Bone-patellar Tendon-bone Autograft Research Articles

How statistically fragile are randomized controlled trials comparing quadriceps tendon autografts with hamstring or bone-patellar tendon-bone autografts in anterior cruciate ligament reconstruction?

To determine the statistical fragility of randomized controlled trials (RCTs) which compare the use of quadriceps tendon (QT) autografts to either hamstring tendon (HT) or bone-patellar tendon-bone (BPTB) autografts in anterior cruciate ligament reconstruction (ACLR). A search was conducted across PubMed, MEDLINE and EMBASE databases for RCTs comparing QT autografts to HT or BPTB autografts in ACLR from inception to 21 April 2024. Studies that reported ≥1 statistically significant continuous outcome, statistically significant dichotomous outcome and/or nonsignificant dichotomous outcome were included for analysis. The fragility index (FI), continuous fragility index (CFI) and reverse fragility index (RFI) were calculated for significant dichotomous outcomes, significant continuous outcomes and nonsignificant dichotomous outcomes, respectively. A total of 11 RCTs comprising 716 patients were included. The mean sample size was 65.8 patients. The median FI among nine outcomes from four studies was 1.0 (interquartile range [IQR], 0.5; 95% confidence interval [CI], 0.6-1.4; range 0.5-1.5). The number of patients lost to follow-up at the final follow-up period was more than the study-specific FI in three (75%) studies. The median CFI among 30 outcomes from six studies was 4.9 (IQR, 10.1, 95% CI, 3.9-8.2; range 0-18.2). The number of patients lost to follow-up at the final follow-up period was more than the study-specific CFI in four (66.7%) studies. The median RFI among 10 outcomes from five studies was 5.0 (IQR, 3.5; 95% CI, 3.4-6.6; range 1.0-9.0). The number of patients lost to follow-up at the final follow-up period was more than the study-specific RFI in four (80%) studies. This systematic review revealed that regardless of the metric used, RCTs comparing QT autografts to HT or BPTB autograft options in ACLR are statistically fragile. While the indices of statistical fragility evaluated in this study are important metrics of robustness to consider, their application in research and clinical practice needs to be further elucidated. Level I.

The Tibial Tunnel Size Relative to the Proximal Tibia Affects the Tibial Tunnel Widening in Anatomical Anterior Cruciate Ligament Reconstruction.

The impact of the bone tunnel size relative to body size on clinical results in anterior cruciate ligament (ACL) reconstruction remains unclear. This study aimed to assess the morphological alteration of the tibial tunnel aperture and relationship between the tibial tunnel size relative to the proximal tibia among the tibial tunnel widening (TW) and clinical results following ACL reconstruction. This study comprised 131 patients who had undergone anatomical ACL reconstruction utilizing bone-patellar tendon-bone autografts. The morphology and enlargement of the tibial tunnel were examined via three-dimensional computed tomography 1 week and 1 year postoperatively. The anteroposterior (AP) and mediolateral (ML) positions were determined as a percentage relative to the proximal AP and ML tibial dimensions, respectively. Clinical assessment was conducted 2 years postoperatively. The association between the primary tibial tunnel size among TW and clinical outcomes was examined. The tibial tunnel significantly migrated posterolaterally. The ML diameter significantly widened; however, the AP diameter did not exhibit widening. AP widening was associated with the AP diameter of the primary tibial tunnel (r = -0.482, p < 0.01), and ML widening correlated with the ML diameter of that tunnel (r = -0.478, p < 0.01). However, there was no significant correlation observed between the primary tibial tunnel size and clinical outcomes. The tibial tunnel migrated and enlarged laterally in the ML plane, but did not enlarge in the AP plane. The primary tibial tunnel diameter relative to the proximal tibia negatively correlated with the tibial TW in the AP and ML planes. Level of evidence: level IV.

Management of Multiligament Knee Injuries Using Anatomic Autograft Reconstructions: A Case Series.

While proven effective management of multiligament knee injury (MLKI) using allograft is often reported, it has shown an increased risk for graft failure compared with autograft and raises availability and cost issues. Osseous stock preservation and tunnel convergence avoidance led us to develop a compromise innovative surgical procedure using only ipsilateral autograft for anatomic reconstruction of Schenck III-L or higher MLKI. We report the description and early outcomes of our initial experience. Our strategy consisted of an anatomic single-bundle posterior cruciate ligament reconstruction with quadriceps tendon autograft and a "Versailles" reconstruction for the posterolateral corner, which we modified to reconstruct the anterolateral ligament in case of anteromedial rotatory instability, called "full lateral." A second-stage surgery was planned for anterior cruciate ligament reconstruction using a bone-patellar tendon-bone autograft. Outcomes were Lysholm, Tegner, and International Knee Documentation Committee (IKDC) scores for functional status, Short Form 12 (SF-12) for quality of life, and visual analog scale (VAS) for pain. Complications, full weight-bearing, return to work, and sport were also computed. Between March 2019 and August 2020, 10 patients were included. At follow-up, light pain was found in nine patients with a mean VAS of 1.2 ± 2.16 during the day. The mean Lysholm, Tegner, and subjective IKDC scores were good, with 61.2 ± 20.6, 2.8 ± 2.1, and 52.6 ± 20.4, respectively. However, quality of life was altered with poor SF-12 scores. In our first 10 patients with Schenck III-L or higher MLKI, our procedure using only ipsilateral autograft enabled correct daily knee functional activities while preserving osseous stock.

Trends in Anterior Cruciate Ligament Reconstruction Techniques and Postoperative Care Among Leaders in the Field: A Survey of the Herodicus Society.

Despite a growing body of literature regarding anterior cruciate ligament reconstruction (ACLR), there remains a wide diversity in surgical technique and clinical practice across providers. To (1) describe current ACLR practice preferences among members of the Herodicus society and (2) determine whether these preferences are influenced by years in practice and overall surgical volume. Cross-sectional study. A 24-question survey investigating surgeons' practices and preferred ACLR surgical techniques was sent via email to all active Herodicus Society members. Survey responses were subdivided by years of experience and overall ACLR annual case volume. Descriptive statistics were compiled and chi-square testing was utilized to determine the significance of experience and case volume on survey responses. Of the 113 invited Herodicus Society members who perform ACLR, 69 (61%) completed the survey. Respondents had a mean ± SD of 30.9 ± 9.8 years of experience in clinical practice and performed a mean of 96.0 ± 50.7 primary and 21.6 ± 16.9 revision ACLR annually. Of revision cases, 72.1% were performed using a single-stage technique. Mean frequency of graft usage by surgeon was bone-patellar tendon-bone autograft (58.6%), quadriceps autograft (14.6%), hamstring tendon autograft (14.0%), and allograft (11.8%). The plurality of surgeons responded that they used anterolateral augmentation "rarely" in primary ACLR (39.1%) and "sometimes" in revision ACLR (31.9%), with the majority performing lateral extra-articular tenodesis (66.7%) rather than anterolateral ligament reconstruction (14.5%). Most surgeons would not allow a 20-year-old football player to return before 7 months after ACLR (71.0%) but highly valued return-to-sports testing to determine readiness (94.2%). Higher volume surgeons performed single-stage revision ACLR at a significantly higher rate (79.8% vs 62.9%, P = .02) and significantly differed in return-to-sports criteria, with a greater proportion relying primarily on biometric testing (P = .01). The survey demonstrated that, in the Herodicus Society, a wide range of preferences exist regarding ACLR surgical technique. Bone-patellar tendon-bone autograft is the most frequent primary ACLR graft choice. Most participants have not embraced newer techniques such as anterolateral or suture tape augmentation. Return to sports is generally not allowed before 7 months and heavily factors-in return-to-sports testing metrics, suggesting that purely time-based criteria for return to sports is not modern practice among elite sports medicine surgeons.

The Minimum Patient Acceptable Symptom State for the ACL-Return to Sport after Injury Scale Among Patients Treated With Anterior Cruciate Ligament Reconstruction.

Despite most patients reporting optimal knee function after anterior cruciate ligament reconstruction (ACLR), not all return to their pre-injury level of sport, often due to psychological factors. The ACL-Return to Sport after Injury Scale (ACL-RSI) was developed to measure the emotions, confidence in performance, and risk appraisal among athletes returning to sport. The purpose of this study was to determine the Patient Acceptable Symptom State (PASS) threshold for the ACL-RSI in patients undergoing ACLR. Patients with an ACL injury that required surgical reconstruction were included in this prospective study. All patients underwent ACLR with a bone-patellar tendon-bone autograft and completed the ACL-RSI 12 months postoperatively. An anchor-based approach was used to generate a receiver operating characteristic curve and establish the PASS threshold. Multivariable regression analyses were used to evaluate the effect of age, sex, and baseline score on likelihood of achieving PASS. A total of 113 patients (37% female) with a mean age of 28.1±8.2 years and a mean body mass index of 24.7±3.5 kg/m2 were included. At 12 months postoperatively, the threshold value for the PASS of the ACL-RSI was 40 (robust area under the curve: 0.89; sensitivity: 81%; specificity: 85%). Baseline score, sex, and age had no significant influence on achieving PASS at 12 months postoperatively. In a group of patients undergoing ACLR with bone-patellar tendon-bone autograft, the PASS threshold value was 40 for the ACL-RSI at 12 months postoperatively. The PASS value for the ACL-RSI established from this study can be useful for designing future clinical trials. [Orthopedics. 202x;4x(x):xx-xx.].

All‐soft tissue quadriceps tendon autograft and bone–patellar tendon–bone autograft demonstrate no significant ACL tunnel widening: An MRI comparison

All‐soft tissue quadriceps tendon autograft and bone–patellar tendon–bone autograft demonstrate no significant ACL tunnel widening: An MRI comparison

Assessment of Functional outcomes Following Arthroscopy-Assisted Anterior Cruciate Ligament Reconstruction Utilizing Autograft Bone-Patellar Tendon-Bone

Anterior cruciate ligament (ACL) injuries are prevalent in athletes and active individuals, necessitating effective surgical interventions for restoring knee stability and function. This study evaluates the outcomes of Arthroscopic ACL reconstruction using bone-patellar tendon-bone (BPTB). This prospective study conducted from March 2022 to August 2023 evaluated the functional outcomes of 21 patients undergoing ACL reconstruction with BPTB autografts. Clinical assessments, including the Lachman and Lysholm scores, were utilized to assess knee stability and function preoperatively and postoperatively. Significant improvements were observed postoperatively in clinical assessments, with mean Lysholm scores increasing from 51.74 preoperatively to 91.64 at the 12-month follow-up (p &lt; 0.001). The study also highlighted the prevalence of associated meniscal injuries and postoperative complications. Despite study limitations, including sample size constraints, our findings support the efficacy of ACL reconstruction with BPTB autografts in restoring knee function and stability. Evidence-based decision-making and comprehensive patient care are crucial for optimizing surgical outcomes in ACL injuries. Further research with larger cohorts and long-term follow-up is warranted to validate these results and explore optimal management strategies.

Evaluating Gait with Force Sensing Insoles 6 Months after Anterior Cruciate Ligament Reconstruction: An Autograft Comparison.

Aberrant knee mechanics during gait 6 months after anterior cruciate ligament reconstruction (ACLR) are associated with markers of knee cartilage degeneration. The purpose of this study was to compare loading during walking gait in QT, bone-patellar tendon-bone (BPTB), and hamstring tendon (HT) autograft patients 6 months post-ACLR using loadsol single sensor insoles, and to evaluate associations between loading and patient reported outcomes. 72 patients (13-40 years) who underwent unilateral, primary ACLR with BPTB, QT, or HT autograft completed treadmill gait assessment, the International Knee Documentation Committee (IKDC) survey and the ACL-Return to Sport after Injury (ACL-RSI) survey 6 ± 1 months post-ACLR. Ground reaction forces were collected using loadsols. Limb symmetry indices (LSI) for peak impact force (PIF), loading response instantaneous loading rate (ILR), and loading response average loading rate (ALR) were compared between groups using separate ANCOVAs. Survey scores were compared between groups using one-way ANOVAs. The relationships between IKDC, ACL-RSI, and LSIs were compared using Pearson's product moment correlation coefficients. There were no significant differences between graft sources for LSI in PIF, ILR, ALR, nor impulse. Patient-reported knee function was significantly different between graft source groups with the BPTB group reporting the highest IKDC scores; however, there was no significant difference between groups for ACL-RSI score. There were no significant associations between IKDC score, ACL-RSI score, and biomechanical symmetry among any of the graft source groups. Autograft type does not influence PIF, ILR, ALR, or impulse during walking 6 months post-ACLR. Limb symmetry during gait is not strongly associated with patient reported outcomes regardless of graft source. Loadsols appear to be a suitable tool for use in the clinical rehabilitation setting.

Comparative Analysis of the Six-Strand Hamstring and Peroneus Longus in Sports Medicine and Rehabilitation

The anterior cruciate ligament (ACL) is crucial for knee stability and is often injured in sports, leading to significant issues like degenerative changes and meniscal tears. ACL tears are prevalent in high-school sports injuries, accounting for 50% of knee injuries in the U.S. Surgical reconstruction, often involving bone-patellar tendon-bone (BPTB) or hamstring autografts, is common, with varying success rates and complications. Emerging alternatives like the peroneus longus tendon show promise but require further comparative studies. This prospective and multicentric study included 110 patients who underwent ACL reconstruction from 2020 to 2022. Fifty-five patients received hamstring tendon autografts (Group H) and fifty-five received peroneus longus tendon autografts (Group P). Surgeries were performed by experienced surgeons using standardized techniques. Patients were evaluated using clinical tests and functional scores including the Lysholm Knee Questionnaire and IKDC-2000 at various postoperative intervals up to 24 months. Data were analyzed using SPSS with a significance level set at p &lt; 0.05. Group H showed superior knee function preoperatively and at 24 months postoperatively compared to Group P. Group H had higher Lysholm and IKDC scores consistently throughout the study period. The anterior drawer and Lachman’s tests indicated better knee stability for Group H. Complications were comparable between groups, with specific issues related to donor site morbidity and muscle weakness observed in each. The six-strand hamstring tendon autograft (Group H) demonstrated superior functional outcomes and knee stability compared to the peroneus longus tendon autograft (Group P) for ACL reconstruction. Despite some donor site morbidity, the hamstring tendon showed better long-term recovery and fewer complications. Future studies should explore larger, multicentric cohorts and integrate regenerative medicine techniques to further enhance ACL reconstruction outcomes.

Comparison of Time Needed to Meet Common Rehabilitation Milestones After Anterior Cruciate Ligament Reconstruction According to Graft Type

Background: The use of bone–patellar tendon–bone (BPTB) and hamstring tendon (HT) autografts is common in anterior cruciate ligament reconstruction (ACLR). After ACLR, patients typically progress through specific rehabilitation milestones, and graft type may play a role in patient progression. Purpose: To compare the time to meet rehabilitation milestones between BPTB and HT autografts after ACLR. Design: Cohort study; Level of evidence, 3. Methods: This was a single-institution study on patients who underwent ACLR with either BPTB or HT autograft between June 2018 and July 2021. The primary outcomes were time to meet return-to-sport criteria, including &gt;90% limb symmetry index (LSI) for isokinetic quadriceps and hamstring strength, horizontal hop, 4-crossover hop, and single-hop height. The time to satisfaction of each criterion was compared between graft groups using Wilcoxon tests and Cox proportional hazards models. Results: Included in the analysis were 410 participants who underwent ACLR with either BPTB (n = 232) or HT (n = 178). The BPTB group took longer to achieve &gt;90% LSI for knee extension than HT (11.1 ± 4.1 vs 7.63 ± 2.8 months; P &lt; .001). Similarly, the BPTB group took longer than the HT group to achieve &gt;90% LSI for horizontal hop (11.4 ± 3.5 vs 9.82 ± 2.8 months; P &lt; .001), 4-crossover hop (11.8 ± 3.6 vs 10.4 ± 2.8 months; P = .002), and single-hop height testing (11 ± 3.7 vs 8.81 ± 3.2 months; P &lt; .001). The median time to achieve &gt;90% LSI for hamstring strength was similar between groups (7.18 ± 3 vs 7.56 ± 3.1 months; P = .2). Conclusion: Patients that underwent ACLR with BPTB autograft took longer than patients with HT to meet commonly used postoperative rehabilitation milestones. Clinicians should consider these differences when guiding patients regarding graft choice, postoperative expectations, and rehabilitation.

Patellar bone defect grafting does not reduce anterior knee pain after bone-patellar tendon-bone anterior cruciate ligament reconstruction.

Donor site morbidity is the main drawback to using bone-patellar tendon-bone (BPTB) as a graft in anterior cruciate ligament (ACL) reconstruction. The objective of the study was to determine whether refilling the patellar bone defect after BPTB harvesting with autograft bone decreased kneeling pain to a greater degree when compared with a group in which bone defect is left unaddressed. This is a randomised single-blinded controlled study. Forty patients were randomised into two groups; group 1: Patellar bone defect filled with autologous bone; group 2: Bone defect left undressed. Pain was measured by means of pressure algometry (PA). Functional outcomes were measured with the Kujala and Victorian Institute of Sport Assessment-Patella (VISA-P) score. Magnetic resonance imaging (MRI) was done to measure bone buildup between groups at the 1-year follow-up. No differences were observed in the different algometry measurements and the scores were assessed at 3, 6 and 12 months postoperatively. The ratio of void filled remained consistently higher (p = 0.003) in group 1 when compared to group 2. Although refilling the lower pole of the patella with autologous bone from the harvested BPTB autograft loads the bone defect, it does not reduce pain at the donor site 1 year after surgery. Therapeutic study level 1.

The Intra-articular Tendinous Graft Diameter of 10-mm Bone-Patellar Tendon-Bone Autografts in Adolescent Patients: An MRI Analysis of 100 Patients.

Bone-patellar tendon-bone (BPTB) autograft size may be one modifiable predictor of anterior cruciate ligament (ACL) reconstruction postoperative success, as smaller graft diameter has been associated with higher rates of rupture requiring revision. However, measuring the true intra-articular tendinous graft diameter of the soft tissue portion of a BPTB graft with standard intraoperative methods is difficult while keeping the graft intact. The purpose of the study was to use 3-dimensional magnetic resonance imaging (MRI) measurements to determine the cross-sectional area of the soft tissue, tendinous portion of a standard BPTB autograft with 10-mm diameter bone plugs, and, by calculation, the collagen graft size (ie, graft diameter), as would typically be reported in ACL reconstruction studies that consider soft tissue graft size. It was hypothesized that the calculated collagen graft diameter of 10-mm BPTB autografts would be significantly smaller than 10 mm. Cross-sectional study; Level of evidence, 3. A total of 100 patients (10 girls and 10 boys at each age from 13 to 17 years) who underwent a knee MRI at a single academic orthopaedic center without documented extensor mechanism pathology were identified. The central 10-mm width of the patellar tendon that would be harvested for BPTB autograft was measured. The region of interest area tool was then used to measure the cross-sectional area of a 10-mm BPTB graft with subsequent soft tissue autograft diameter calculation. The mean calculated tendinous graft diameter of a 10 mm-wide BPTB graft was 6.3 ± 0.5 mm and was significantly smaller than a 10-mm reference (P≤ .001). There was no significant association between age and cross-sectional area or graft diameter. Modern 3-dimensional imaging-based measurement techniques demonstrated that the true intra-articular tendinous soft tissue portion of 10-mm BPTB autografts shows substantial variation and is significantly smaller in diameter than the tunnels typically reamed to accommodate the bone plug portions of these grafts. Moreover, as graft size is a predictor of rupture rate, preoperative MRI-based evaluation may be an important tool when considering BPTB autograft for ACL reconstruction. Future comparative clinical research utilizing graft size as a study variable should consider quantifying and utilizing the diameter of the soft tissue component of BPTB autografts.

Incidence of Osteoarthritis Between ACL Reconstruction With Different Graft Types and Between ACL Reconstruction and Repair: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Variation in stiffness, fixation methods, and donor-site morbidity after anterior cruciate ligament reconstruction (ACLR) with different graft types and with anterior cruciate ligament suture repair (ACLSR) can lead to differences in dynamic knee laxity and consequent differences in posttraumatic osteoarthritis (PTOA) development. To compare the incidence of PTOA between different graft types used for primary ACLR and between primary ACLR and ACLSR. It was hypothesized that the incidence of PTOA would vary between ACLR with different autografts and allografts and between ACLR and ACLSR. Systematic review; Level of evidence, 1. A search of the literature was performed to identify all randomized controlled trials (RCTs) comparing radiographic evidence of PTOA after ACLR between different graft types-hamstring tendon (HT) autograft, bone-patellar tendon-bone (BPTB) autograft, quadriceps tendon autograft, and allograft-and between ACLR and ACLSR. The minimum follow-up was 2 years. Study quality was assessed using the modified Coleman Methodology Score. A meta-analysis was performed to determine whether there was a difference in the incidence of PTOA between the different graft types and between ACLR and ACLSR. Eleven randomized controlled trials were included in the meta-analysis-HT: 440 patients (mean follow-up, 9.7 years); BPTB: 307 patients (mean follow-up, 11.8 years); allograft: 246 patients (mean follow-up, 5 years); ACLSR, 22 patients (5 years). No study reporting the incidence after ACLR with quadriceps tendon was included. The study quality ranged from 70 to 88. The meta-analysis indicated no significant difference in the incidence of PTOA between graft types used for ACLR and between ACLR and ACLSR (risk ratios: HT vs BPTB, 1.05; HT vs allograft, 0.81; BPTB vs allograft, 0.82; HT vs ACLSR, not estimable [P > .05 for all]). The combined number of patients with PTOA in all studies per graft type showed that patients who underwent ACLR with a BPTB autograft had the highest percentage of PTOA (HT, 23.4%; BPTB, 29.6%; allograft, 8.1%; ACLSR, 0%). However, excluding studies with a follow-up <5 years resulted in similar outcomes for patients with an HT autograft and a BPTB autograft. This meta-analysis reported no difference in the incidence of PTOA between graft types used for ACLR and between ACLR and ACLSR. More research is necessary to make a reliable conclusion about which technique is associated with the lowest incidence of PTOA after ACL surgery.

Functional Outcomes of Bone-Patellar Tendon-Bone Versus Quadrupled Semitendinosus and Gracilis Autografts for Anterior Cruciate Ligament Reconstruction.

Introduction Anterior cruciate ligament reconstruction (ACLR) with autografts has been available for decades; however, the choice of graft is still debated. Here, we compared the functional outcomes of the two most widely used autografts, bone-patella tendon-bone (BPTB) and quadruple-stranded semitendinosus/gracilis (ST/G) autografts, at six months following ACLR. Materials and methods This prospective study was performed in the Department of Orthopedics of Yenepoya Medical College and Hospital located in Mangalore, Karnataka, India,a tertiary care institute over a period of 18 months (November 2018 to April 2020). The study included 38 adult patients whounderwent ACLR and were randomly divided into two groups: BPTB autograft (n=19) or ST/G autograft (N=19). The patients were followed up at one-, three-, and six months. Postoperatively, surgical morbidity, knee stability functional outcome on Lysholm score, and knee range of motion (ROM) were assessed. Results The groups were homogenous and comparable regarding age, sex, side of ACL affected, duration of tear to treatment, and muscle wasting (all p-values > 0.05). At six months, the majority of the patients had a tibial translation of 0-2 mm on the Lachman test and anterior drawer test, and the groups did not differ significantly (both p-values > 0.05). Additionally, at six months, both groups demonstrated a significant increase in mean Lysholm score and mean ROM (both p-values < 0.001). However, the groups did not differ in mean Lysholm score and mean ROM at baseline and any of the follow-up visits (all p-values > 0.05). Conclusion At six months, ACLR with BPTB and ST/G autografts produced significant and comparable knee stability, functional outcome, and ROM.

Association of Smaller Intercondylar Notch Size With Graft Failure After Anterior Cruciate Ligament Reconstruction.

Smaller intercondylar notch sizes have been consistently associated with a predisposition for primary anterior cruciate ligament tears. To evaluate the association between intercondylar notch size, graft size, and postoperative complications, including knee stiffness and return to the operating room, after primary anatomic anterior cruciate ligament reconstruction (ACLR). Case-control study; Level of evidence, 3. This was a retrospective analysis of prospectively collected data from consecutive patients who underwent anatomic single-bundle primary ACLR using a bone-patellar tendon-bone or quadriceps tendon autograft performed by fellowship-trained orthopaedic sports medicine surgeons between April 2009 and August 2019. Graft failure was defined as patient report of instability, pathologic laxity on clinical examination, or graft rerupture confirmed by magnetic resonance imaging and/or subsequent arthroscopy. To ensure the purposeful selection of covariates, univariate analyses were conducted on the list of potential confounders selected a priori, and those with a significance value of P < .10 were considered for the multivariate regression model. Covariates found to be statistically significant with univariate analysis were patient age, notch size, and graft type. After validating all potential covariates, they were added to the regression model and then eliminated in a stepwise fashion. In total, 252 patients were included for analysis (99 bone-patellar tendon-bone and 153 quadriceps tendon autograft; age, 22.2 ± 7.0 years; graft size, 9.8 ± 1.0 mm; time to follow-up, 50.4 ± 28.9 months). Knee stiffness developed in 23 patients (9.1%), and 15 grafts failed (6.0%). Smaller notch size on magnetic resonance imaging was significantly associated with graft failure (P = .005). There was a significantly higher risk of graft failure with notch size <16 versus ≥16 mm (17.6% vs 2.3%; P = .005) with an odds ratio (OR) of 5.0 (95% CI, 1.7-15.1; P = .004). Notch size <15 mm was associated with the highest risk of graft failure (22.2%; OR, 5.8; 95% CI, 1.6-20.6; P = .006). There was no significant association between notch size or graft-notch size ratio and knee stiffness, meniscal injury, or cartilage damage at the time of ACLR, regardless of graft type. Intercondylar notch size <16 mm was associated with a 5-fold increased risk of graft failure after primary anatomic ACLR.

No Clinically Significant Differences in Outcomes After Anterior Cruciate Ligament Reconstruction When Comparing Quadriceps, Bone–Patellar Tendon–Bone, and Hamstring Autografts of 9 mm or Greater

To determine whether there are patient-reported outcome differences in bone-patellar tendon-bone (BPTB), quadriceps tendon (QT), and hamstring (HS) grafts of comparable size. We performed a retrospective analysis of global registry data to include all patients who had an anterior cruciate ligament reconstruction with BPTB, QT, or HS autograft of at least 9 mm in diameter between 2010 and 2021 with complete 1- and 2-year outcome scores. We compared 1- and 2-year postoperative outcome scores (visual analog scale [VAS], Knee Injury and Osteoarthritis Outcome Score [KOOS] pain, Marx Activity Rating Scale [MARS], Veterans RAND 12-Item Health Survey [VR-12]) between BPTB, QT, and HS of the same size graft. In total, 2,318 subjects were included in the analysis, and all graft types showed improved patient-reported outcome measures at 1 and 2 years postoperatively when compared with baseline. The KOOS pain score for the BPTB group was significantly better than the HS (between-group difference= 2.71, P < .01) and QT (between-group difference= 2.51, P < .01) groups at 1 year, and the BPTB group was better than HS (between-group difference= 1.88, P < .01) at 2 years. However, the differences were small and not clinically meaningful. When we compared graft type, there were no differences in the percentage of patients who reached Minimal clinically important difference, or clinical scores VAS or MARS at 2-year follow-up. There is no clinically meaningful difference in KOOS-pain, VR-12, VAS, and MARS at 1 and 2 years postoperatively in patients having anterior cruciate ligament reconstruction with BPTB, HS, or QT if graft size is at least 9 mm in diameter. Level III, retrospective comparative study.

Patient and Operative Risk Factors for Osteoarthritis After Primary Anterior Cruciate Ligament Reconstruction: A Cohort Study of 41,976 Patients

Background: The reported incidence of posttraumatic knee osteoarthritis (PTOA) after primary anterior cruciate ligament reconstruction (ACLR) varies considerably. Further, there are gaps in identifying which patients are at risk for PTOA after ACLR and whether there are modifiable factors. Purpose: To (1) determine the incidence of PTOA in a primary ACLR cohort and (2) identify patient and perioperative factors associated with the development of PTOA after primary ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: Data from the Kaiser Permanente ACLR Registry were used to conduct a cohort study. Patients who had undergone primary ACLR without a previous diagnosis of osteoarthritis were identified (2009-2020). The crude incidence of PTOA was calculated using the Aalen-Johansen estimator with a multistate model. The association of patient and operative factors with the development of PTOA after primary ACLR was modeled as a time to event using multistate Cox proportional hazards regression. Models stratified by age (<22 and ≥22 years) were also conducted because of the effect modification of age. Results: The study sample included 41,976 cases of primary ACLR. The incidence of PTOA was 1.7%, 5.1%, and 13.6% at 2, 5, and 10 year follow-ups, respectively. Risk factors for PTOA that were consistently identified in the overall cohort and age-stratified groups included a body mass index ≥30 versus <30 and an allograft or quadriceps tendon autograft versus a hamstring tendon autograft. Patients presenting with knee pain after ACLR were further identified when considering postoperative factors. Other risk factors for PTOA in the overall cohort included age ≥22 versus <22 years, bone–patellar tendon–bone autograft versus hamstring tendon autograft, hypertension, cartilage injury, meniscal injury, revision after primary ACLR with concomitant meniscal/cartilage surgery, multiligament injury, other activity at the time of injury compared with sport, and tibial tunnel drilling technique rather than the anteromedial portal. Conclusion: Knee pain after ACLR may be an early sign of PTOA. Surgeons should consider the adverse associations of a higher body mass index and an allograft or quadriceps tendon autograft with the development of PTOA, as these were factors identified with a higher risk, regardless of a patient’s age at the time of primary ACLR.

Hamstring autografts demonstrate either similar or inferior outcomes to quadriceps or bone-patellar tendon-bone autografts in revision anterior cruciate ligament reconstruction: A systematic review of comparative studies.

To evaluate the clinical outcomes in patients undergoing revision anterior cruciate ligament reconstruction (r-ACLR) using hamstring tendon (HT) autografts with those using either quadriceps tendon (QT) or bone-patellar tendon-bone (BPTB) autografts or allografts. Three databases were searched on 8 August 2023. The authors adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, surgical details, patient-reported outcome measures (PROMs), rates of instability, failure and return to sport (RTS) were extracted. Eleven studies comprising 859 patients were included in this review. Five studies compared HT and QT autografts. One study each reported greater IKDC scores (p = 0.04) and Tegner scores (p = 0.04) in the QT group, while one study each reported higher anterior translation (p = 0.04), rates of positive pivot shift (p = 0.03) and rates of failure (p = 0.03) in the HT group. Six studies compared HT and BPTB autografts with one study each reporting greater Lysholm scores (p = 0.02) and less side-to-side anterior laxity (p < 0.01) in the BPTB group. Two studies compared HT autografts with allografts with only one study reporting a faster time to RTS in the HT group than the allograft group (p < 0.001). All other comparisons were not significant. HT autografts result in either similar or inferior outcomes in r-ACLR when compared to QT or BPTB autograft options. Allografts resulted in similar outcomes to HT autografts apart from greater time to RTS for r-ACLR. Level III.

Poster 339: Outcomes of Anterior Cruciate Ligament Reconstruction in Competitive Ice Hockey Players: Outcomes, Reoperations, and Return to Play at 7 Years Mean Follow-Up

Objectives: Ice hockey is a physically demanding sport, with young athletes prone to anterior cruciate ligament (ACL) injuries. Currently, there is a paucity of data examining the results of ACL reconstruction (ACLR) in competitive hockey players. The purpose of this study was to assess return to hockey (RTH) and reoperation rates following ACLR for ACL injuries in a cohort of competitive hockey players. Methods: All competitive ice hockey players (including, youth, high school, juniors, collegiate, or professional) with a history of ACL injury and subsequent ACLR at a single academic institution between 2000 and 2022 were identified. Exclusion criteria included ACL injuries that did not occur during hockey, history of ACLR prior to hockey injury, and recreational hockey players. Graft failure was defined as a retear (as determined via clinical or advanced imaging evaluation) and/or revision ACLR. Results: Ultimately, 50 knees in 44 hockey players were included at a mean (± standard deviation) follow-up time of 7.0 years ± 5.4 years (Table 1). The mean age at the time of index surgery was 18.9 years ± 3.0 years, with 38 males (76%), and the distribution of bone-patellar tendon-bone (BPTB) and hamstring tendon (HT) autografts was 40 (80%) and 10 (20%), respectively. RTH occurred in 66% of hockey players at a mean of 10.2 months ± 6.2 months. Graft failure occurred in 9 knees (18%) at a mean of 5.9 years ± 5.8 years after the index ACLR. All patients who sustained a retear underwent reoperation. Kaplan-Meier survivorship free from surgical failure of the entire cohort was 94% at 1 year, 88% at 5 years, 74% at 10 years, and 67% at 15 years (Figure 1A). BPTB autograft demonstrated a lower failure rate compared with HT autograft (13% vs 40%; P = 0.041) and was associated with better survival compared with HT autograft up to 15 years after the index ACLR (80% vs 39%; P = 0.047; Figure 1B). Conclusions: ACL injury remains a concern for competitive hockey players after ACLR. Return to competitive ice hockey was observed in 66% of athletes after ACLR, with 18% of hockey players experiencing graft failure and undergoing subsequent reoperation. BPTB autograft was associated with better survival than HT autograft.

Poster 345: External Validation of the Norwegian Anterior Cruciate Ligament Reconstruction Revision Prediction Model Using Patients From the Stability 1 Trial

Objectives: Machine learning has emerged as a potential tool for improving outcome prediction accuracy in anterior cruciate ligament (ACL) reconstruction (ACLR). A machine learning-based ACL revision prediction model has been developed using data from the Norwegian Knee Ligament Register (NKLR) but lacks external validation outside of Scandinavia. This study aimed to assess the external validity of the previously published ACL revision prediction model ( https://swastvedt.shinyapps.io/calculator_rev/ ) using data from the Stability 1 randomized clinical trial. The hypothesis was that the model's performance would be similar, indicating validity of the algorithm. Methods: This was a level 3 cohort study. The Cox Lasso prediction model from the original study was selected for external validation owing to its superior performance during model development and internal validation testing. The Stability 1 trial was an external randomized controlled trial that assigned patients to receive either hamstring tendon (HT) autograft or HT with lateral extra-articualr tenodesis (LET). Patients from Stability 1 with all 5 predictors required by the Cox Lasso model were included. Since all patients in the Stability 1 trial received hamstring HT plus/minus LET, three configurations were tested: 1: all patients coded as HT, 2: HT + LET group coded as bone-patellar tendon-bone (BPTB) autograft, 3: HT + LET group coded as unknown/other graft choice. The different configurations were tested because previous evaluation of the Stability 1 cohort by the Multicenter Orthopaedic Outcomes Network (MOON) suggests failure rates of HT + LET are most similar to the failure rates of patients who receive BPTB. Concordance and calibration were calculated to determine model performance with censoring of the time-to-event outcome. Results: In total, 591 patients from the Stability 1 trial were included, and 39 patients (6.6%) underwent revision surgery within 2 years. Model performance was best when patients randomized to HT + LET were coded as BPTB. Validation concordance was similar to the original NKLR prediction model for 1- and 2-year revision prediction (Stability: 0.71; NKLR: 0.68-0.69). Concordance CI ranged from 0.63-0.79. The model was well calibrated for 1-year prediction while the 2-year prediction demonstrated evidence of miscalibration. Conclusions: The most important finding of this study was that when patients in the Stability 1 trial who received HT + LET were coded as BPTB in the Norwegian prediction calculator, the model concordance was similar to the index study. However, the CI for the validation set was wider than the original model, suggesting that more data is required to definitively determine the external validity. The finding that HT + LET behaved most similarly to BPTB supports the notion that the addition of LET can decrease the failure and subsequent revision rate of primary ACLR when HT is used. In addition, if further external validation efforts are consistent with this study, the prediction model may require updating to equate HT + LET to BPTB for the purposes of prospectively estimating revision surgery risk.