Bone-patellar Tendon-bone Group Research Articles

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.

Eighteen-year outcome of anterior cruciate ligament reconstruction with patellar tendon or hamstring autograft.

To evaluate patient reported outcomes and radiographic arthritic changes of transtibial anterior cruciate ligament reconstruction (ACLR) with either bone-patellar tendon-bone (BPTB) or hamstrings (HS) auto-grafts at a minimum of 15-year follow-up. Ninety-four patients (51 of the HS group, 43 of BPTB group) who were operated between the years 2000 to 2005 in two tertiary referral hospitals were contacted and invited to a retrospective evaluation. The interview included subjective outcomes using the Lysholm knee scoring questionnaire, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Tegner activity level scale, Visual Analogue Scale (VAS) for pain and patients' satisfaction scale. Knee examination included measurements of motion and stability. Knee radiographs were evaluated for osteoarthritic changes according to the Kellgren-Lawrence (KL) score. The average evaluation time from surgery was 18.6 years. Subjectively, there was no significant difference between groups except for a better post-operative level of activity and satisfaction in the HS group. Objectively, there was no significant difference between groups in knee stability and range of motion. Most patients had grade KL ≤ 1 radiographic osteoarthritits changes and there was no significant difference between groups. Recurrent complete tear of the reconstructed graft occurred in 3 patients of each group. In both groups 84% had no further surgery while the indications for further surgery were mostly a meniscal tear or tibial hardware removal. Very long-term outcomes and clinical stability of transtibial HS or BPTB graft ACL reconstruction are good with low rate of graft failure and radiographic osteoarthritis.

Young men undergoing anterior cruciate ligament reconstruction with patellar tendon autograft and anteromedial drilling outperform at 5- to 10-year follow-up in terms of graft stability and activity levels compared to those undergoing reconstruction with hamstring autograft and transtibial drilling

ObjectiveTo compare 5- to 10-year outcomes of anterior cruciate ligament (ACL) reconstruction in young men performed with bone-patellar tendon bone (BPTB) autograft and anteromedial portal to reconstruction with hamstring autograft and transtibial technique. It was hypothesised that in young adult men, at 5- to 10-year follow-up, superior restoration of knee laxity and activity levels would be demonstrated using BPTB autograft and anteromedial portal technique. MethodsNinety-four men who had ACL reconstruction with BPTB autograft and anteromedial portal were eligible for comparison to 106 men who had reconstruction with hamstring autograft and transtibial technique. Inclusion criteria were: (1) age 18–35 years, (2) ACL tear caused by sports trauma only, (3) no concomitant ligament reconstruction and (4) 5- to 10-year follow-up. Outcome measures compared between the two groups included Lachman and pivot shift tests, KT side-to-side difference, Tegner and Marx scores, International Knee Documentation Committee (IKDC)-subjective score, Knee Osteoarthritis Outcome Scale (KOOS), Short Form (SF)-36, and single hop test for distance. P value ​< ​0.05 indicated statistical significance. ResultsForty-five patients with BPTB and 55 patients with hamstring ACL reconstruction were available for in-person assessment at 5–10 years after surgery. Outcomes in the BPTB group compared to the hamstring group showed KT difference 1.4 ​± ​1.9 mm vs. 2.8 ​± ​2.3 mm (p ​< ​0.01), pivot shift grade 2–3 in 4% vs. 34% (p ​< ​0.01), return to preinjury Tegner level in 51% vs. 36% (p ​= 0.1) and to preinjury Marx score in 29% vs. 11% (p ​= 0.02), and IKDC-subjective 88 ​± ​10 vs. 82 ​± ​13 vs (p ​< ​0.01), respectively. Statistically significant inter-relationships were found between KT side-to-side difference and the Tegner, Marx and IKDC-subjective scores at follow-up (r ​= ​−0.314, p ​< ​0.01; r ​= ​−0.263, p ​< ​0.01; r ​= ​−0.218, p ​= ​0.03, respectively). ConclusionYoung men undergoing ACL reconstruction with patellar tendon autograft and anteromedial drilling outperform at 5- to 10-year follow-up in terms of graft stability and activity levels compared to young men undergoing reconstruction with hamstring autograft and transtibial drilling. Level of EvidenceIII (Retrospective cross-sectional comparative study).

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.

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.

Minimally Invasive Bone-Patellar Tendon-Bone Graft Harvest Is Associated With Less Frequent Anterior Knee Pain at Rest Than Hamstring Graft Harvest After Anterior Cruciate Ligament Reconstruction at the 1-Year Follow-Up

To compare the incidence of postoperative anterior knee pain at rest and during "knee walking" in patients who had anterior cruciate ligament reconstruction (ACLR) surgery with hamstring tendon (HT) grafts versus bone-patellar tendon-bone (BPTB) grafts harvested using a minimally invasive double-incision technique with autografting of the bone harvest defects. Adult patients who had undergone an ACLR and had completed a questionnaire enquiring about anterior knee symptoms at a minimum of 1 year postoperatively were identified. Two groups were compared: 1) patients who had received a BPTB graft harvested using a minimally invasive double-incision technique with autografting of the bone harvest defects, and 2) patients who had received a HT graft. A total of 142 adult patients were included: 88 had a BPTB graft and 54 had a HT graft. The prevalence of anterior knee pain at rest was 10% in the BPTB group and 28% in the HT group (P= .006). Overall, knee walking scores were worse in the BPTB group when compared to the HG group, but the difference in the proportions of patients who found it impossible to knee-walk was not statistically significant (17% vs 6%; P= .069). Our results showed that pain at rest was less in the BTPB group compared to the HT group contradicting historic literature. In addition, there was no statistically significant difference between the 2 grafts when comparing the proportion of patients who found it "impossible" to knee-walk. Level III, retrospective comparative study.

Poster 330: Quadriceps Autograft Leads to Improved Psychological Readiness for Return to Play Compared to Hamstring and Bone-Patellar Tendon-Bone Autografts Following ACL Reconstruction

Poster 330: Quadriceps Autograft Leads to Improved Psychological Readiness for Return to Play Compared to Hamstring and Bone-Patellar Tendon-Bone Autografts Following ACL Reconstruction

Paper 26: Clinical Outcomes of Combined ACL and Anterolateral Ligament Reconstruction Versus Isolated ACL Reconstruction With Bone-Patellar Tendon-Bone Autograft As The Gold Standard: A Matched-Pair Analysis of 2018 Patients

Objectives: The aims of this study were to compare the clinical outcomes following “gold standard” ACL reconstruction (ACLR) with a Bone-Patellar Tendon-Bone (BPTB) autograft versus ACLR combined with an anterolateral ligament reconstruction (ALLR) using hamstring tendon autografts (HT), in a large series of propensity matched patients. The hypothesis was that combined ACLR+ALLR would confer better graft rupture rates and lower non-graft rupture related re-operation rates than isolated ACLR with BPTB Methods: A retrospective analysis of prospectively collected data was performed. Patients undergoing ACLR+ALLR using HT between January 2003 and December 2019 were propensity matched in a 1:1 ratio to patients undergoing isolated ACLR using BPTB. At the end of the study period rates of graft rupture and any other re-operations or complications that occurred following the index procedure were identified by database interrogation, review of medical records and standardized telephone interview. Kaplan Meier survivorship analyses and Cox-proportional hazards models were used to evaluate graft survivorship, re-operation free survivorship and the significance of potentially important risk factors. Results: A total of 2018 patients (1009 matched pairs) were included. The mean duration of follow-up was 101.3 months. Kaplan Meier Analysis demonstrated a significantly better graft survivorship in the ACLR+ALLR group when compared to the BPTB group at every time point (Fig 1 and Table 1). The Cox model demonstrated that patients in the BPTB group were &gt; 3-fold more likely to experience graft failure (Hazard Ratio (HR) = 3.554 [1.744;7.243], p = 0.0005). Patients aged less than 20 years were at particularly high risk of graft rupture (HR = 5.65 [1.834;17.241], p = 0.0002) and further analysis of this subgroup demonstrated that isolated ACLR with BPTB also conferred a &gt; 3 fold increased risk of graft rupture in young patients when compared to ACLR+ALLR. Multivariate analysis did not identify any other significant risk factors for graft rupture. Overall, there was a significantly higher reoperation rate following isolated ACLR (BPTB group 20.5%, ACLR+ALLR group 8.9%, p &lt; 0.0001). This finding was accounted for by significantly higher rates of graft rupture (9.9% vs 3.5%, p &lt;0.0001), cyclops syndrome (3.3% vs 1.5%, p &lt;0.0001), and secondary meniscectomy (5% vs 2.9%, p=0.0196) in the BPTB group. Conclusions: Patients who underwent isolated ACLR with BPTB autografts experienced significantly worse ACL graft survivorship and overall re-operation free survivorship when compared to those who underwent combined ACLR+ALLR with hamstring autografts. The risk of graft rupture was more than 3-fold higher in patients who underwent isolated ACLR using BPTB. [Table: see text]

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.

The reverse fragility index: RCTs reporting non-significant differences in failure rates between hamstring and bone-patellar tendon-bone autografts have fragile results.

The reverse fragility index (RFI) is a novel metric to appraise the results of studies reporting statistically non-significant results. The purpose of this study was to determine the statistical robustness of randomized controlled trials (RCTs) reporting non-significant differences in anterior cruciate ligament reconstruction (ACLR) graft failure rates, defined as re-rupture/revision ACLR rate, between hamstring tendon (HT) and bone-patellar tendon-bone (BTB) autografts by calculating RFIs. A systematic review was performed to identify RCTs that compared HT to BTB grafts for ACLR through January 2022. Studies reporting non-significant differences in graft re-rupture and revision ACLR rate (n.s.) were included. The RFI, defined as the fewest number of event reversals needed to change the non-significant graft re-rupture/revision outcome to statistically significant (P < 0.05), was recorded for each study. In addition, the number of studies in which the loss to follow-up exceeded the RFI was recorded. Among the 16 included RCTs, the median (interquartile range [IQR]) sample size was 71 (64-114), and the median (IQR) total number of graft re-rupture/revision ACLR events was 4 (4-6). The median (IQR) graft re-rupture/revision ACLR rate was 4.3% (3.0-6.4) overall, 4.1% (2.6-6.7) in the BTB group, and 5.4% (3.0-6.3) in the HT group. The median (IQR) RFI was 3 (3-4), signifying that a reversal of the outcome in 3 patients in one arm was needed to flip the studies' result from non-significant to statistically significant (P < 0.05). The median (IQR) number of participants lost to follow-up was 11 (3-13), and 13 (81.3%) of the included studies had a loss to follow-up greater than the studies' RFI. The results of RCTs reporting statistically non-significant re-rupture/revision ACLR rates between HT and BTB autografts would become significant if the outcome were reversed in a small number of patients-a number that was less than the loss to follow-up in the majority of studies. Thus, the neutrality of these studies is fragile, and a true statistically significant difference in re-rupture/revision rates may have been undetected. Level I.

Efficacy comparison between a new generation of artificial ligaments and bone-patellar tendon-bone autograft for anterior cruciate ligament revision

Objective: To compare the clinical efficacy of a new generation of ligaments (LARS artificial ligament) and bone-patellar tendon-bone (BPTB) autograft as grafts in anterior cruciate ligament (ACL) revision. Methods: A retrospective cohort study. The clinical data of 54 patients who underwent ACL revision from January 2018 to June 2020 in the First Hospital Affiliated to Army Medical University were retrospectively analyzed. There were 44 males and 10 females with a mean age of (28.5±7.7) years (15-45 years). Among them, 24 cases underwent ACL revision with LARS artificial ligament (LARS group), the other 30 cases underwent ACL revision with BPTB (BPTB group). The subjective and objective knee joint evaluation indexes were compared between the two groups to evaluate the clinical efficacy. The subjective evaluation indexes included Tegner score, Lysholm score and the International Knee Documentation Committee (IKDC) score. The objective evaluation indexes included the Lachman test, pivot-shift test, the anterior tibial translation (ATT) measurement at the weight-bearing position and the rate of patients returned to pre-injury sports. Results: The follow-up period was (32.8±5.3) months (24-42 months). At the last follow-up, the IKDC score, Tegner score and Lysholm score in the two groups significantly increased when compared with those before surgery (all P<0.05), and there was no significant difference in those indexes between the two groups (all P>0.05). The ATT measurement in the weight-bearing position was (3.1±0.7) mm in the LARS group and it was (4.1±0.9) mm in the BPTB group, which were significantly improved when compared with those before surgery (both P<0.05), and it was better in the LARS group than in the BPTB group (P<0.05). Postoperative Lachman test and pivot-shift test results in the LARS group were better than those in the BPTB group with statistically significant difference (both P<0.05). The rate of patients returned to pre-injury sports one year after surgery was 79.2%(19/24) in the LARS group and it was 50.0%(15/30) in the BPTB group, and the difference was statistically significant (P=0.029). Conclusions: Both LARS artificial ligament and BPTB autograft can achieve good short-term clinical efficacy in ACL revision, but LARS artificial ligament group has more advantages than BPTB autograft group in knee stability and early return to sports.

Revision ACL reconstruction using quadriceps, hamstring and patellar tendon autografts leads to similar functional outcomes but hamstring graft has a higher tendency of graft failure

PurposeThe purpose of this study was to evaluate the differences in the patient-reported functional outcomes, and graft failure in revision ACL reconstruction using quadriceps tendon (QT), Hamstring tendon (HT) and bone-patellar tendon-bone (BPTB) autografts.MethodsBetween 2010 and 2020, 97 patients who underwent revision ACL reconstruction (40 patients received a QT, 26 an HT and 31 a BPTB graft) met the inclusion criteria. Pre-injury and at 2-year postoperatively patients were evaluated for patient-reported functional outcomes; Lysholm knee score, Tegner activity level and VAS (visual analogue scale) for pain; and graft failure. Patient-reported outcomes and graft failure were compared between the QT, HT and BPTB groups. The patients with graft failure were not included for outcome analysis at 2-years of follow-up.ResultsAll three revision groups with QT, HT and BPTB autograft did not differ significantly in terms of age, sex, time from injury to surgery, concomitant injuries and single-stage or double-stage procedures (n.s.). No significant difference was found in the pre-injury patient-reported outcome; Lysholm knee score, Tegner activity and VAS for pain (n.s.) between the three groups. At the 2-year follow-up functional outcomes improved in all three groups and all the patients returned to pre-injury activity level; however, no significant difference was found in functional outcomes at the 2-year follow-up between the three groups (n.s.). Graft failure occurred in 4 (10%), 5 (19%) and 3 (10%) patients of QT, HT and BPTB groups, respectively. However, the rate of failure did not differ significantly between groups.ConclusionAll three autografts (QT, HT and BPTB) demonstrated satisfactory patient-reported outcomes in revision ACL reconstruction. Compared with QT and BPTB grafts, HT graft showed a higher tendency for failure rates. With the increasing incidence of revision ACL reconstruction, surgeons should be aware of all the available graft options. The findings of this study will assist the surgeons in the graft selection for revision ACL reconstruction.Level of evidenceLevel III.

Influence of Graft Type on Lower Extremity Functional Test Performance and Failure Rate After Anterior Cruciate Ligament Reconstruction.

Both autografts and allografts are used to reconstruct the anterior cruciate ligament (ACL) after injury; however, it is unclear whether graft source affects lower extremity functional test performance or failure rate in an active military population. To compare lower extremity functional test performance and graft failure rates between ACL grafts [allograft, hamstring, bone-patellar tendon-bone (BTB)]. Cross-sectional. Level 2. Ninety-eight cadets entering a US Service Academy with a history of unilateral ACL reconstruction (ACLR) agreed to participate. Before basic training, participants completed 4 lower extremity functional tests. Active injury surveillance was conducted within the study cohort to identify all subsequent graft failures. Cadets with hamstring autografts outperformed the BTB and allograft groups on the Lower Quarter Y-Balance Test-Posteromedial direction and single-leg hop test, respectively. No differences were detected by graft type for the other functional tests. The incidence of subsequent ipsilateral graft failures in patients with autograft was 8.11%. No failures were observed in the allograft group during the follow-up period. After controlling for sex, joint hypermobility, and time since injury and surgery, the risk of graft failure was 9.8 times higher for patients with a hamstring autograft than with a BTB (P = 0.045). After ACLR, graft type appears to influence some single-limb measures of lower extremity function and the risk of subsequent failure. Hamstring autografts demonstrated better functional performance but increased risk of graft failure. Surgeons need to weigh the pros and cons of all graft options in relation to the patient's lifestyle. Regardless of graft type, individuals with an ACLR may require additional rehabilitation to regain neuromuscular control during dynamic single-limb tasks and mitigate graft failure.

Paper 02: ACL Reconstruction in Cutting and Pivoting Athletes: Soft Tissue Quadriceps Tendon Autograft vs. Bone-Patellar Tendon-Bone Autograft

Objectives:ACL reconstruction is one of the most common knee procedures performed annually in the United States. Athletes participating in cutting and pivoting sports are at high risk for ACL injury. In the general population, most graft choices including allograft, bone-patellar tendon-bone (BTB) autograft, hamstring autograft and quadriceps autograft have all been shown to excellent results following reconstruction. However, in the high-level cutting and pivoting athlete, the optimal graft for reconstruction remains controversial. Most consider BTB autograft to be the gold standard for such athletes. However, BTB autografts have drawbacks including anterior knee pain, difficulty kneeling and possible patellar fracture and patellar tendon rupture. Quadriceps autograft has increased in popularity since it offers a thicker graft with more favorable tensile properties compared to BTB and hamstring autografts. The quadriceps autograft has nearly twice the cross sectional area, higher load to failure and greater stiffness than the BTB autograft. Studies have shown equivalent outcomes when directly comparing BTB autograft vs. soft tissue quadriceps autograft in the general population. No studies have directly compared these two grafts in athletes participating in cutting and pivoting sports. We hypothesized that the quadriceps autograft would lead to similar patient outcomes, re-tear rates, return to sport and complications as BTB autografts in the cutting and pivoting athlete.Methods:A retrospective review of cutting and pivoting athletes with ACL tears treated with BTB autograft or soft tissue quadriceps autograft with at least 2 years of follow up was performed. Only athletes participating in cutting and pivoting sports were included in the study. Four sports were considered to be cutting and pivoting including soccer, football, lacrosse and basketball. The decision on which graft to use was based on the athlete’s choice after discussing the pros and cons of each graft. Exclusion criteria included those athletes with recurrent ACL tears, multiligamentous injuries, previous meniscal surgery and those requiring osteotomies. International Knee Documentation Committee Subjective Knee Evaluation (IKDC) and Lysholm knee scoring scale were used to evaluate patient reported outcomes. Through chart review, ability to return to sport, time to return to sport and complications were identified. The postoperative rehabilitation protocol for both grafts was identical.Results:There were 32 athletes in the soft tissue quadriceps autograft group and 36 in the BTB autograft group. The average age was 18.6 years for the quad group and 19.7 years for the BTB autograft group (p=0.63). Females made up 62.5% of the quadriceps group and 44.4% of the BTB group (p=0.14). The quad group was made up of 56.3% high school and 43.7% college athletes compared to 61.1% high school and 38.9% college athletes in the BTB autograft group (p=0.53). Soccer was the most common sport with 16 in the quad group and 14 in the BTB group. The rest of the quad group included 8 football players, 4 lacrosse and 4 basketball players. The remaining BTB group consisted of 12 football players, 8 lacrosse and 2 basketball players. Meniscal surgery was performed in combination with the ACL reconstruction in 17 (53.1%) of the quad group and 22 (61.1%) of the BTB autograft group (p=0.37). Average graft size was 9.5mm for the quad autograft group and 10 for the BTB autograft group. The 2-year IKDC score was 93.6 for the quad group and 95.1 for the BTB group (p=0.45). The 2 year Lysholm scores were 95.7 and 96.1 for the quad and BTB groups respectively. Return to play at the same or higher level was 90.6% in the quad group and 86.1% in the BTB autograft group (p=0.82). Time to return was also similar between the groups with 7.1 months for the quad group and 7.6 months for the BTB autograft group. There was 1 re-tear which required revision in the BTB group and no re-tears in the quad group (p=0.34). Arthrofibrosis requiring MUA and lysis of adhesions occurred in 2 quad autografts and 4 BTB autografts (p=0.49). One contralateral ACL rupture occurred in the quad autograft group and 4 in the BTB autograft group (p=0.21).Conclusions:The optimal ACL graft in high level athletes participating in cutting and pivoting sports remains in question. In our comparison of quadriceps autograft compared to BTB autograft in this athletic population, no difference in patient reported outcomes, return to sport or re-tear rates was identified. Based on these findings, quadriceps autograft is as effective as BTB autografts in cutting and pivoting athletes and should be part of the graft choice discussion with the athlete.

Comparison of Clinical Outcomes after Revision Anterior Cruciate Ligament Reconstruction using a Bone-patellar Tendon-bone Autograft and that Using a Double-Bundle Hamstring Tendon Autograft.

The purpose of this study was to compare clinical outcomes between revision anterior cruciate ligament reconstruction (ACLR) using a bone-patellar tendon-bone (BPTB) autograft and that using a double-bundle hamstring tendon (HT) autograft. Consecutive cases of revision ACLRs were reviewed. The Lysholm knee scale and Knee Osteoarthritis Outcome Score (KOOS) were recorded at the final follow-up. The pivot shift test, Lachman test, and anterior knee laxity measurement using an arthrometer were evaluated before revision ACLR and at final follow-up. Contralateral knee laxity was also evaluated, and side-to-side differences noted. The Lysholm knee scale, KOOS, the pivot shift test, Lachman test, and anterior knee laxity were compared between HT versus BPTB autograft recipient groups using the Mann-Whitney test or the t-test. Forty-one patients who underwent revision ACLR and followed up for at least 2 years were included. The graft source was a BPTB autograft in 23 patients (BPTB group) and a double-bundle HT autograft in 18 patients (HT group). The mean postoperative follow-up period was 44 ± 28 months in the BPTB group and 36 ± 18 in the HT group (p = 0.38). The HT group had significantly higher KOOS in the pain subscale (less pain) than the BPTB group at the final follow-up (BPTB group 84.2 vs. HT group 94.4; p = 0.02). The BPTB group showed significantly smaller side-to-side difference in anterior knee laxity (superior stability) than the HT group (0.3 vs. 2.6 mm; p < 0.01). The percentage of patients with residual anterior knee laxity in the BPTB group was significantly lower than that in the HT group (9.5% vs. 46.7%; odds ratio, 8.3; p = 0.02). This was a level 3 retrospective study. Revision ACLR with a BPTB autograft was associated with superior results regarding restoration of knee joint stability as compared with that with a double-bundle HT autograft, whereas double-bundle HT autograft was superior to BPTB autograft in terms of patient-reported outcomes of pain. The rest of the patient-reported outcomes were equal between the two groups.

Quadriceps Tendon Autograft Versus Bone–Patellar Tendon–Bone and Hamstring Tendon Autografts for Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Background: The best type of autograft for anterior cruciate ligament (ACL) reconstruction remains debatable. Hypothesis: Compared with bone–patellar tendon–bone (BPTB) and hamstring tendon (HT) autografts, the quadriceps tendon (QT) autograft has comparable graft survival as well as clinical function and pain outcomes. Study Design: Meta-analysis; Level of evidence, 4. Methods: A systematic literature search was conducted in PubMed, Embase, Scopus, and the Cochrane Library to July 2020. Randomized controlled trials (RCTs) and observational studies reporting comparisons of QT versus BPTB or HT autografts for ACL reconstruction were included. All analyses were stratified according to study design: RCTs or observational studies. Results: A total of 24 studies were included: 7 RCTs and 17 observational studies. The 7 RCTs included 388 patients, and the 17 observational studies included 19,196 patients. No significant differences in graft failure (P = .36), the International Knee Documentation Committee (IKDC) subjective score (P = .39), or the side-to-side difference in stability (P = .60) were noted between QT and BPTB autografts. However, a significant reduction in donor site morbidity was noted in the QT group compared with the BPTB group (risk ratio [RR], 0.17 [95% CI, 0.09-0.33]; P < .001). No significant differences in graft failure (P = .57), the IKDC subjective score (P = .25), or the side-to-side stability difference (P = .98) were noted between QT and HT autografts. However, the QT autograft was associated with a significantly lower rate of donor site morbidity than the HT autograft (RR, 0.60 [95% CI, 0.39-0.93]; P = .02). A similar graft failure rate between the QT and control groups was observed after both early and late full weightbearing, after early and late full range of motion, and after using the QT autograft with a bone plug and all soft tissue QT grafts. However, a significantly lower rate of donor site morbidity was observed in the QT group compared with the control group after both early and late full weightbearing, after early and late full range of motion, and after using the QT autograft with a bone plug and all soft tissue QT grafts. No difference in effect estimates was seen between RCTs and observational studies. Conclusion: The QT autograft had comparable graft survival, functional outcomes, and stability outcomes compared with BPTB and HT autografts. However, donor site morbidity was significantly lower with the QT autograft than with BPTB and HT autografts.

Radiographic assessment of bone tunnels after anterior cruciate ligament reconstruction: A comparison of hamstring tendon and bone-patellar tendon-bone autografting technique.

Objectives This study aims to compare the postoperative change of femoral and tibial tunnel widths after hamstring tendon (HT) and bone-patellar tendon-bone (BPTB) autografting in primary anterior cruciate ligament (ACL) reconstruction surgery with the anteromedial portal technique.Patients and methods This case-control and retrospective study included 39 patients (36 males, 3 females; mean age 30.1±7.9; range, 17 to 44 years) who underwent primary ACL reconstruction surgery with either BPTB autografting method (BPTB group, n=18) or HT autografting method (HT group, n=21) between March 2014 and December 2016. Femoral fixation was achieved with bioabsorbable screw in BPTB group and endobutton in HT group. Tibial fixation was achieved with bioabsorbable interference screw in both groups. Femoral and tibial tunnel widths of groups were compared on digital radiographs.Results When we compared the baseline values with the second-year results, the mean of femoral tunnel widths were significantly lower on radiographs at the second-year evaluation in both groups (p<0.001 for all). However, the means of tibial tunnel widths were significantly lower only in the BPTB group (p<0.001 for BPTB group and p=0.616 for HT group). Change levels of anteroposterior and lateral widths were more prominent in BPTB group than HT group (p<0.001 for all).Conclusion Changes in tunnel widths show us superior ossification in BPTB grafting. This can be explained by superior bone-to-bone healing. As a result of radiological evaluation, we think that BPTB grafting can be more strong and durable.

All-Inside Quadrupled Semitendinosus vs. BTB ACL Reconstruction in Young Athletes: RCT

Anterior cruciate ligament (ACL) reconstruction is challenging in young athletes. An important clinical question is optimal graft choice in this high-risk group. The purpose of this investigation was to compare clinical outcomes of ACL autograft reconstruction using all-inside GraftLink quadrupled semitendinosis (GraftLink) versus the “gold standard” bone-patellar tendon-bone (BTB) in a high-risk athletic population 24 years or younger. Skeletally mature candidates younger than 24 years old with an ACL tear were randomized into either the GraftLink (n=32) or BTB (n=32) groups and were followed for two years. MRIs were obtained at one-year follow-up, and radiographs were obtained at two-year follow-up. The primary outcome measure was KT- 1000 stability testing. Secondary outcome measures included: IKDC Knee Evaluation Form, IKDC Subjective Form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Marx Activity Scale, and SF-12. At 2-year follow-up, no statistical difference existed with KT-1000 measured side to side laxity between GraftLink (0.3 ± 0.7 mm) and BTB (0.0 ± 0.8 mm) (p = 0.197). Additionally, no statistical differences between the groups were found for any secondary outcome measure or with regards to imaging findings. BTB patients reported significantly higher postoperative pain scores at days 3 (p=0.05) and 7 (p=0.018) and had significantly greater kneeling pain at 2 years (p < 0.019). A return to sport questionnaire at 2 years revealed no significant difference between the groups for returning to preoperative level of sport activity (83% GraftLink, 74% BTB; p=0.415). Two graft retears (7%; p=0.222) occurred in the GraftLink group. Three patients in the BTB group experienced ACL tears in the contralateral knee (9%; p=0.239). ACL reconstruction with all-inside quadrupled semitendinosis autograft GraftLink construct was equivalent to patellar BTB autograft based on KT-1000 stability testing and validated outcome measures, including IKDC, in athletes 24 years or younger (average age 17.7). There was no significant difference in graft retear rate or return to sport at the same preoperative level between the groups. However, there was significantly less kneeling pain in the GraftLink cohort.

Autograft type affects muscle strength and hop performance after ACL reconstruction. A randomised controlled trial comparing patellar tendon and hamstring tendon autografts with standard or accelerated rehabilitation

PurposeTo evaluate and compare changes in quadriceps and hamstring strength and single-leg-hop (SLH) test performance over the first 24 postoperative months in patients who underwent anterior cruciate ligament reconstruction (ACLR) with bone-patellar tendon-bone (BPTB) or hamstring tendon (HT) autografts and followed either a standard or an accelerated rehabilitation protocol.MethodsA total of 160 patients undergoing ACLR were randomised in four groups depending on the graft that was used and the rehabilitation protocol (40 BPTB/standard rehab, 40 BPTB/accelerated rehab, 40 HT/standard rehab, 40 HT/accelerated rehab). Isokinetic concentric quadriceps and hamstring strength at 90°/s and the SLH test performance were assessed preoperatively and 4,6,8,12 and 24 months postoperatively. The results were reported as the limb symmetry index (LSI) at the same time point. Linear mixed models were used to compare the groups at the different time points.ResultsAn average quadriceps strength LSI of 78.4% was found preoperatively. After ACLR, the LSI first decreased at 4 months and then increased from 6 to 24 months, reaching an overall value of 92.7% at the latest follow-up. The BPTB group showed a significantly decreased LSI at 4, 6, 8 and 12 months compared with the HT group. No significant differences between the graft groups were found at 24 months.An average hamstring strength LSI of 84.6% was found preoperatively. After ACLR, the LSI increased from 4 to 24 months in the BTPB group. In the HT group, the LSI first decreased at 4 months and then increased from 6 to 24 months. An LSI of 97.1% and 89.1% was found at the latest follow-up for the BPTB and the HT group, respectively. The HT group showed a significantly decreased LSI at all follow-ups compared with the BPTB group.An average SLH test LSI of 81% was found preoperatively. After ACLR, the LSI increased from 4 to 24 months, reaching 97.6% overall at the latest follow-up. The BPTB group showed a significantly decreased LSI only at 4 months postoperatively compared with the HT group. No significant differences in any of the three tests were found between the standard and accelerated rehabilitation groups for either of the graft groups at any time point.ConclusionMuscle strength and SLH test performance recovered progressively after ACLR overall, but they did not all fully recover, as the injured leg performed on average less than 100% compared with the uninjured leg even 24 months postoperatively. After ACLR, inferior quadriceps strength and a poorer SLH test performance were found at 4, 6, 8 and 12 months and at 4 months, respectively, for the BTPB group compared with the HT group. Persistent, inferior hamstring strength was found at all postoperative follow-ups in the HT group. Rehabilitation, standard or accelerated, had no significant impact on the recovery of muscle strength and SLH test performance after ACLR in any of the graft groups.Level of EvidenceLevel I.

Hamstring autograft versus patellar tendon autograft for anterior cruciate ligament reconstruction, which graft has a higher contralateral anterior cruciate ligament injury rate?: A meta-analysis of 5561 patients following the PRISMA guidelines.

Background:Contralateral anterior cruciate ligament (CACL) injury is one of the devastating complications after anterior cruciate ligament (ACL) reconstruction. Whether the risk of CACL tear is related to graft selection remains controversial due to contradictory results in studies. There are no meta-analyses to compare which graft has a higher CACL injury rate. Hence, this meta-analysis was conducted to compare the incidence of the CACL injury after ACL reconstruction with bone-patellar tendon-bone (BPTB) autografts compared with hamstring (HT) autografts.Methods:A comprehensive search of literature published between 1980 and January 2020 was performed using MEDLINE, EMBASE, Web of Science, and the Cochrane Library databases. RevMan 5.3 software was used for meta-analysis. The overall risk ratio (RR) was calculated using a fixed- or random-effects. The heterogeneity among the included results was analyzed by chi-square test with significance set at P < .10, and the heterogeneity was quantitatively detected by I-square tests.Results:Fifteen prospective comparative studies met inclusion criteria. In the BPTB group, the CACL rupture rate ranged from 1.8% to 30%, with a pooled percentage of 8.5%. In the HT group, the CACL rupture rate ranged from 0% to 14.4%, with a pooled percentage of 3.3%. The overall CACL rupture rate was 3.1% and ranged from 1.1% to 27.1%, with a pooled percentage of 4.9%. The pooled results indicate that there was a statistical significant difference in CACL rupture risk rate between BPTB and HT autograft. (RR, 1.53; 95% CL, 1.21–1.91; P = .0004).Conclusion:This review showed that patients undergoing primary ACL reconstruction with BPTB autograft were more likely to have CACL rupture than patients treated with HT autograft.