positive linear relationship with QI. In the involved limb, addition of PT CSA significantly improved the model (R2 = 0.781, ΔR2 = 0.211, p for ΔR2 < 0.001). In the uninvolved limb, the addition of Quad CSA improved the model, but the addition of PT CSA did not. PT LSI was more predictive of QI than Quad CSA LSI. Involved limb PT CSA mattered more in predicting peak knee extensor torque than did Quad CSA, but in the uninvolved limb, Quad CSA was the most important predictor of peak knee extensor torque. Graft site patellar tendon hypertrophy is key for strong quadriceps early after ACLR. Early targeted loading via exercise to promote healing of the graft site patellar tendon may bring patients a step closer to winning their battle against quadriceps dysfunction. Level I.

Full-Thickness Peroneus Longus Tendon Autograft Harvest

Background: Despite extensive evidence of excellent biomechanical and clinical outcomes of ligament reconstructions with bone-patellar tendon-bone, hamstring tendon, and quadriceps tendon autografts, these are not without limitations, including knee-related donor site morbidity, decreased range of motion, and potential for anterior knee pain. Therefore, researchers have explored other options, including the peroneus longus (PL) autograft. Indication: Anterior cruciate ligament (ACL) reconstruction (both primary and revision), as well as multiligament reconstruction, particularly in areas where access to allografts is limited. Surgical Technique: A 3-cm longitudinal skin incision is placed 2 fingerbreadths (or 3 cm) proximal to the tip of the lateral malleolus, and 3 mm posterior to the fibula. The PL and peroneus brevis tendons are identified and isolated, followed by a tenodesis at the distal limit of the incision. The PL is whipstitched proximal to the tenodesis site, and then incised between the tenodesis and whipstitched portion. A closed tendon stripper is inserted and advanced proximally until the PL graft is released. Discussion/Conclusion: PL autograft harvest has been shown to generate thicker and longer grafts relative to the semitendinosus, with demonstrated efficacy in terms of both biomechanical and clinical outcomes. Current literature points largely to a good safety profile, although there is still conflicting evidence in terms of foot and ankle morbidity and no mid- to long-term follow-up data available. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form.

Tibial Press-Fit Fixation Technique in Anterior Cruciate Ligament Reconstruction Surgery

Implant-free press-fit tibial fixation technique has recently gained popularity in anterior cruciate ligament reconstruction because it does not cause tunnel widening, does not cause complications associated with additional fixation materials, allows bone-to-bone healing, and does not cause defects in revision surgery. Bone-patellar tendon autograft offers the advantage of direct bone-to-bone integration of the graft, and anterior knee pain is less expected than bone-patellar tendon-bone autograft. This technical report includes details of arthroscopic ACL reconstruction of patellar tendon-tibial tubercle bone autograft distal press-fit fixation technique. We call this the Kocabey distal press-fit technique.

Postoperative quadriceps weakness and male sex are risk factors for patellofemoral articular cartilage lesions after anatomical anterior cruciate ligament reconstruction

PurposePatellofemoral (PF) compartment cartilage lesions are a frequent problem after anterior cruciate ligament (ACL) reconstruction. This study aimed to determine the factors that influence PF cartilage lesions after anatomical ACL reconstruction.MethodsThis study enrolled a total of 114 patients who did not manifest PF compartment cartilage lesions during anatomical ACL reconstruction and underwent second-look arthroscopy 18 months postoperatively. Arthroscopy using the International Cartilage Repair Society (ICRS) classification was used to assess cartilage lesions. The correlation between surgical findings, radiographic factors, and clinical factors and change of ICRS grade was analysed. Multivariate regression analysis was conducted to reveal the independent risk factors for PF cartilage lesions among patients’ demographic data and parameters that correlated with the change of ICRS grade in the correlation analyses.ResultsICRS grade changes in PF cartilage were significantly correlated with age, sex, quadriceps strength at 1 year postoperatively, hamstrings strength at pre- and 1 year postoperatively, and single leg hop test at 1 year postoperatively. However, no significant correlation was found between the time between injury and surgery, posterior tibial slope angle, pre- and postoperative Tegner activity scale, graft type, initial graft tension, meniscus injury, meniscus injury treatment, pre- and postoperative range of motion, anteroposterior laxity and preoperative quadriceps strength, and the change in ICRS grade. Multivariate regression analysis revealed male (P = 0.019) and quadriceps strength weakness at 1 year postoperatively (P = 0.009) as independent risk factors for PF cartilage lesions.ConclusionsQuadriceps strength weakness 1 year after ACL reconstruction and males were correlated with a new PF cartilage lesion after anatomical ACL reconstruction, with no significant correlation between bone-patellar tendon-bone autograft, initial graft tension, or extension deficit and new PF cartilage lesion. Rehabilitation that focuses on quadriceps strength after ACL reconstruction is recommended to prevent new PF cartilage lesions.Level of evidenceLevel IV.

Quadriceps tendon autograft has similar clinical outcomes when compared to hamstring tendon and bone-patellar tendon-bone autografts for revision ACL reconstruction: a systematic review and meta-analysis.

Research regarding revision anterior cruciate ligament reconstruction (RACLR) with quadriceps tendon (QT) autografts is lacking. The purpose of this study was to perform a systematic review and meta-analysis of RACLR with QT and compare its patient outcomes to RACLR with hamstring tendon (HT) and bone-patellar tendon-bone (BTB) autografts. Adhering to PRISMA guidelines, a search for studies using QT in RACLR was performed within PubMed, Scopus, and CINAHL from database date of inception through December 26, 2022. Primary outcomes sought included: failure rate, Lysholm scores, International Knee Documentation Committee (IKDC) scores, IKDC grades, arthrometric knee side-to-side differences (STSD), pivot shift grade, donor site morbidity, return to sport, visual analog scale (VAS) pain scores. Nine studies were included consisting of 606 RACLR: 349 QT, 169 HT, and 88 BTB. Overall failure rates were 7.6% QT, 13.3% HT, and 8.7% BTB. Mean weighted Lysholm scores were 85.8 ± 3.8 QT, 82.5 ± 3.8 HT and 86.6 ± 4.5 BTB. IKDC average scores were 82.3 ± 1.6 QT, 80.1 ± 1.7 HT, and 81.7 ± 5.5BTB. Combined rates of IKDC A/B grades were 88.4% and 80.0% for QT and HT, respectively. VAS average scores were 0.9 ± 1.1 QT, 1.4 ± 0.2 HT, and 0.7 ± 0.8 for BTB. Side-to-side difference was reported for QT and HT with average values of 1.7 ± 0.6mm and 2.1 ± 0.5mm, respectively. Grade 0 or 1 pivot shifts were reported in 96.2% of QT patients and 91.3% of HT. Donor site morbidity, only reported for QT and HT, was 14.6 ± 9.7% and 23.6 ± 14.1%, respectively. QT resulted in a mean Tegner score of 5.9 ± 1.5 versus HT 5.7 ± 1.5. Rate of return to pivoting sports was 38.0% QT, 48.6% HT, and 76.9% BTB. Across all outcomes, there was no significant difference when comparing QT to HT, QT to BTB, and QT compared to HT and BTB combined. RACLR with QT yields satisfactory patient reported outcomes, satisfactory improvement in knee laxity, expected return to sport rates, and has an overall 7.6% failure rate. Outcomes are comparative to those of HT and BTB making it an acceptable graft choice for RACLR. Surgeons should consider using QT autograft for RACLR, especially when other autografts are unavailable. IV.

Strength symmetry after autograft anterior cruciate ligament reconstruction

ObjectiveTo compare postoperative isometric quadriceps strength indices (QI%) and hamstring strength limb symmetry indices (HI%) between partial thickness quadriceps tendon (pQT), full thickness quadriceps tendon (fQT), and bone-patellar-tendon bone (BPTB) autograft anterior cruciate ligament reconstruction (ACLR). MethodsPatients with primary ACLR with pQT, fQT, or BPTB autograft with the documentation of quantitative postoperative strength assessments between 2016 and 2021 were included. Isometric Biodex data, including QI% and HI% (calculated as the percentage of involved to uninvolved limb strength) were collected between 5 and 8 months and between 9 and 15 months postoperatively. ResultsIn total, 124 and 51 patients had 5–8- and 9–15-month follow-up strength data, respectively. No significant difference was detected between groups for sex. However, patients undergoing fQT were found to be older than those undergoing BPTB (24.6±7 vs 20.2±5; ​p = 0.01). There were no significant differences in the number of concomitant meniscus repairs between the groups (pQT vs. fQT vs. BPTB). No significant differences were detected in median (min–max) QI% between pQT, fQT, and BPTB 5–8 months [87 ​% (44%–130 ​%), 84 ​% (44%–110 ​%), 82 ​% (37%–110 ​%) or 9–15 months [89 ​% (50%–110 ​%), 89 ​% (67%–110 ​%), and 90 ​% (74%–140 ​%)] postoperatively. Similarly, no differences were detected in median HI% between the groups 5–8 months or 9–15 months postoperatively. ConclusionThe study was unable to detect differences in the recovery of quadriceps strength between patients undergoing ACLR with pQT, fQT, and BPTB autografts at 5–8 months and 9–15-months postoperatively. Level of evidenceIII.

Role of Quadriceps Tendon Autograft in Primary and Revision Anterior Cruciate Ligament Reconstruction.

» The quadriceps tendon (QT) autograft is becoming increasingly popular in both primary and revision anterior cruciate ligament reconstruction (ACLR).» The biomechanical properties of the QT are similar to those of the native ACL, the hamstring tendon (HT), and bone-patellar tendon-bone (BTB) autografts.» QT autograft allows surgeons to be flexible with their graft size and reconstruction technique.» The QT autograft performs in a similar fashion to the BTB and HT autografts, with excellent patient-reported outcomes, consistent postoperative knee stability, and low rates of postoperative complications including graft failure and donor site morbidity.» There are emerging data that the QT autograft is a viable option in revision ACLR.

Current development in surgical techniques, graft selection and additional procedures for anterior cruciate ligament injury: a path towards anatomic restoration and improved clinical outcomes-a narrative review.

Anterior cruciate ligament (ACL) reconstruction has been widely used for ACL injury for a long time. However, residual rotational instability and osteoarthritic changes after ACL reconstruction have been identified as problems. Thus, anatomic reconstruction techniques, various types of grafts and additional procedures have been desired to improve the clinical outcomes and knee instability. Although clinical outcomes and knee stability are better than in the past, ipsilateral graft failures still occur in 4-17% and osteoarthritic changes are seen in about 20% of patients after ACL reconstruction. To remedy these problems, it is necessary to improve the understanding of various surgical techniques and grafts and to pursue further improvement of surgical techniques. Therefore, the objective of this review is to summarize the advantages and disadvantages of various surgical techniques and graft selection, and additional procedures for ACL injury. A literature review was conducted on the surgical procedures for ACL injury. Recent trends in surgical techniques, graft selection, and additional procedures for ACL injury were described. We performed a literature search in PubMed for studies published from origin to May 8, 2023. Studies were required to be English-language articles. Although many reports indicate that double-bundle ACL reconstruction is comparable to anatomic single-bundle (SB) reconstruction, intraoperative complications such as tunnel coalition exist in double-bundle reconstruction, and the technique needs to be improved. ACL repair has shown good short-term results, but long-term results need to be examined in the future. Quadriceps tendon autograft is being used more frequently, but hamstrings tendon autograft and bone-patellar tendon-bone autograft also have good results. In addition, in higher-risk cases, lateral extra-articular tenodesis (LET) and anterolateral ligament (ALL) reconstruction can be performed with good results. To further improve clinical outcomes, more anatomical reconstructions should be pursued. Autografts are better than allografts and synthetic grafts, but further study is needed to determine which graft is better. Additional procedures should be performed in highly unstable cases and in revision cases.

ACL Reconstruction With Quadriceps Soft Tissue Autograft Versus Bone-Patellar Tendon-Bone Autograft in Cutting and Pivoting Athletes: Outcomes at Minimum 2-Year Follow-up.

The optimal graft choice for anterior cruciate ligament (ACL) reconstruction (ACLR) in the high-level cutting and pivoting athlete remains controversial. Studies have shown similar outcomes when directly comparing bone-patellar tendon-bone (BPTB) autograft versus quadriceps soft tissue (QST) autograft in the general population. However, no studies have directly compared these 2 grafts in athletes participating in cutting and pivoting sports. It was hypothesized that, compared with BPTB autograft, the QST autograft would result in similar patient-reported outcomes and rates of retear, return to sport, and complications. Cohort study; Level of evidence, 3. A retrospective review was performed on athletes participating in cutting and pivoting sports (soccer, American football, lacrosse, and basketball) who underwent primary ACLR with either BPTB autograft or QST autograft chosen by the athlete between January 2015 and January 2019. The International Knee Documentation Committee (IKDC) subjective knee evaluation and Lysholm Knee Scoring Scale were used to evaluate patient-reported outcomes. Return-to-sport and complication rates were identified. Descriptive statistics were expressed using Mann-Whitney test or Student t test for continuous variables and the chi-square test for categorical variables. A total of 68 athletes (32 QST, 36 BPTB) were included for analysis. The percentage follow-up was 89% (32/36) for the QST autograft group and 86% (36/42) for the BPTB autograft group. The 2-year IKDC score (QST, 90.5 ± 6.6 vs BPTB, 89.7 ± 7.8) and 2-year Lysholm score (QST, 91.3 ± 7.5 vs BPTB, 90.5 ± 8.6) were similar between groups. The percentage of athletes able to return to sport within the follow-up period was also similar (88% vs 83%; P = .63). There were 2 retears requiring revision in the BPTB group (6%) and no retears in the QST group (P = .18). One contralateral ACL rupture occurred in the QST group (3%) and 4 in the BPTB group (11%) (P = .21). The QST and BPTB autografts demonstrated similar patient-reported outcomes, return-to-sport rates, and complication rates after primary ACLR at 2-year follow-up. Both autografts appear to be reliable and consistent options for ACLR in the cutting and pivoting athlete.

Tips and Tricks for Anatomic ACL Reconstruction With Soft-Tissue Quadriceps Tendon and Remnant Repair

Background: Quadriceps tendon (QT) autograft represents an excellent option for anterior cruciate ligament (ACL) reconstruction (ACLR), with minimal donor site morbidity and failure rates comparable with bone-patellar tendon-bone (BPTB) autograft. This video aims to provide technical tips for ACLR using all-soft-tissue QT autograft. Indications: ACLR with QT autograft is indicated in young, active ACL-injured patients who desire a return to sport. It represents a viable option in both primary and revision ACLR, as well as in skeletally immature patients. It is particularly indicated in those who kneel frequently, such as wrestlers or laborers, due to the lower incidence of postoperative anterior knee pain. Technique Description: A vertical incision is used to harvest a 10 mm × 70 mm partial thickness, all-soft-tissue QT graft. Care is taken not to violate the capsule or musculature. If necessary, graft size is modified based on preoperative magnetic resonance imaging (MRI) measurement of the notch width. The graft is then prepared with continuous loop suspensory fixation on the femoral side and draw sutures on the tibial side. The lateral femoral notch is debrided to allow for visualization of the posterior wall to enable anatomic tunnel placement. When possible, the tibial stump is preserved. The femoral tunnel is drilled via an anteromedial portal and the tibial tunnel via a tibial guide. The graft is then passed through the tibial stump into the femur. It is fixed on the tibial side with a PEEK interference screw in full extension with application of a posterior drawer. Results: Outcomes following ACLR with QT autograft are excellent, with laxity and patient-reported outcomes comparable with those following ACLR with BPTB and hamstring autograft. Furthermore, QT ACLR has been shown to result in less donor site morbidity than BPTB autograft, and lower rates of failure and infection compared with hamstring autograft. Conclusion: ACLR with QT autograft is a good option in young, active patients in both the primary and revision settings. Advantages of QT ACLR include less donor site morbidity than BPTB, and lower rates of failure compared with hamstring autograft in young patients. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Patients With Segond Fracture Demonstrate Similar Rates of Return to Sport and Psychological Readiness After Anterior Cruciate Ligament Reconstruction: A Matched Cohort Study at Minimum 2-Year Follow-Up

To compare clinical outcomes, rate of return to sports, and psychological readiness among patients undergoing anterior cruciate ligament reconstruction (ACLR) with and without concomitant Segond fracture. We retrospectively identified patients who underwent primary ACLR from January 2012 to December 2020 with minimum 2-year follow-up. Exclusion criteria were additional ligamentous injury, age <16 years, or a concomitant lateral augmentation procedure. Preoperative knee radiographs were reviewed to identify Segond fractures. Identified patients were matched 1:2 to controls by age/sex/body mass index/graft type. Charts were reviewed for pre- and postoperative knee stability. Surveys administered included preinjury sport participation and return status, Lysholm score, Tegner activity scale, and ACL-Return to Sport Index (ACL-RSI), a metric of psychological sport readiness. Multivariable logistic regression was conducted to identify predictors of return to sport. There were 120 patients who were included in the final analysis (40 Segond, 80 controls) at a mean follow-up of 5.7 ± 2.4 years. A total of 52.5% of patients received bone-patellar tendon-bone autograft. The overall rate of return to sport was 79.5% in the Segond group compared with an 83.8% rate of return in the control group (P= .569). In total, 48.7% of the Segond group and 56.8% of the control group returned to their preinjury level of sport (P= .415). Lysholm (89.6 ± 10.3 vs 85.4 ± 16.7, P= .296), Tegner (5.7 ± 1.8 vs 6.1 ± 2.2, P= .723), and ACL-RSI (62.2 ± 25.4 vs 56.6 ± 25.4, P= .578) scores were similar between Segond and control groups. There was a single graft failure in the Segond group 5 years' postoperatively. Increasing ACL-RSI score was significantly predictive of return to sport (P < .001). Patients who had an ACL tear and a concomitant Segond fracture who underwent isolated ACLR without lateral augmentation procedures had similar clinical outcomes and rates of return sport compared with a matched isolated ACLR control group at minimum 2-year follow-up. There was no significant difference in psychological readiness between groups as measured by the ACL-RSI. Level III, retrospective cohort study.

Outcome of Primary Anterior Cruciate Ligament Reconstruction with Peroneus Longus and Bone–Patellar Tendon–Bone Autografts: A Clinical Comparative Study

Background: The aim of this study is to compare the mid-term outcomes of primary tear of the anterior cruciate ligament (ACL) reconstruction via the use of peroneus longus tendon (PLT) and bone–patellar tendon–bone (BPTB) autografts. Methods: 53 patients (group 1) received ACL reconstruction via BPTB, whereas 55 patients (group 2) received arthroscopic ACL reconstruction using PLT autograft. Results: In group 1, the mean preoperative and postoperative scores on the Lysholm Knee Questionnaire (LKQ) scale resulted in 69.2 ± 10.7 points and −92.2 ± 6.4 points, respectively. The average preoperative and postoperative value on the International Knee Documentation Committee (IKDC) scale was 68.2 ± 10.6% and −90.1 ± 9.5%, respectively. For KT-1000, according to the results of surgical treatment, it is −3.7 ± 1.4 mm, and for the American Orthopaedic Foot &amp; Ankle Society (AOSAF) it is −95.3 ± 4.5%. The autograft ruptured within 2 years after operation in 4 of 50 patients. In group 2, the mean score on the LKQ scale before the operation was 70.2 ± 11.6 points, after −94.3 ± 0.5 points. The average value on the IKDC scale before surgery was 68.6 ± 8.7%, after −91.5 ± 8.2%. KT-1000 −3.4 ± 1.2 mm. Conclusion: The results in both groups can be assessed as good; peroneus longus muscle tendon autograft is an alternative graft for the primary reconstruction of ACL, preserving the dynamic stabilizers of the knee and has no effect on the formation of flat feet and other disease in the postoperative period.

Clinical outcomes of different autografts used for all-epiphyseal, partial epiphyseal or transphyseal anterior cruciate ligament reconstruction in skeletally immature patients – a systematic review

BackgroundDifferent types of grafts can be used for anterior cruciate ligament reconstruction (ACLR). There is little published data regarding skeletally immature patients. The purpose of this systematic review was to assess the clinical outcomes and complications for different autograft types used in all-epiphyseal, transphyseal and partial epiphyseal/hybrid ACLR in skeletally immature children and adolescents.MethodsPubMed, Embase and Cochrane databases were systematically searched for literature regarding ACLR using hamstrings, quadriceps or bone-patellar-tendon-bone (BPTB) autografts in skeletally immature patients. Studies were included if they examined at least one of the following outcomes: graft failure, return to sport(s), growth disturbance, arthrofibrosis or patient reported outcomes and had a minimum follow-up of 1 year. Case reports, conference abstracts and studies examining allografts and extra-articular or over-the-top ACL reconstruction techniques were excluded. Graft failure rates were pooled for each graft type using the quality effects model of MetaXL. A qualitative synthesis of secondary outcomes was performed.ResultsThe database search identified 242 studies. In total 31 studies were included in this review, comprising of 1358 patients. Most patients (81%) were treated using hamstring autograft. The most common used surgical technique was transphyseal. The weighted, pooled failure rate for each graft type was 12% for hamstring tendon autografts, 8% for quadriceps tendon autografts and 6% for BPTB autografts. Confidence intervals were overlapping. The variability in time to graft failure was high. The qualitative analysis of the secondary outcomes showed similar results with good clinical outcomes and low complication rates across all graft types.ConclusionsBased on this review it is not possible to determine a superior graft type for ACLR in skeletally immature. Of the included studies, the most common graft type used was the hamstring tendon. Overall, graft failure rates are low, and most studies show good clinical outcomes with high return to sports rates.

Comparison of “ligamentization” process between preserved insertion hamstring tendon autograft and bone-patellar tendon-bone autograft

BackgroundLigamentization is a complex process and effect of preservation of hamstring tendon graft insertion on this process is not well studied. Present study was conducted to analyze and compare the ligamentization of semitendinosus gracilis graft with preserved tibial insertion (STGPI) and bone-patellar tendon-bone (BPTB) autografts. MethodsA total of 50 sportspeople who underwent ACL reconstruction using either BPTB (group A; n = 25) or STGPI (group B; n = 25) autografts were included in the study. Contrast enhanced MRI was done at 8 months and 14 months post-ACL reconstruction to evaluate the ligamentization using Signal noise quotient (SNQ), graft intensity and enhancement index. Clinical outcomes (Lysholm score) and knee laxity were also assessed at 8 months and 14 months. Results18/23 (78%) patients in group A and 14/23 (61%) patients in group B had hyperintense graft signal at 8 months (n.s.) and at 14 months, 1/23 patients in group A and none of the patients in group B had hyperintense graft. SNQ at 8 months was 3.6 ± 2 and 3.7 ± 2 in group A and B respectively (n.s.) and at 14 months, SNQ was 2.5 ± 1.5 in group A and 2.4 ± 1.3 in group B (n.s.). Enhancement index at 8 months was 1.5 ± 0.3 and 1.2 ± 0.3 in group A and B respectively (p = 0.0001). Enhancement index at 14 months was 1.21 ± 0.2 in group A and 1.07 ± 0.2 in group B (p = 0.003). Functional outcomes and knee laxity were comparable in both the groups at 8 and 14 months (n.s.). ConclusionBoth the grafts i.e. BPTB and STGPI are similar in terms of rate and extent of ligamentization. Clinical outcomes and knee laxity are also comparable between two grafts.

Increased Bone Plug Depth From the Joint Increases Tunnel Enlargement in Anterior Cruciate Ligament Reconstruction Using Bone–Patellar Tendon–Bone Autograft With Suspensory Femoral Fixation

To determine a safe bone plug depth fixation zone based on early tunnel enlargement rates in anterior cruciate ligament (ACL) reconstruction using bone-patellar tendon-bone (BPTB) autograft with suspensory femoral fixation. Patients who had undergone rectangular tunnel ACL reconstruction using BPTB autograft with suspensory femoral fixation were retrospectively identified. Femoral and tibial tunnel aperture areas were measured on computed tomography 2 weeks and 6 months after surgery to calculate rates of femoral and tibial tunnel enlargement (FTE and TTE), respectively. Femoral bone plug depth (FBPD) and tibial bone plug depth (TBPD) were defined as the distance of the tip of the plug from the respective joint lines. Optimal FBPD and TBPD cutoff values were calculated for the following rates of FTE and TTE, respectively: 0%, 15%, 30%, and 50%. Sixty-four patients (19 females, 45 males; mean age, 29.5 ± 12.3 years) were included in the study. The femoral and tibial tunnel apertures significantly enlarged over time. FBPD (P < .001; r= 0.607) and TBPD (P= .013; r= 0.308) were positively correlated with FTE and TTE, respectively. The optimal FBPD cutoff value was 2.8 mm for FTE rates of 0% and 15%, 3.6 mm for 30%, and 6.0 mm for 50%. The optimal TBPD cutoff value was 1.48 mm for a 0% TTE rate and 5.1 mm for those higher. The cutoff value specificities were lower for the tibial tunnel than the femoral tunnel for each tunnel enlargement rate. Early tunnel enlargement and bone plug depth were significantly correlated in bone the femoral and tibial tunnels. The degree of correlation was higher in the femoral tunnel. To minimize bone tunnel enlargement, the distal end of the femoral bone plug should be placed less than 2.8 mm from the tunnel aperture. Level IV, therapeutic case series.

Anterior Cruciate Ligament Reconstruction and Accelerated Rehabilitation with InternalBrace™ Augmentation in a Professional Footballer.

Interest in anterior cruciate ligament (ACL) repair has been increasing as an alternative to traditional reconstructive techniques and encouraging results have been demonstrated using internal bracing with suture tape augmentation (FiberTape®, Arthrex, Naples, Florida). ACL repair is challenging if the rupture is mid-substance or distal. We describe the case of a hybrid ACL reconstruction with internal brace augmentation. This retrospective case report documents the rehabilitation process of a 31-year-old professional footballer who had an isolated ACL rupture. The patient underwent a hybrid ACL reconstruction with bone-patellar tendon-bone autograft and suture tape augmentation 10 days after his injury. A task-based rehabilitation programme defined by six progressive phases relevant to performance-based outcome measures was undertaken. Each phase had clear, functional, progressive goals incorporating exercises to improve mobility, neuromuscular control, strength, and a progressive return to running and sport-specific movements. Using the rehabilitation framework outlined, this player produced excellent results in all objective criteria postoperatively and was able to return to unrestricted full team training in under five months (146 days) following surgery. This case presentation demonstrates the safe and accelerated return to professional football following ACL reconstruction augmented with internal bracing. The player was able to meet all criteria-based aspects of return to play.