Bone-patellar Tendon-bone Allograft Research Articles

A Single-Surgeon 35-Year Experience With ACL Reconstruction Using Patellar Tendon Auto- and Allografts With the Transtibial Technique.

Long-term follow-up for anterior cruciate ligament reconstruction (ACLR) is limited due to heterogeneity in the number of techniques utilized, the number of surgeons included, and attrition bias. To analyze a single surgeon's 35-year experience with ACLR using the transtibial technique, with an emphasis on temporal trends in graft selection and subanalyses on rates of revision surgery, contralateral ACLR, and nonrevision reoperation among different demographic cohorts of patients. Case series; Level of evidence, 4. All patients who underwent arthroscopically assisted single-bundle ACLR between 1986 and 2021 were identified from a prospectively maintained single-surgeon registry. Outcomes of interest included revision, reoperation, and contralateral rupture rates. A total of 2915 ACLRs were performed during the senior surgeon's career. The mean age for primary ACLR was 29.4 ± 14.8 years. During primary ACLR, 98.4% of patients received a central-third bone-patellar tendon-bone (BPTB) graft. Increasing patient age was associated with increasing allograft usage (P < .01), with a significant temporal increase in allograft usage over the senior surgeon's career (P < .01). There was a higher revision rate among younger patients (P < .01), female patients aged 21 to 25 years (P = .01), and patients who received an allograft during the primary procedure (P = .04). The contralateral rupture rate showed no difference between sexes (P = .34); however, patients who underwent ACLR with autograft had a greater rate of contralateral injury compared with those with allograft (P < .01). The contralateral rupture rate was greater than the revision rate (P < .01). The most common causes of nonrevision reoperation were failed meniscal repair, new meniscal tears, arthrofibrosis, and painful hardware removal. The findings of this single-surgeon registry reveal temporal trends in ACLR over a 35-year career. There was a trend toward increasing BPTB allograft use in ACLR, especially in older patients and revision cases. A greater revision rate was observed among younger patients, female patients, and those receiving allografts during primary surgery. Contralateral ACLR was more common than revision surgery.

Patients’ under 25 subjective readiness to return to sport after ACL reconstruction with bone-patellar-bone grafts: Autograft vs. allograft

PurposeTo assess the difference in perceived readiness to return to sport (RTS) within the first year postoperative period between individuals undergoing anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BTB) autografts or allografts. MethodsThis was a prospective cohort study of patients undergoing primary ACL reconstruction done either with BTB autograft or allograft from 2010 to 2018. Skeletally mature patients aged 14 to 25 were eligible for inclusion. Patients completed the Marx Activity Rating Scale (MARS) questionnaire postoperatively evaluating perceived ability to perform various activities to compare subjective ability to RTS. Those patients who were outside outlined cohort age, failed to complete a single post-operative survey, underwent revision procedures, or underwent simultaneous or staged additional ligament surgery were excluded. ResultsFifty-nine patients (20.1 ± 3.19 years, 57.6 % Male) were included in the study. Sixteen patients underwent ACL reconstruction with allograft (19.8 ± 3.43 years) while 43 patients received autograft (20.2 ± 3.13). At 3 months autograft recipients reported higher perceived ability to cut (P = .003). At 6-months, allograft recipients reported higher perceived ability to run (P = .033), cut (P = .048), and decelerate (P = .008) as well as a higher overall perceived ability to RTS (P = .032). At all other times, there was no significant difference between cohorts’ subjective readiness to perform activities. ConclusionThe results of this study indicate that at times within the first year of recovery following ACL reconstruction, patients who receive allografts and autografts may have significantly different perceived ability to perform activities or RTS. However, while present at various times throughout the first year of recovery, any difference in perceived ability to perform activities or in overall RTS is no longer present at 12 months. Level of evidenceLevel II, Prospective cohort study.

Recurrent cyclops lesion after primary anterior cruciate ligament reconstruction using bone tendon bone allograft: A case report

BACKGROUND Cyclops lesions are a known complication of anterior cruciate ligament (ACL) reconstruction, with symptomatic cyclops syndrome occurring in up to 11% of surgeries. Recurrent cyclops lesions have been rarely documented; this case study documents the successful treatment of a recurrent cyclops lesion. CASE SUMMARY A 28-year-old female presented following a non-contact injury to the right knee. Workup and clinical exam revealed an ACL tear, and arthroscopic reconstruction was performed. Two years later a cyclops lesion was discovered and removed via arthroscopic synovectomy. Seven months postoperatively, the patient presented with pain, stiffness, and difficulty achieving terminal extension. A smaller recurrent cyclops lesion was diagnosed, and a repeat synovectomy was performed. The patient recovered fully. CONCLUSION To the best of our knowledge, this is the first documented case of recurrent cyclops lesion after bone-patellar tendon-bone allograft ACL reconstruction presenting as cyclops syndrome.

Femoral Fixation Strength as a Function of Bone Plug Length in Anterior Cruciate Ligament Reconstruction Utilizing Interference Screws.

To determine femoral construct fixation strength as bone plug length decreases in anterior cruciate ligament reconstruction (ACLR). Sixty fresh-frozen bone-patellar tendon-bone allografts were utilized and divided into 20-, 15-, and 10-mm length bone plug groups, subdivided further so that half utilized the patella side (P) for testing and half used the tibial side (T). Ten mm diameter recipient tunnels were created within the anatomic anterior cruciate ligament footprint of 60 cadaveric femurs. All bone plugs were 10 mm in diameter; grafts were fixed using a 7 × 23 mm metal interference screw. An Instron was used to determine the load to failure of each group. A one-way multivariate analysis of variance (MANOVA) was conducted to test the hypothesis that there would be one or more mean differences in fixation stability between 20- or 15-mm plug lengths (P or T) versus 10 mm T plug lengths when cross-compared, with no association between other P or T subgroups. The mean load to failure of the 20 mm plugs (20 P + T) was 457 ± 66N, 15 mm plugs (15 P + T) was 437 ± 74N, and 10 mm plugs (10 P + T) was 407 ± 107N. There was no significant difference between P + T groups: 20-versus 15-mm (p = 1.000), 15-versus 10-mm (p = 0.798), and 20-versus 10-mm (p = 0.200); P + T MANOVA (p = 0.291). Within groups, there was no significant difference between patella and tibial bone plug subgroups with a pullout force range between 469 ± 56N and 374 ± 116N and p-value ranging from p = 1.000 for longer bone plugs to p = 0.194 for shorter bone plugs; P versus T MANOVA (p = 0.113). In this human time zero cadaver model, there was no significant difference in construct failure between 20-,15-, and 10-mm bone plugs when fixed with an interference screw within the femoral tunnel, although fixation strength did trend down when from 20- to 15- to 10-mm bone plugs. There is a balance between optimal bone plug length on the femoral side for achieving adequate fixation as well as minimizing donor site morbidity and facilitating graft passage in ACLR. This study reveals utilizing shorter plugs with interference screw fixation is potentially acceptable on the femoral side if shorter plugs are harvested.

Bone-Patellar Tendon-Bone Allograft Preparation Technique for Anterior Cruciate Ligament Reconstruction

Background: Allograft anterior cruciate ligament (ACL) reconstruction, while it may have a higher failure rate in younger and more active populations, continues to serve as a viable graft option for the appropriately indicated patient. Efficient bone-patellar tendon-bone (BTB) allograft preparation is beneficial to reduce operating time and ensure optimal reconstruction with bony fixation. Indications: ACL reconstruction with BTB allograft is indicated for skeletally mature and older patients, patients who are less active and have fewer physical demands, patients who have had previously harvested autograft, circumstances where an autograft harvest is inadequate, patients with multiligament knee injuries, and patients who prefer allograft use. Technique Description: The central third of the BTB allograft is harvested, aiming for a graft diameter of 10 mm along the tendon. The tibial bone plug is first cut to a length of 25 to 30 mm and width of 10 mm with the saw at a 70° angle to the bone. The patellar bone plug is cut to a length of 25 mm and width of 10 mm with the saw at a 45° angle to the bone. The bone plugs are mobilized, and soft tissue is dissected to free the graft. The graft is trimmed until it fits through a 10-mm sizer on each side. A single hole is created with a k-wire in the patellar bone plug, and a #5 Ethibond suture is passed. On the tibial bone plug, 2 holes are made perpendicular to one another, and a #2 Fiberwire suture is passed through each of these holes. These sutures allow for facilitated graft passage and tensioning. Once the graft is affixed with interference screws, the graft is arthroscopically evaluated throughout range of motion. Results: ACL reconstruction with BTB allograft provides high success rates in appropriately selected patients. Data demonstrate more optimal mechanical properties by harvesting the central third of the allograft tendon in younger donors. Non-irradiated and less chemically processed grafts are also preferred to optimize biomechanical properties. Discussion/Conclusion: Bone-patellar tendon-bone allograft with 2 bone plugs offers a reliable alternative to other allografts or autografts. Preparing the allograft in a fashion similar to an autograft harvest may increase familiarity with techniques and facilitate surgical efficiency and graft passage. 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.

Outcomes Following Bone-patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction In Patients &lt;30 Years: Allograft Vs. Autograft

PURPOSE: The purpose of this study was to investigate differences in failure rates and functional outcomes between patients <30 years of age that underwent allo- or autograft Bone-Patellar Tendon-Bone (BPTB) ACLR. METHODS: All patients aged 16-30 years who underwent a BPTB allo- or autograft ACLR with bioabsorbable interference screws by a single surgeon (1995-2019) were included. Exclusion criteria were follow-up <2 years, osteochondral drilling, revision ACLR, and multi-ligamentous injuries. The allograft was always <5 years than patient age and not terminally irradiated. Meniscal repairs were completed as necessary. All patients completed a decelerated, conservative rehab program with required bracing for 3 months and return to pivoting sports >6 months. An independent physical exam including knee ROM and stability testing, (manual max KT-1000, Lachman, pivot shift) was performed. Patients completed Lysholm, IKDC, Tegner and pain Visual Analogue Score (VAS) to assess clinical outcomes. Failure was defined as positive Lachman or pivot shift test or MRI evidence of re-tear. RESULTS: 13 patients with BPTB allograft (5 male/8 female; 24.3 ± 4.0 years) and 35 patients with BPTB autograft (28 males/7 females; 22.3 ± 4.2 years) ACLR were included (p = 0.136). Average follow-up was 11.7 ± 3.9 years in the allograft group and 13.9 ± 5.9 years in the autograft group (p = 0.685). There were no significant differences in functional outcomes between groups (Lysholm: p = 0.226; IKDC: p = 0.107; Tegner: p = 0.610). There was no significant difference in laxity between groups (KT-1000 30 lbs: p = 0.131; manual maximum: p = 0.416; side to-side difference 30 lbs: p = 0.310; side-to-side difference manual max: p = 0.472). All patients returned to preoperative sports (Tegner score ≥ 5). Overall failure rate was 1.8% (1/48) with 1 failure in the autograft group (p = 0.548). CONCLUSION: In this cohort of young patients, no difference in failure rate was seen between allograft and autograft. At a mean of >10-year follow-up, laxity and all patient reported outcomes were not different between the groups. Careful selection of an allograft for use in ACLR and a decelerated rehabilitation program can be a good alternative in young patients >30 years to return to preoperative sports with no evidence of increased failure rates in this cohort.

Anterior to Posterior Bone Plug Suture Tunnels Provide Optimal Biomechanics for Bone−Patellar Tendon−Bone Anterior Cruciate Ligament Graft

PurposeTo evaluate different bone−patellar tendon−bone (BPTB) plug suture configurations for pull through strength, stiffness, and elongation at failure in a biomechanical model of suspensory fixation.MethodsForty nonpaired, fresh-frozen human cadaveric BPTB allografts with an average age of 65.6 years were tested. Tensile testing was performed with the use of a custom-designed fixture mounted in a dynamic tensile testing machine. A preload of 90 N was applied to the graft and held for 5 minutes. Following this, a tensile load-to-failure test was performed. The ultimate failure load, elongation at failure, and mode of failure were recorded, and the resulting load–elongation curve was documented.ResultsThe drill tunnel through the cortical surface (anterior to posterior) was found to be significantly stronger than the drill tunnel through the cancellous surface (medial to lateral). There were no significant differences found when comparing the strength of the suture augmentation through the tendon and the drill tunnel alone (P = .13 among cancellous groups, P = .09 among cortical groups). The cortical drill tunnel with suture augmentation through the tendon showed significantly greater elongation values (13.7 ± 3.2) at failure when compared with either the cancellous or cortical drill tunnel only test groups (P = .0003 compared with cancellous alone, P = .009 when compared with cortical alone). Conclusions: The BPTB suture configuration with an anterior to posterior–directed suture tunnel without a suture through tendon augmentation provides the optimal strength and stiffness while minimizing graft elongation after fixation in a biomechanical model. This configuration is best for preventing suture pull through and failure when passing sutures through the BPTB plug.Clinical RelevanceThis study biomechanically evaluates the optimal suture configuration in the proximal bone plug for suspensory fixation in the setting of BPTB grafts.

Paper 87: Anterior Cruciate Ligament Reconstruction in Patients Age 50 and Older: Outcomes and Tips for Success

Objectives:As people remain physically active later in life, there is an increased incidence of anterior cruciate ligament (ACL) injuries in patients 50 years of age and older. Historically, ACL reconstructions have not been recommended for patients over 50 years of age. While there is abundant literature on the outcomes of ACL reconstruciton in patients under 40 years of age, little has been published on the outcomes in this age group. The purpose of this study was to investigate whether ACL reconstruction in patients fifty years of age and older rwill esult in an improvement in function, stability, and quality of life at 5-year follow up. We also study the indications, outcomes, and tips for success.Methods:A retrospective review was performed of patients fifty years or older with a minimum follow up of two years who underwent an ACL reconstruction using a bone patellar tendon bone (BPTB) allograft by a single fellowship trained orthopedic sports medicine surgeon over a sixyear period. Patients were excluded from the study if they had significant radiographic osteoarthritic changes, or concurrent ligamentous or bony procedures performed. Patients were asked to return for an evaluation, including physical examination and KT-2000 instrumented stability measurements. Both the operative and non-operative knees were evaluated for range of motion, tenderness, stability on anterior drawer, Lachman, and pivot shift testing. Bilateral KT-2000 measurements which were taken at 10, 20, and 30 pounds as well as maximum manual testing. Each measurement was taken three times and averaged. The following scores were used pre- and post-operatively to assess function and pain: Lysholm, International Knee documentation Committee (IKDC), Tegner Activity, and SF-12. A physical examine including KT-2000 measurements was performed in a subset of these patients.Results:Fifty patients with an average follow-up of 5 years (range 2-8 years) underwent an ACL reconstruction using BPTB allograft. The average age at surgery was 55 years (range 50-68 years). Tegner scores improved from a pre-operative score of 3.3 to a post-operative score of 5.3 (p = .0001, 95% CI 2.2-3.5). The average post-operative IKDC score was 81.3 (SD 16.4), Lysholm score 88.5 (SD 16.3), SF-12 physical 54.3 (SD 6.6) and SF-12 mental 51.8 (SD 8.3). Forty (80%) patients reported good to excellent results, six (12%) patients reported fair results and four (8%) patients reported poor results. The patients that returned for a physical examinaiton had a range of motion that averaged flexion to 135 (SD 5.4), and all achieved full extension. There was one patient (2%) that had greater than 4mm translation on Lachman testing, and no patients had a positive pivot shift. There were no identified surgical complications.Conclusions:An anterior cruciate ligament reconstruction using BTB allograft successfully restores stability and allows return to pre-injury level of activity with few complications in patients 50 years or older at an average of 5 years follow-up. Our data set represents the largest case series of ACL reconstructions for this age demographic in the literature, using validated outcome tools, and complimented with a physical examination in a sub-set of the cohort. We have found no comparison that yields a clinically significant difference (based on MCID of 10 on theLysholm scale). Thus, older patients can be counseled to expect a functional return close to their pre-injury level, similar to younger patient cohorts.

Paper 18: Treatment of Lateral Meniscus Tears Influences OA Rate following ACL Reconstruction at 9-year Follow-Up

Objectives:Recent studies have described an increased risk of osteoarthritis (OA) following ACL reconstruction (ACLR). Systematic reviews have suggested that meniscal pathology, which occurs in up to 60% of patients with ACL injury, increases this risk. The purpose of this study was to determine the influence of lateral meniscus tears and repair versus partial lateral meniscectomy on the risk of OA in patients following ACLR.Methods:All patients who underwent primary autograft or allograft bone-patellar tendon-bone (BPTB) transtibial ACLR by a single surgeon between 1999-2019, were identified. Revision ACLR, multi-ligamentous reconstructions, and patients with less than 2-year imaging follow-up were excluded. Patients with lateral meniscus pathology at the time of ACLR were identified and treatment (e.g. lateral meniscectomy or lateral meniscus tear) was extracted. OA was defined at follow-up as Kellgren-Lawrence (KL) grade III-IV on plain radiographs. Chi-square tests assessed differences in incidence rates (p<0.05).Results:A consecutive series of 113 patients (57 males, 56 females; age 35.7±11.9 years) with BPTB ACLR were included. The mean follow-up was 9±5 years. The prevalence of lateral meniscus tears was 60.2% (68/113) and the prevalence of lateral compartment OA at follow-up was 14% (16/113) Patients with a lateral meniscus tear were 4.7 times more likely to develop OA compared to patients with no lateral meniscus tear. 20.6% of patients (14/68) with lateral meniscus tear developed lateral OA compared to 4.4% of patients (2/45) without lateral meniscus tear (p=0.0158). Patients who underwent lateral meniscal repair (n=16) had significantly lower prevalence of OA (0/16) compared to patients who underwent lateral meniscectomy (14/52) (p=0.0196).Conclusions:At nine-year follow-up, patients with a lateral meniscus tear at time of ACLR were more likely to develop OA compared to patients with no lateral meniscus tear and patients treated with partial meniscectomy had higher prevalence of OA compared to those treated with meniscus repair. In patients who require ACLR, care should be taken in evaluating and treating the lateral meniscus to decrease the likelihood of the development of OA. We believe lateral meniscal repair is essential for lateral meniscus tears at the time ACL reconstruction to help avoid development of OA.Figure 1.

Allograft contamination during suture preparation for anterior cruciate ligament reconstruction: an ex vivo study.

Effects of suture preparation on graft contamination remain unknown in anterior cruciate ligament reconstruction (ACLR). This study aimed to evaluate the incidence of allograft contamination at different time points of graft preparation and investigate differences in contamination between different sites of the allografts. Fourteen hamstring tendon (HT), 9 quadriceps tendon (QT), and 9 bone-patellar tendon-bone (BTB) allografts were harvested, sterilised, and stored following routine procedures. Graft suture preparation was performed with baseball stitching for soft tissue and bone drilling for bone plug. The time was recorded simultaneously. The graft was kept moist in a standard operating room environment for 30min after the initiation of preparation. The specimens were obtained from the middle and both ends of each graft for culture at three different time points: pre-suturing, post-suturing, and 30min after the initiation of preparation. A total of 192 specimens were transferred to the microbiology laboratory for culture, identification, and semi-quantitative assessment. Culture results were classified as negative, poor, and abundant based on the extent of growth. Contamination level was recorded as low or high corresponding to culture results of poor or abundant. The duration of suture preparation was 348, 301, and 246s for HT, QT, and BTB (P = 0.090). The specimens had a positive culture rate of 41/192 (21.4%), of which 21 were from the ends and 20 from the middle. More positive samples with abundant bacterial growth were detected from the ends than from the middles post-suturing (7/8 vs. 1/7, P = 0.010) and at 30min (6/11 vs. 0/11, P = 0.012). The total graft contamination rate was significantly higher at 30min (19/32, 59.4%) than pre-suturing (4/32, 15.6%) and post-suturing (9/32, 28.1%) (P < 0.001). The contamination rate with abundant bacterial growth was higher post-suturing (7/32, 21.9%) than pre-suturing (0%). No statistically significant differences were found among the three types of allografts. The contamination rate increases significantly at 30min compared with pre-suturing and post-suturing. Suture preparation may have introduced the high-level contamination, to which the ends of the graft were more prone than the middle. Therefore, routine prophylactic decontamination after suture preparation should be considered, especially for the ends of the grafts.

Bone Marrow Aspirate Concentrate Augmentation May Accelerate Allograft Ligamentization in Anterior Cruciate Ligament Reconstruction: A Double-Blinded Randomized Controlled Trial

To assess the effect of bone marrow aspiration concentrate (BMAC) augmentation on clinical outcomes and magnetic resonance imaging (MRI) findings in anterior cruciate ligament (ACL) reconstruction (ACLR) with bone-patellar tendon-bone (BTB) allografts. A double-blinded, randomized controlled trial was conducted on 80 patients undergoing ACL reconstruction using BTB allografts. Patients were randomized to 2 groups: (1) bone marrow aspirate was collected from the iliac crest, concentrated, and approximately 2.5 mL was injected into the BTB allograft, or (2) a small sham incision was made at the iliac crest (control). MRI was performed at 3 months and 9 months postoperatively to determine the signal intensity ratio of the ACL graft. Seventy-three patients were available for follow-up at 1-year postoperatively (36 BMAC, 37 control). International Knee Documentation Committee (IKDC) scores were significantly greater in the BMAC group versus the control at the 9-month postoperative period (81.6 ± 10.5 vs 74.6 ± 14.2, P= .048). There was no significant difference in the proportion of patients who met the minimal clinically important difference for IKDC between the BMAC and control groups at 9 months (89% vs 85%; P= .7). Three months postoperatively, signal intensity ratio of the inferior third of the ACL graft was significantly greater in the BMAC group versus the control group (3.2 ± 2.2 vs 2.1 ± 1.5; P= .02). Patients who received BMAC augmentation of the BTB allograft during ACL reconstruction demonstrated greater signal intensity scores on MRI at 3 months, suggesting increased metabolic activity and remodeling, and potentially accelerated ligamentization. Additionally, patients in the BMAC group had greater patient-reported outcomes (IKDC) at 9 months postoperatively when compared with those who underwent a standard surgical procedure. There was no significant difference in the proportion of patients who met the minimal clinically important difference for IKDC between the BMAC and control groups at 9 months, suggesting limited clinical significance at this time point. I, randomized control trial.

Anterior Cruciate Ligament Reconstruction Using Bone–Patellar Tendon–Bone Allograft in Patients Aged 50 and Older Leads to Improved Activity Levels and Acceptable Patient-Reported Outcomes

PurposeTo evaluate patient-reported outcomes in patients aged 50 years and older undergoing anterior cruciate ligament reconstruction (ACLR) using bone–patellar tendon–bone (BPTB) allograft with minimum 2-year follow-up.MethodsA retrospective review was performed on a consecutive series of patients aged 50 and older who underwent ACLR using BPTB allograft by a single surgeon with minimum 2-year follow-up. Postoperative International Knee Documentation Committee (IKDC), Lysholm, and Physical Component Summary of the 12-item Short-Form Health Survey were used to assess outcomes, as well as preoperative and postoperative Tegner activity scores, which were compared using a paired sample t test.ResultsFifty patients met inclusion criteria, with a mean age of 55.3 ± 4.4 years and mean follow-up of 4.8 ± 1.9 years. Tegner activity scores improved from a mean preoperative score of 3.26 to a mean postoperative score of 5.25 (P < .001). The mean postoperative scores for Lysholm, IKDC, and Physical Component Summary were 87.3, 81.1, and 54.3, respectively. In total, 36 (72%) patients achieved a patient acceptable symptom state score for IKDC and 37 (74%) patients achieved a minimal clinically important difference for Tegner activity score. Thirty-eight (76%) patients reported good-to-excellent results, 6 (12%) patients reported fair results, and 6 (12%) patients reported poor results.ConclusionsACLR with BPTB allograft in patients aged 50 and older leads to good patient-reported outcomes with significantly increased postoperative activity status at a minimum 2-year follow-up.Level of EvidenceLevel IV, therapeutic case series.

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

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

Optimizing anterior cruciate ligament reconstruction: Individualizing the decision-making process using data from the Kaiser Permanente ACLR Registry: 2018 OREF award paper.

Despite years of study, controversy remains regarding the optimal graft for anterior cruciate ligament reconstruction (ACLR), suggesting that a single graft type is not ideal for all patients. A large community based ACLR Registry that collects prospective data is a powerful tool that captures information and can be analyzed to optimize surgery for individual patients. The studies highlighted in this paper were designed to optimize and individualize ACLR surgery and have led to changes in surgeon behavior and improvements in patient outcomes. Kaiser Permanente (KP) is an integrated health care system with 10.6 million members and more than 50 hospitals. Every KP member who undergoes an ACLR is entered into the Registry, and prospectively monitored. The Registry uses a variety of feedback mechanisms to disseminate Registry findings to the ACLRR surgeons and appropriately influence clinical practices and enhance quality of care. Allografts were found to have a 3.0 times higher risk of revision than bone-patellar tendon-bone (BPTB) autografts. Allograft irradiation >1.8 Mrad, chemical graft processing, younger patients, BPTB allograft, and male patients were all associated with a higher risk of revision surgery. By providing feedback to surgeons, overall allograft use has decreased by 27% and allograft use in high-risk patients ≤21 years of age decreased 68%. We have identified factors that influence the outcomes of ACLR. Statement of Clinical Significance: We found that information derived from an ACLR Registry and shared with the participating surgeons directly decreased the use of specific procedures and implants associated with poor outcomes.

Staged patellar tendon reconstruction using doubled bone-patellar tendon-bone allograft for infected patellar tendon rupture: a rare case report of three years follow-up

BackgroundPatellar tendon rupture is a relatively rare injury that usually requires surgical treatment. The optimal therapeutic strategy is still controversial, especially when either concomitant patellar tendon infection or soft tissue infection surrounds the patellar tendon. Until recently, most reported reconstruction methods are extensive and difficult to apply because of the poor condition of the soft tissue surrounding the patellar tendon.Case presentationA 19-year-old male patient presented to our clinic three weeks following a motorcycle accident. There was a 5 x 4 cm sized skin defect with soft tissue infection below the inferior pole of patella. We performed a staged patellar tendon reconstruction using a doubled bone-patellar tendon-bone allograft (BPTB) to the infected patellar tendon rupture, following local random fasciocutaneous flap and split-thickness skin graft. Three months following surgery, the patient was able to perform an active knee motion with no extension lag and excellent clinical functional result.Discussion and conclusionsOur technique introduced in this specific case is a relatively simple method to reconstruct chronic patellar tendon defects with limited incision exposing only the patellar tendon areas. We expect it can be less invasively performed on patients who have a soft tissue problem and cannot have extensive surgery.

Mesenchymal Stem Cells in BTB allograft ACL reconstruction:A Prospective Randomized Controlled Trial

Biologic adjuncts have shown promise in improving clinical outcomes following ACL reconstruction (ACLR). Post-operative ligament construct healing is a slow process that involves graft incorporation into bone tunnel sites and intra-articular graft ligamentization, during which failure load and stiffness of grafts decreases. Radiologic imaging has been shown to correspond with histological changes related to the ligamentization process (Hakozaki et al.). The purpose of this study is to evaluate the effects of bone marrow-aspirate concentrate (BMAC), containing mesenchymal stem cells (MSCs), on graft healing, maturation, and integration in patients, as well as patient reported outcome measures (PROMs), undergoing ACL reconstruction with bone-patellar tendon-bone (BTB) allografts. : IRB approval was obtained for a single-blinded randomized controlled trial on patients undergoing ACLR utilizing BTB allografts. Patients were randomized to receive either MSC injection into the ACL allograft or a sham incision with no BMAC harvest or graft injection. Bone marrow aspirate was harvested from the anterior superior iliac crest and concentrated via centrifuge. A minimum of 1.25mL of BMAC was injected into the tendinous/ligamentous portion of the BTB allograft at proximal, middle, and distal sites, with 0.5 mL reserved for post-operative ELISA assay and receptor testing for validation of MSCs within the BMAC harvest. Post-operatively, patients underwent identical standard, accelerated rehabilitation protocols. Outcomes were collected at 6 weeks, 3 months, 6 months, 9 months, 12 months, and 24 months. Knee range of motion, pivot-shift test, anterior-posterior translation, and patient reported outcomes using the KOOS Jr, IKDC, Lysholm surveys, and PROMIS scores including physical function, pain interference, and depression were assessed at the above time points. MRI was performed at 3 months and 9 months. The T2-weighted MRI Signal Intensity Ratio (SIR) of the reconstructed ACL was calculated and standardized to the intensity of the PCL by a musculoskeletal radiologist. A total of 60 patients have been enrolled (54% female, 57% BMAC). The mean age for BMAC and control groups was 34.9 and 35.8, respectively (p=0.7). Mean graft soaking time was 15.9 minutes. Mean time from injury to surgery was 3.7±3.7 months for control and 6.8±14.6 months for BMAC patients (p=0.305). Signal intensity ratios at 3 months revealed significant improvement in the BMAC cohort as compared to control (3.47 and 1.78, respectively, p<0.05). Analysis of secondary clinical outcomes demonstrated that the BMAC cohort significantly outperformed control in degrees of flexion (133º vs. 128º, p=0.02), International Knee Documentation Committee (IKDC) score (64.2 vs. 61.7, p=0.04), and VR12 Mental Health (57.0 vs. 54.7, p=0.002) at 9 months postoperatively. MSC injection into BTB ACL allograft reconstructions demonstrated significantly superior signal intensity ratio on radioimaging during the early ligamentization process. We also observed improved PROMs during the early post-operative period in patients receiving BMAC. This study provides a basis and rationale for continued investigation and application of biologic augmentation of ACLR allograft constructs. Future studies may further elucidate the impact of BMAC on the ligamentization process, clinical outcomes, and PROMs.

Relationship of Graft Type and Vancomycin Presoaking to Rate of Infection in Anterior Cruciate Ligament Reconstruction: A Meta-Analysis of 198 Studies with 68,453 Grafts.

Infection is a devastating complication in anterior cruciate ligament reconstruction (ACLR) surgery. Given the rarity of infection, pooling individual studies via meta-analysis can allow more meaningful evaluation of factors influencing infection rates. We aimed to determine the relationship of graft type and vancomycin graft presoaking to bacterial infection rates following ACLR. A systematic literature search was conducted on PubMed, Ovid MEDLINE, Embase, and CENTRAL (Cochrane Register of Controlled Trials). Included articles were those reporting on primary arthroscopic or open ACLR procedures, using hamstring (HT) or bone-patellar tendon-bone (BPTB) autografts or allografts of any type, with regard to the outcome of infection (deep infection or septic arthritis). Meta-analyses were performed to estimate the overall infection rates in ACLR surgery according to graft type and to examine the effect of presoaking grafts in vancomycin on infection rates. We identified 306 bacterial infections in 68,453 grafts across 198 studies. The overall estimated ACL graft infection rate in our meta-analysis was 0.9% (95% confidence interval [CI] = 0.8% to 1.0%). HT autografts were associated with a higher infection rate (1.1%, CI = 0.9% to 1.2%) than BPTB autografts (0.7%, CI = 0.6% to 0.9%) and allografts (0.5%, CI = 0.4% to 0.8%) (Q = 15.58, p < 0.001). Presoaking HT autografts in vancomycin reduced infection rates to 0.1% (CI = 0.0% to 0.4%) (Q = 10.62, p = 0.001). Infection following ACLR remains a rare but serious complication. HT autografts are associated with higher infection rates than other graft types. Presoaking HT autografts in vancomycin reduces infection rates by an estimated tenfold. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Network meta-analysis of knee outcomes following anterior cruciate ligament reconstruction with various types of tendon grafts.

Various grafts were selected for restoring knee stability and regaining pre-injury activity levels after anterior cruciate ligament (ACL) rupture. This review aimed to compare the short-term knee outcomes of different tendon grafts for primary ACL reconstruction (ACLR). Databases of PubMed, Embase, and CENTRAL were retrieved for identifying the published RCT comparing the short-term (≤ 2years) knee outcomes of different tendon grafts for ACLR. The main outcomes include the International Knee Documentation Committee (IKDC) subjective and objective scores, side-to-side difference on knee laxity, Lachman test, pivot-shift test, Lysholm score, Tegner score, all recorded complications and graft re-ruptures. A total of 32 trials involving 2962 patients and 17 grafts were included. Superior IKDC subjective score was found for quadriceps tendon autograft (QTB) when compared with autografts including bone-patellar tendon-bone (BPTB), four-strand hamstring tendon (4S-HT), and double-bundle HT. The 4S-HT autograft was associated with poorer anteroposterior and rotational knee stability than the BPTB autograft. Artificial ligament also was found to provide lower knee stability compared with the autografts including the BPTB, patellar tendon, 4S-HT, 4S-HT with preserved tibial insertion, 6S-HT, and four-strand semitendinosus tendon. Additionally, the BPTB allograft showed a statistically higher knee laxity than 6S-HT allograft, while no difference was found between the genuine autografts and non-irradiated allografts. QTB was recommended to be used even over the BPTB and 4S-HT autografts. BPTB autograft was more effective on restoring the knee stability than 4S-HT autograft. Non-irradiated allografts could be safely used as alternatives to autografts. However, artificial ligaments were not recommended for primary ACLR for significantly increased risk of knee laxity.

Meniscal Repair with Concurrent Anterior Cruciate Ligament Reconstruction: Is ACL Graft Choice Predictive of Meniscal Repair Success?

Objectives: The success rate of meniscal repair is known to increase with concurrent anterior cruciate ligament (ACL) reconstruction. However, the influence of ACL graft choice has not been described. The current study examines the effect of ACL graft choice on the outcome of meniscal repair performed in conjunction with ACL reconstruction (ACLR). Methods: Patients who underwent meniscal repair with concurrent primary ACLR were identified from a longitudinal, prospective cohort. Patient demographics and subjective outcome measures including the International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), and Marx activity rating scale were collected preoperatively. Arthroscopic assessment of meniscal tear characteristics and associated repair technique were recorded intraoperatively. Patients with subsequent repair failure, defined as any subsequent surgical procedure addressing the meniscus repaired at index surgery, were identified and operative notes were obtained in order to accurately classify pathology and treatment. A logistic regression model was built to assess the association of patient specific factors, ACL graft, baseline Marx activity level and meniscal tear laterality with the occurrence of repair failure at 6-year follow-up. Results: A total of 646 patients underwent ACLR with concurrent meniscal repair. Bone-patellar tendon-bone (BTB) and soft tissue (ST) autograft were used in 55.7% and 33.9% of cases, respectively, while allografts were utilized in the remaining cases. Table 1 summarizes the univariate analysis of each baseline variable. A total of 101 patients (15.6%) required subsequent surgery on the meniscus repaired at index surgery, including 89 meniscectomies (87 partial, 2 subtotal), 11 revision meniscal repairs, and 1 meniscus allograft transplantation. No statistically significant difference in meniscal repair failure rate was observed based on patient age, sex, BMI or smoking status. The odds of meniscal repair failure within 6 years of surgery for patients with only a lateral meniscal repair are 68% less than those with only a medial meniscal repair (CI: 41%, 83%; p&lt;0.001). There is a statistically significant relationship between baseline Marx activity and the risk of subsequent meniscal repair, though it is nonlinear—patients with low or high baseline activity are at the highest risk of meniscal repair failure (CI: 1.05,1.31; p=0.004, Figure 1). The estimated odds of meniscal repair failure for BTB allograft, ST allograft, and ST autograft were 2.78 (CI: 0.84,9.19; p=0.09), 2.29 (CI: 0.97,5.45; p=0.06), and 1.42 (CI:0.87,2.32; p=0.16) times that of BTB autograft, respectively, although none proved statistically significant. Meniscal repair failure is associated with significantly lower 6-year scores for all KOOS components and the IKDC (p&lt;0.001). However, there was no significant difference in MARX activity at 6-years (p=0.27). Conclusion: In the setting of primary ACLR, the risk of meniscal repair failure is increased with medial versus lateral meniscal repair. Patients with low or high baseline activity levels are also at an increased risk. ACL graft choice seems to have an effect on meniscal repair failure that approaches but does not reach statistical significance. A larger sample size may be required to accept the null hypothesis. [Table: see text][Figure: see text]

Survivorship of allograft ACL reconstruction in adolescent patients

PurposeThe overall benefits of ACL reconstructive surgery in young athletes has been previously established. Graft selection for ACL reconstruction, specifically in this population however, remains controversial. The literature is limited and long-term survival rate of allograft ACL reconstruction in the adolescent population remains poorly defined. Current evidence, none level I, appears to demonstrate increased failure and subsequent revision rates in allograft reconstruction of complete ACL tears compared to autograft; 7–35% compared to 3–13% respectively. The purpose of the present study was to evaluate revision rate and functional outcomes of allograft ACL reconstruction in the adolescent population at extended follow-up. MethodsA retrospective chart review was performed. Forty patients who underwent transphyseal ACL reconstruction with either bone patellar tendon bone (BTB) or Achilles tendon bone (ATB) allograft performed by a single surgeon over a 12-year period were identified. Demographic and surgical details were analyzed. Enrolled patients completed a Lysholm Knee Scoring Scale and a Tegner Activity Level Scale during phone interviews. All secondary surgeries performed on the ipsilateral knee were recorded. ResultsTwenty-five patients were enrolled; fifteen were lost to follow-up. There were ten male and fifteen female patients included for analysis. Average age at index surgery was 16 years (range 13–18 years). BTB allograft was used for seven patients, and ATB allograft was used for the remaining eighteen patients. Average follow-up was 54 months (range 13–136 months). The average Lysholm score at follow-up was 87 (range 57–100). The average Tegner score at follow-up was 6.8 (range 3–10). Three patients underwent revision ACL surgery (12% study group, 7.5% all) for traumatic re-rupture. Re-rupture occurred 12, 13 and 38 months after index surgery. ConclusionsAutograft remains the standard for ACL reconstruction in the general pediatric population. In the adolescent population, however, the use of BTB or ATB allograft is a reasonable alternative with satisfactory outcomes, decreased harvest site morbidity, decreased post-operative pain and faster rehabilitation. The traumatic re-rupture rate in this series was similar to previously published traumatic failure rates in young adult athletes after reconstruction with autologous tissue (11–13%). Further prospective studies are needed to determine any true difference in the use of either allograft or autograft in the adolescent population.