BTB Graft Research Articles

Comparison of Postoperative Strength Progression and Outcomes Following Primary Versus Secondary ACL Reconstruction in the Young Athlete.

Return to sport testing after ACL reconstruction (ACLR) is becoming increasingly popular. Anecdotally, some believe that patients who undergo a second ACL surgery on either the ipsilateral or contralateral leg progress through their rehabilitation goals faster the second time through. The purpose of this study was to evaluate the rate of strength progression in return to sport testing after primary and secondary ACLR surgeries in a young, active population. A retrospective review of patients who underwent ACLR between September 2013 and December 2022 was performed. Patients were included if they underwent an ACLR and completed at least 2 postoperative strength tests. Strength testing was commonly performed at 3, 6, and 9 months. Exclusion criteria included age older than 30 and those who had a contralateral graft harvest. Structural equation modeling was performed for each strength assessment by the timepoint it was performed. A linear combination of parameters was performed to compare the path coefficients between the primary and secondary ACL groups for each strength test to assess statistical differences in the rate of change of each strength test over time. Three hundred ninety-six patients in the primary ACLR group and 50 patients in the secondary ACLR group met the inclusion criteria. Patients who received secondary ACL surgery were older, had a higher percentage of BTB grafts, lateral augments, and internal brace augments. Months from surgery had a significant positive correlation with nearly all strength tests in both groups. There was no difference between primary and secondary surgery in the progression of any postoperative strength test. There was no difference in progression of IKDC or RSI scores between groups. This study suggests that patients who undergo a second ACL surgery do not progress their strength faster or slower than after primary ACLR. This implies that these patients do not require different return-to-play protocols from a strength perspective. Retrospective study, level III evidence.

Anterior Cruciate Ligament Hybrid Remnant Preserving Reconstruction With Bone–Patellar Tendon–Bone Autograft: A Surgical Technique Video

Background: Anterior cruciate ligament (ACL) ruptures occur frequently, with ACL reconstruction among the most commonly performed orthopaedic sports surgeries. The remnant ACL is typically debrided for visualization. However, further evidence has suggested that this remnant tissue contains a wealth of proprioceptive nerve fibers and a vascular blood supply. Theoretically, preserving the ACL remnant may improve joint proprioception and graft synovialization. Therefore, ACL hybrid remnant preservation reconstruction (HRPR) was developed to preserve and tension the native remnant in combination with an ACL reconstruction. Indications: Patients with proximal tears or femoral-sided avulsions, Sherman type 1 or 2, may be indicated for ACL-HRPR. Technique Description: In this technique, we use a bone–patellar tendon–bone (BTB) autograft, which can be harvested based on the surgeon's preference. After performing a diagnostic arthroscopy, the notch of the knee is debrided, with care to preserve the tibial ACL remnant. The tibial remnant is then undermined with electrocautery. Nonabsorbable suture is passed through the remnant tissue. A tibial guide is placed, and a pin is drilled just posterior to the tibial insertion. Next, the appropriately sized tibial tunnel is drilled just posterior to the tibial remnant insertion. Using an anteromedial-portal technique with the knee maximally flexed, an over-the-top guide with appropriate offset is used to insert the guide pin, and the femoral tunnel is drilled. The proximal graft bone block and the remnant sutures are then passed through the femoral tunnel. Metal screws are then inserted to fix the BTB graft bone blocks on the femoral side, followed by the tibial side. Backup fixation is also used by placing a biocomposite anchor 1 cm distal to the tibial tunnel. Results: A myriad of techniques exist for preserving the ACL remnant. For the present surgical technique, a retrospective cohort revealed that patients undergoing ACL-HRPR achieved full range of motion without extension loss and equivalent patient-reported outcomes, without increased complication rates. Discussion/Conclusions: For patients with femoral-sided ACL tears or avulsion, ACL-HRPR is a viable option that may augment traditional ACL reconstruction. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Reviewing Revision Anterior Cruciate Ligament Reconstruction: Why and How?

Introduction & Objectives: Revision ACL reconstruction occurred in 3.9- 9.2% cases of ACL repairs cases. Multiple revisions also increased comorbidities and lowers return-to-sport opportunity. We aimed to answer risk factors affecting requirements of revision ACL reconstruction and comparison of different techniques utilized for ACL reconstructions. Materials & Methods: PubMed and Europe PMC database were searched using following MeSH terms: “(“revision” AND ("acl" OR "anterior cruciate ligament") AND "reconstruction" AND "outcomes")”. This systematic review was conducted using PRISMA algorithm, searches yielded 1,649 abstracts for screening After employing screening criteria, final number of 32 relevant peer-reviewed open access studies from years 2018-2023. All authors read and voted for inclusion to paper. All papers were compiled, relevant information extracted, and narrated. Results: Gender was found to play some role in subsequent ACL reconstruction after primary ACL reconstruction failure. Another risk factors for revision ACL reconstruction included younger age (less than 30 years old) and use allograft for reconstruction. Revision ACL reconstruction conducted less than one year after symptoms were first experienced resulted in better outcome. The revision group more frequently experienced failure of the previous meniscal repair. Higher sport activity, or on the opposite, involvement in sport was an outcome of better revision ACL reconstruction. Surgical ACL reconstruction with internal bracing significantly decreased risk of ACL revision. Choices of graft, including greater utilization of autograft, and usage of BTB graft may improve patient outcomes. Conclusions: Younger age, allograft use, higher physical activity, and failure to repair meniscal damage risked revision ACL repair. Newer techniques may prevent ACL re-rupture and improve primary ACL repair outcomes. Choosing autograft and newer techniques results in better outcomes.

Poster 312: Prospective and Randomized Evaluation of Three Different Anterior Cruciate Ligament (ACL) Reconstruction Techniques Including a Lateral Extra-Articular Tenodesis (LET): A Clinical and Radiographic Evaluation at Minimum 20 Years Follow-Up

Objectives: Modern lateral extra-articular tenodesis (LET) has shown promising results at short term follow-up but there is a lack of studies investigating the incidence of complication and lateral osteoarthritis (OA) at long-term. The aim of the study was to compare in terms of failure rates, clinical outcomes and OA incidence three different ACL reconstruction techniques including hamstring single-bundle (HS group), patellar tendon (BTB) and hamstring over-the-top with LET (LET group). Methods: Seventy-five patients were randomized to receive one of the three ACL reconstruction techniques. At the last follow-up, patients reported outcomes (PROMs), complication and reoperation were collected for every patient. An objective clinical evaluation was performed including anteroposterior laxity measurement (KT-1000) and pivot shift quantification (PS, triaxial-accelerometer). Clinical failures were considered patients with evidence of graft rupture or those with KT-1000 side-to-side > 5mm or with PS side-to-side > >1mm/s2. A radiographic evaluation was performed to assess the incidence of tibiofemoral and patellar OA. Results: Final analysis was conducted on 61 patients (81.3%) at an average 23.0 ± 1.1 years follow-up, 38 patients completed the clinical and radiological evaluation. The LET group showed a higher Tegner score compared to the BTB (p=0.026), mean of 4.41 (up to 7) against 3.47 (up to 5). No difference was identified in the other clinical scores among the three groups (p>0.05). Revision rate and clinical failure were respectively 15.8% and 57.1% for the BTB group, 4.6% and 38.5% for the HS group and 4.6% and 18.8% for the LET group (P= 0.09 to 0.8, ns). No difference in the quantitative evaluation of the Pivot Shift were reported, while AP side-to-side difference was lower in the BTB group compared to the HS group (mean -0.1mm vs. +1.5mm). Finally, the BTB group showed a higher rate of patellofemoral OA compared to the other two groups (p=0,009) while the incidence of lateral OA was not increased in the LET group compared to the other techniques (p=0.50). Conclusions: Satisfactory clinical outcomes after ACL reconstruction at long-term follow-up could be achieved with different modern surgical techniques. However, the BTB graft was associated with increased incidence of patellofemoral OA when compared with the other techniques. Finally, LET was associated with increased sport participation and similar rate of lateral OA compared to other techniques at long-term follow-up.

Body Mass Index Between 15 and 30 Does Not Influence Patient-Reported Outcomes After Anterior Cruciate Ligament Surgery Using a 10-mm-Diameter Bone-Tendon-Bone Graft

PurposeThe purpose of this study was to investigate the relationship between body mass index (BMI) and outcomes after anterior cruciate ligament reconstruction (ACLR) using 10mm diameter bone- patellar tendon- bone (BTB) grafts. MethodsThe retrospective study used the Surgical Outcome System to measure patient-reported outcomes before and after ACL (anterior cruciate ligament) reconstruction between 2015 and 2019. Inclusion criteria involved patients undergoing primary ACLR by the senior surgeon, with recorded ages >15 years and BMI 15.0>30. Exclusion criteria involved revisions, concomitant procedures, age <15 years, or unknown BMI. Patients were divided into cohorts to evaluate MARS, Tegner, IKDC, and Lysholm scores at various timepoints from injury to 2-years post operatively. results137 patients (100 male, 37 female) with an average age of 33 [30.6, 35.4] years and average BMI of 23.58 [23.1, 24.0] were divided into Group A (n= 69; BMI: 15>23.4) and Group B (n=68; BMI: 23.5>30). A significant difference was demonstrated in MARS scores between BMI groups at pre-treatment with means of 11.55 (group A) and 9.41 (Group B) (p= 0.011), and at 2-years, Tegner scores indicated significance with scores of 6.45 and 5.41 for groups A and B respectively (p=0.009). Daily function scores were all insignificant. Females exhibited no significant differences across any PROMS or timepoints. Contrarily, males expressed a significant difference in pre-treatment MARS scores (Group A: 14.30; Group B: 9.96; p=0.011). Additionally, scores at 2-years depicted Tegner values of 7.40 (Group A) and 5.30 (Group B) and IKDC values of 96.92 (Group A) and 90.47 (Group B) (Tegner p=0.012; IKDC p=0.048). All results for females and males under 30 years old indicated no significance. ConclusionRegardless of patient age or sex, BMI is not significantly associated with patient reported outcomes after ACL reconstruction utilizing 10mm diameter BTB grafts. Level IIIRetrospective Cohort Study

Augmentation of ACL Autograft Reconstruction With an Amnion Collagen Matrix Wrap and Bone Marrow Aspirate Concentrate: A Pilot Randomized Controlled Trial With 2-Year Follow-up.

It is theorized that the lack of a synovial lining after anterior cruciate ligament (ACL) injury and ACL reconstruction (ACLR) contributes to slow ligamentization and possible graft failure. Whether graft maturation and incorporation can be improved with the use of a scaffold requires investigation. To evaluate the safety and efficacy of wrapping an ACL autograft with an amnion collagen matrix and injecting bone marrow aspirate concentrate (BMAC), quantify the cellular content of the BMAC samples, and assess 2-year postoperative patient-reported outcomes. Randomized controlled trial; Level of evidence, 2. A total of 40 patients aged 18 to 35 years who were scheduled to undergo ACLR were enrolled in a prospective single-blinded randomized controlled trial with 2 arms based on graft type: bone-patellar tendon-bone (BTB; n = 20) or hamstring (HS; n = 20). Participants in each arm were randomized into a control group who underwent standard ACLR or an intervention group who had their grafts wrapped with an amnion collagen matrix during graft preparation, after which BMAC was injected under the wrap layers after implantation. Postoperative magnetic resonance imaging (MRI) mapping/processing yielded mean T2* relaxation time and graft volume values at 3, 6, 9, and 12 months. Participants completed the Single Assessment Numeric Evaluation Score, Knee injury and Osteoarthritis Outcome Score, and pain visual analog scale. Statistical linear mixed-effects models were used to quantify the effects over time and the differences between the control and intervention groups. Adverse events were also recorded. No significant differences were found at any time point between the intervention and control groups for BTB T2* (95% CI, -1.89 to 0.63; P = .31), BTB graft volume (95% CI, -606 to 876.1; P = .71), HS T2* (95% CI, -2.17 to 0.39; P = .162), or HS graft volume (95% CI, -11,141.1 to 351.5; P = .28). No significant differences were observed between the intervention and control groups of either graft type on any patient-reported outcome measure. No adverse events were reported after a 2-year follow-up. In this pilot study, wrapping a graft with an amnion collagen matrix and injecting BMAC appeared safe. MRI T2* values and graft volume of the augmented ACL graft were not significantly different from that of controls, suggesting that the intervention did not result in improved graft maturation. NCT03294759 (ClinicalTrials.gov identifier).

Comparison of Knee Pain and Difficulty With Kneeling Between Patellar Tendon and Hamstring Tendon Autografts After Anterior Cruciate Ligament Reconstruction: A Study From the New Zealand ACL Registry

Background: The bone–patellar tendon–bone (BTB) autograft is associated with difficulty with kneeling after anterior cruciate ligament (ACL) reconstruction; however, it is unclear whether it results in a more painful or symptomatic knee compared with the hamstring tendon autograft. Purpose: To identify the rate and risk factors for knee pain and difficulty with kneeling after ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: Primary ACL reconstruction procedures prospectively recorded in the New Zealand ACL Registry from April 2014 to May 2021 were analyzed. The Knee injury and Osteoarthritis Outcome Score (KOOS) was used to identify patients reporting consequential knee pain (CKP), defined as a KOOS Pain subscore of ≤72 points, and severe kneeling difficulty (SKD), defined as a self-report of “severe” or “extreme” difficulty with kneeling. Absolute values of the KOOS Pain and Symptoms subscales were also compared. Results: A total of 10,999 patients were analyzed. At 2-year follow-up, 9.3% (420/4492) reported CKP, and 12.0% (537/4471) reported SKD. The most important predictor of CKP at 2-year follow-up was having significant pain before surgery (adjusted odds ratio, 4.10; P < .001). The most important predictor of SKD at 2-year follow-up was the use of a BTB autograft rather than a hamstring tendon autograft (21.3% vs 9.4%, respectively; adjusted odds ratio, 3.12; P < .001). There was no difference between the BTB and hamstring tendon grafts in terms of CKP (9.9% vs 9.2%, respectively; P = .494) or in absolute values of the KOOS Pain (mean, 88.7 vs 89.0, respectively; P = .37) and KOOS Symptoms (mean, 82.5 vs 82.1, respectively; P = .49) subscales. Conclusion: At 2-year follow-up after primary ACL reconstruction, 9.3% of patients reported CKP, and 12.0% reported SKD. The BTB autograft was associated with difficulty with kneeling, but it did not result in a more painful or symptomatic knee compared with the hamstring tendon autograft.

Posteromedial Portal Technique With Bone–Patellar Tendon–Bone Graft for Inside-Out Revision of Anterior Cruciate Ligament Reconstruction

Bone–patellar tendon–bone (BTB) is a graft material used in anterior cruciate ligament (ACL) reconstruction. We describe creating a femoral tunnel using an inside-out posteromedial (PM) portal technique during anatomic double-bundle ACL reconstruction with a hamstring graft. We hypothesized that applying this femoral tunnel creation method to the revision ACL reconstruction using BTB would enable reconstruction in 1 stage. In this technique, an anteromedial, an anterolateral, and a PM portal are created to confirm the original ACL footprint and location and direction of the bone tunnel during primary reconstruction. The surgeon then drills from the PM portal, so that the femoral tunnel opening touches the posterior proximal articular cartilage margin in the ACL footprint. Even if the opening partially overlaps with the primary tunnel, it is possible to create a new tunnel with a different direction. Finally, the BTB graft is guided from the tibial tunnel to the femoral tunnel and fixed with interference screws. Intraoperative PM arthroscopic views can confirm that the femoral tunnel has been created, avoiding overlap, and that the revision ACL has been reconstructed. This procedure may be useful for 1-stage revision ACL reconstruction for reinjury after primary ACL reconstruction by other conventional procedures.

Effects of Eccentric-Oriented Strength Training on Return to Sport Criteria in Late-Stage Anterior Cruciate Ligament (ACL)-Reconstructed Professional Team Sport Players.

Background and Objectives: An effective post-injury training program is essential to regain performance and fulfill criteria for return to sport for team sport athletes following anterior cruciate ligament (ACL) reconstruction. The aim of this study was to compare the effects of 6 weeks of eccentric-oriented strength training vs. traditional strength training during the late-stage ACL-rehab phase on leg strength and vertical and horizontal jumping performance in professional team sport athletes. Materials and Methods: Twenty-two subjects (14 males, 8 females, age 19.9 ± 4.4 years, mass 77.4 ± 15.6 kg, height 182.4 ± 11.7 cm) (mean ± SD) with a unilateral reconstructed ACL (BTB graft) were included in the study. All participants enrolled in the same rehabilitation protocol prior to the training study. Players were randomly assigned to an experimental (ECC: n = 11, age 21.8 ± 4.6 years, mass 82.7 ± 16.6 kg, height 185.4 ± 12.2 cm), and a control group (CON: n = 11, age 19.1 ± 2.1 years, mass 76.6 ± 16.5 kg, height 182.5 ± 10.2 cm). Both groups underwent an equivolumed rehabilitation program, with the only difference being in strength training, which consisted of flywheel training vs. traditional strength training for the experimental and control groups, respectively. Testing was organized before and after the 6-week training programs and included isometric semi-squat tests (ISOSI-injured and ISOSU-uninjured legs), vertical jump tests (CMJ), single-leg vertical jump tests (SLJI-injured and SLJU-uninjured legs), single-leg hop tests (SLHI-injured and SLHU-uninjured legs), and triple hop tests (TLHI-injured and TLHU-uninjured legs). In addition, limb symmetry indexes were calculated for the isometric semi-squat (ISOSLSI) test, the single-leg vertical jump (SLJLSI), and the hop (SLHLSI) tests, as well as the triple-leg hop (THLLSI) test. Results: Main effects of time across training were observed for all dependent variables (posttest > pretest, p < 0.05). Significant group-by-time interactions were found for ISOSU (p < 0.05, ES = 2.51, very large), ISOSI (p < 0.05, ES = 1.78, large), CMJ (p < 0.05, ES = 2.23, very large), SLJI (p < 0.05, ES = 1.48, large), SLHI (p < 0.05, ES = 1.83, large), and TLHI (p < 0.05, ES = 1.83, large). Conclusions: This study suggests that eccentric-oriented strength training in late-stage ACL recovery, undertaken twice or three times weekly for 6 weeks, results in better outcomes than traditional strength training in leg strength, vertical jump ability, and single and triple hop tests with injured legs in professional team sport athletes. It seems that flywheel strength training can be recommended in late-stage ACL recovery for professional team sport athletes in order to regain recommended performance outcome levels faster.

Lateral posterior tibial slope does not affect femoral but does affect tibial tunnel widening following anatomic anterior cruciate ligament reconstruction using a Bone–Patellar Tendon–Bone graft

BackgroundTunnel widening (TW) after anterior cruciate ligament (ACL) reconstruction has been a research area of interest in ACL reconstruction. In recent years, it has been noted that posterior tibial slope (PTS) affects several types of outcomes after ACL reconstruction including TW. However, the relationships between femoral and tibial TW and between PTS and TW following anatomical ACL reconstruction using a bone–patellar tendon–bone (BTB) graft are often not understood. Therefore, the purpose of this study was to retrospectively clarify the magnitude of femoral and tibial TW and the effect of PTS on TW following anatomical ACL reconstruction using a BTB graft. MethodsA total of 111 patients who underwent isolated ACL reconstructions using BTB grafts were included in this study. Femoral and tibial tunnel aperture areas were measured using three-dimensional computed tomography (3D CT) at 1 week and 1 year postoperatively, and femoral and tibial TW (%) was calculated. Lateral and medial PTS was also measured using 3D CT. ResultsAs compared with 1 week postoperatively, the mean tibial tunnel aperture areas increased by 30.6% ± 28.5%, and the mean femoral tunnel aperture areas increased by 28.3% ± 27.9% when measured at 1 year postoperatively. Although no significant difference was observed between femoral and tibial TW, a significant positive correlation was noted between femoral and tibial TW (r = 0.240, p = 0.011). A significant correlation was observed only between lateral PTS and tibial TW (r = 0.354, p < 0.001). There was no significant correlation between medial PTS and tibial TW, lateral PTS and femoral TW, or medial PTS and femoral TW. ConclusionSignificant positive correlation was observed between femoral and tibial TW. Steeper lateral PTS correlated with greater tibial TW; on the other hand, medial PTS did not correlate with tibial TW. Although lateral PTS affected tibial TW, it did not affect femoral TW.

A Comparative Randomized Clinical Study of Arthroscopic Anterior Cruciate Ligament Reconstruction with Patellar Tendon and Hamstring Tendon Autologous Grafts

Aim: To determine and compare differences in the results following arthroscopic anterior cruciate ligament reconstruction using patellar-tendon-bone (PTB) auto-grafts and hamstrings tendon auto-grafts. Study design: Randomized controlled trial. Place and duration: Department of Orthopedic Surgery, Shaikh Zayed Hospital Lahore from July 2019 to July 2021. Methodology: This prospective study included 72 of total patients with clinical diagnosis of having anterior cruciate ligament (ACL) tear who did not have activities like a healthy person and wished to maintain a level of activity as it was before injury. Institutional ethical committee granted approval and a written informed consent was taken. Two groups of study population (patellar tendon and hamstring tendon) were formed. Lottery method was used for randomization of patients. Arthroscopic ACL reconstruction was done according to their respective groups. Patients of patellar tendon group (n=36) and hamstring tendon group (n=36) were under examination for 4 to 5 days and to grant 0 to 900 movement, knee brace was locked. Patients were questioned about their activities on follow up visits. Results: No significant difference amongst patients of two groups was noted.14 patients (38.9%) with PTB graft were unable to kneel on their knee as compared to 12 patients (33%) with hamstrings graft. Patients with BTB graft had similar difficulty in bending their knee as compared to the patients of the other group. Conclusion: Patients from PTB graft group showed comparable results as compared to the hamstrings group in terms of strenuous activity, highest level of activity, rising from a chair and kneeling and squatting on functional outcomes. Keywords: Anterior Cruciate Ligament, Patellar Auto-graft, Hamstring Auto-graft, Bone Graft

A Modified Lemaire Lateral Extra-Articular Tenodesis in High Risk Adolescents Undergoing Anterior Cruciate Ligament Reconstruction: Two-Year Clinical Outcomes

Background:The incidence of anterior cruciate ligament reconstruction (ACLR) in patients aged 19 years or younger is increasing significantly and many patients possess risk factors that predispose to ACL re-tear. Lateral extra-articular tenodesis (LET) may be performed in conjunction with ACLR to reduce the risk of ACL re-tear.Purpose:To evaluate the safety and efficacy of performing a lateral extra-articular tenodesis (LET) with a modified Lemaire technique (MLT) in conjunction with anterior cruciate ligament reconstruction (ACLR) in children and adolescents at increased risk for failed ACLR.Methods:A consecutive series of patients who underwent ACLR and LET with a minimum of 2-year follow-up data was analyzed retrospectively. ACLR techniques included all-epiphyseal (AE) and complete transphyseal (CT) and were indicated based on skeletal age. Skeletally immature patients underwent a QUAD ACLR. Patients with closed or closing growth plates underwent a BTB ALCR. Outcome measures included participants’ return to sports, concomitant or subsequent surgical procedures and multiple patient-reported outcome measures, including Single Assessment Numeric Evaluation (SANE), Pediatric International Knee Documentation Committee (Pedi-IKDC) and HSS Functional Activity Brief Scale (HSS Pedi-FABS) scores.Results:Sixty-seven consecutive patients (mean age 15.16 ±1.74 years, range 11-19 years, 64% female) were analyzed (Table 1). Sixty-five patients (97%) participated in organized sports including soccer, basketball, football and lacrosse, with soccer being the most popular one. The median grade at the time of surgery was 9th grade. Eleven patients (16%) were revision ACLR procedures. Eight (12%) patients underwent AE and 59 (88%) underwent CT ACLR. Forty-six (69%) cases employed a QUAD autograft, while 21 (31%) utilized a BTB autograft. All patients underwent a LET with a MLT and 2 patients underwent simultaneous implant mediated guided growth with a plate for structural genu valgum. At two-year follow-up, median SANE score was 97, median Pedi-IKDC score was 91, and median HSS-Pedi Fabs score was 25. RTS rate was 93%. Fifteen patients had subsequent surgical procedures, including 3 hardware removal procedures for hemiepiphysiodesis, 4 contralateral ACLR, 5 meniscus surgeries, 1 lysis of adhesions, 1 hammertoe correction and 1 revision ACLR for BTB graft re-rupture. Two patients were lost to follow-up and excluded from the study.Conclusion:The findings suggest that concomitant LET and ACLR in adolescent patients with risk factors for failed ACLR is associated with favorable patient-reported outcomes, high return to sports participation, and low ACL re-rupture rate at two years follow-up.Table 1Patient Demographics and Surgical Characteristics

Functional Recovery after Revision Anterior Cruciate Ligament Reconstruction with a Second Autograft: A Matched Cohort Analysis in Adolescent Patients (197)

Objectives:Young patients are the highest risk demographic for ACL graft failure and revision surgery. Previous studies have shown higher rates of graft failure with the use of allograft tissue for ACL reconstruction (ACLR) in both primary and revision surgeries. However, questions remain regarding the functional consequence of harvesting a second autograft from the ipsilateral knee for revision ACLR. The purpose of this study was to evaluate 6-month functional testing in patients who underwent revision ACLR with use of a second autograft from the ispilateral knee, when compared to matched cohorts of primary ACLR patients.Methods:A retrospective review of prospectively collected data from patients aged 19 or younger who underwent revision ACLR with a second autograft of an opposite muscle group (either revision patellar tendon (BTB) following primary hamstring (HS) or revision HS following primary BTB) at the study institution was performed. Exclusion criteria were patients who underwent iliotibial band autograft ACLR, those with two autografts from synergistic muscle groups, grafts from the contralateral knee, debilitating injury or surgery to the contralateral lower extremity, and multi-ligamentous knee injury. All subjects underwent functional return to sports (RTS) testing 5-8 months after revision surgery, which included anthropometric measures, isometric strength, Y-Balance, and functional hop testing. Side-to-side deficits were then compared using standard limb symmetry index (LSI) metrics, after matching a cohort of primary ACLR patients based on age, sex, and body mass index (BMI). Multivariate analysis of variance (MANOVA) was used to compare RTS metrics, and if significance was detected, pairwise comparison was performed by Bonferroni post-hoc correction. Statistical significance of p<0.05 was applied.Results:The cohort of 37 revision ACLR patients were compared to cohorts of 62 primary HS and 47 BTB ACLR patients, respectively (Table 1). The revision cohort showed comparable knee extension strength deficits to the BTB cohort (-9.45±12.09% vs -8.81±13.83%, p=0.999), which were significantly greater than that of the HS cohort (-9.45±12.09% vs -0.99±12.00%, p<0.05). Greater knee flexion strength deficits were seen in the HS cohort than the revision cohort (-38.90±16.21% vs -28.13±23.22%, p=0.009), whose deficits were, in kind, significantly greater than that of the BTB cohort (-28.13±23.22% vs -1.17±12.41%, p=0.001). The HS cohort also showed greater triple hop deficit (-21.08±25.99%) than the other two cohorts (-21.08±25.99% vs -10.75±12.85 vs -6.84±23.81, p=0.024), which were not significantly different from each other.Conclusions:After revision ACLR with a second autograft from the opposing muscle group of the ipsilateral knee, adolescents show similar knee extension strength deficits compared to primary ACLR patients with BTB grafts, but improved knee flexion strength deficits compared to primary ACLR patients with HS grafts.

No Difference in Ligamentous Strain or Knee Kinematics Between Rectangular or Cylindrical Femoral Tunnels During Anatomic ACL Reconstruction With a Bone-Patellar Tendon-Bone Graft.

Background:As our understanding of anterior cruciate ligament (ACL) anatomy has evolved, surgical techniques to better replicate the native anatomy have been developed. It has been proposed that the introduction of a rectangular socket ACL reconstruction to replace a ribbon-shaped ACL has the potential to improve knee kinematics after ACL reconstruction.Purpose:To compare a rectangular femoral tunnel (RFT) with a cylindrical femoral tunnel (CFT) in terms of replicating native ACL strain and knee kinematics in a time-zero biomechanical anatomic ACL reconstruction model using a bone–patellar tendon–bone (BTB) graft.Study Design:Controlled laboratory study.Methods:In total, 16 fresh-frozen, human cadaveric knees were tested in a 5 degrees of freedom, computed tomography–compatible joint motion simulator. Knees were tested with the ACL intact before randomization to RFT or CFT ACL reconstruction using a BTB graft. An anterior translation load and an internal rotation moment were each applied at 0°, 30°, 60°, and 90° of knee flexion. A simulated pivot shift was performed at 0° and 30° of knee flexion. Ligament strain and knee kinematics were assessed using computed tomography facilitated by insertion of zirconium dioxide beads placed within the substance of the native ACL and BTB grafts.Results:For the ACL-intact state, there were no differences between groups in terms of ACL strain or knee kinematics. After ACL reconstruction, there were no differences in ACL graft strain when comparing the RFT and CFT groups. At 60° of knee flexion with anterior translation load, there was significantly reduced strain in the reconstructed state ([mean ±standard deviation] CFT native, 2.82 ± 3.54 vs CFT reconstructed, 0.95 ± 2.69; RFT native, 2.77 ± 1.71 vs RFT reconstructed, 1.40 ± 1.76) independent of the femoral tunnel type. In terms of knee kinematics, there were no differences when comparing the RFT and CFT groups. Both reconstructive techniques were mostly effective in restoring native knee kinematics and ligament strain patterns as compared with the native ACL.Conclusion:In the time-zero biomechanical environment, similar graft strains and knee kinematics were achieved using RFT and CFT BTB ACL reconstructions. Both techniques appeared to be equally effective in restoring kinematics associated with the native ACL state.Clinical Relevance:These data suggest that in terms of knee kinematics and graft strain, there is no benefit in performing the more technically challenging RFT as compared with a CFT BTB ACL reconstruction.

Effect of Patient Height and Sex on the Patellar Tendon and Anterior Cruciate Ligament.

Background:Graft-tunnel mismatch is an avoidable complication in anterior cruciate ligament (ACL) reconstruction. Patient height and sex may be predictors of patellar tendon length (PTL) and intra-articular ACL length (IAL). Understanding these relationships may assist in reducing graft-tunnel mismatch during ACL reconstruction with bone–patellar tendon–bone (BTB) autograft.Purpose:To determine the association of patient height and sex with PTL and IAL.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Magnetic resonance imaging (MRI) studies were obtained on the healthy knees of 100 male and 100 female patients. Patients with prior surgery, open physes, significant degenerative changes, ACL rupture, or extensor mechanism injury were excluded. Three independent readers measured PTL, IAL, and Caton-Deschamps Index (CDI) on MRI. Bivariate and linear regression analysis was performed to detect the association of anthropometric data with anatomic parameters measured on MRI studies.Results:The mean age and body mass index were not significantly different between the male and female patients; however, male patients were significantly taller than female patients (1.75 vs 1.72 m, respectively; P < .001). There was a substantial agreement between the 3 readers for all parameters (κ > 0.75). Overall, female patients had significantly longer PTL (47.38 vs 43.92 mm), higher CDI (1.146 vs 1.071), and shorter IAL (33.05 vs 34.39 mm) (P < .001 for all). Results of the linear regression analysis demonstrated that both height and female sex were predictive of longer PTL. Further, height was independently predictive of IAL but sex was not.Conclusion:PTL was correlated more with patient sex than height. IAL was also correlated with patient sex. Longer BTB grafts are expected to be harvested in female patients compared with male patients of the same height despite shorter IAL. These associations should be considered during BTB ACL reconstruction to minimize graft-tunnel mismatch.

Comparative Analysis of the Results of Lateral Extra-Articular Tenodesis in Anatomical Anterograde Plasty of the Anterior Cruciate Ligament

AIM OF STUDY To analyze the results of lateral extra-articular tenodesis (LET) of the semitendinosus muscle tendon (STMT) and iliotibial tract (ITT) in patients with severe anterior rotational instability of the knee joint during anatomical anterograde reconstruction of the anterior cruciate ligament (rACL) with a BTB graft. MATERIAL AND METHODS We studied 138 patients with the Pivot shift test – 3+ and the Lachman test 2+ or 3+ degree after arthroscopic rACL with a BTB autograft. In 65 cases (47.1%) rACL was supplemented with LET of STMT (group 1), the remaining 73 patients (52.9%) – LET of ITT (group 2). RESULTS According to IKDC-2000, KOSS and Lysholm-Tegner scores, the groups did not differ statistically. However, pain in the LET zone, LET failure with the appearance of the Pivot shift test – 1+, revision reconstructions – were more often observed in group 2 (p&lt;0.05). Popliteal hematomas (p&lt;0.001), longer operations (p&lt;0.01) were more often observed in group 1. CONCLUSION Lateral extra-articular tenodesis is a clinically effective addition to anatomical anterograde reconstruction of the anterior cruciate ligament with BTB autograft in patients with Pivot shift test 3+ and Lachman test 2+ or 3+. However, a more reliable option is lateral extra-articular tenodesis of the semitendinosus muscle tendon. At the same time, lateral extra-articular tenodesis of the iliotibial tract is a simpler, faster and more cost-effective technique, still demonstrating good indicators of knee joint stability.

The Challenges of Treating Female Soccer Players With ACL Injuries: Hamstring Versus Bone-Patellar Tendon-Bone Autograft.

Background:Although anterior cruciate ligament (ACL) injuries are common in female soccer players, the optimal graft option for ACL reconstruction is currently unclear.Purpose/Hypothesis:To compare the outcomes of female soccer players after ACL reconstruction using either hamstring tendon autograft or bone–patellar tendon–bone (BTB) autograft. We hypothesized that there would be no difference in clinical outcome scores, return to sport, or retear rates between BTB and hamstring grafts in our study cohort.Study Design:Case series; Level of evidence, 4.Methods:We performed a retrospective review of all skeletally mature adolescent female soccer players who underwent primary ACL reconstruction using either hamstring tendon or BTB autograft between 2013 and 2016. Demographic, injury, and surgical variables were documented. Outcome measures included the Lysholm score, Single Assessment Numeric Evaluation, Tegner activity score, and visual analog scales for pain and for satisfaction, as well as ability to return to sport.Results:Overall, 90 female soccer players met the inclusion criteria, of whom 79% (41 BTB and 30 hamstring) were available for a minimum 2-year follow-up or had a graft failure before the follow-up. The BTB group had a lower body mass index (mean ± SD, 23 ± 3 vs 25 ± 4; P = .02) and shorter postoperative follow-up time in months (mean ± SD, 37.4 vs 46.1; P ≤ .001); otherwise, no differences in demographic, injury, or surgical variables between groups were noted. Regarding outcome measures, the BTB group achieved a higher Tegner score (6.0 vs 4.2; P = .004), and there was no other difference between groups. Of the patients who did not return to soccer, 44.7% reported fear as the reason. Of the patients who did return to soccer, 31.9% sustained another ACL injury (retear or contralateral tear), with no differences in reinjury rates based on graft selection.Conclusion:Adolescent female soccer players undergoing ACL reconstruction had relatively high satisfaction and outcome scores independent of autograft choice. Notwithstanding, patients and families need to be counseled that less than half of patients will return to their preinjury level of sport and, if an athlete attempts to return, there is a high risk of further ACL injury.

An update on graft-tunnel mismatch in anterior cruciate ligament reconstruction: A survey of the experts in the field of orthopedic sports medicine demonstrates no clear consensus in management

BackgroundThe purpose of this study was to identify and report on the rate at which leaders in orthopaedic surgery are encountering GTM, their treatment methods and to identify whether these clinicians’ demographics or techniques correlate with their GTM incidence and/or treatment algorithms. MethodsA survey was sent to identify the rate at which member orthopaedic surgeons of the American Orthopaedic Society for Sports Medicine (AOSSM), the National Football League Physicians Society (NFLPS), and the Herodicus Society are encountering GTM in ACL reconstruction with BTB graft and to establish what methods are most commonly utilized. ResultsIn total, 260 orthopaedic surgeons completed the survey. Respondents most frequently reported GTM in 1–5% of cases, with GTM most often between 5 and 10 mm. For lower levels of GTM, surgeons are most frequently recessing the femoral bone plug and adding a cortical suspensory device or outside–in fixation. Higher degrees of GTM are most commonly supplemented with a screw/post on the tibia. Those with >15 years of experience were more commonly using a transtibial femoral drilling with lower tibial tunnel angulation, and lower incidences of GTM than their less experienced counterparts. ConclusionThere is tremendous variability in the incidence and management of GTM in ACL reconstruction with BTB graft with no clear consensus among experts. Differences are seen in ACL reconstruction techniques and means of correcting GTM when evaluating based on years of surgical experience and Sports Medicine Fellowship completion.

Graft Choice for Adolescent Athletes Returning to High-Risk Sports: A Matched Cohort Analysis of Patellar Tendon and Hamstring Autografts

Objectives:Graft selection for skeletally mature adolescents undergoing anterior cruciate ligament (ACL) reconstruction is guided by surgeon and patient preference. In young patients returning to high-risk cutting and pivoting sports, graft rupture is the most feared complication of ACL reconstruction. Some studies have demonstrated slightly lower rates of graft failure and decreased laxity in the short term associated with patellar tendon (BTB) autografts as compared to hamstring (HS) autografts, but these studies are limited by their heterogeneity of ages and activity level. The purpose of this study is to compare the rates of graft failure between BTB and HS ACL reconstruction cohorts matched by age, sex, and sport.Methods:A single-institution retrospective review was performed of consecutive patients less than 19 years of age treated with ACL reconstructions using either patellar tendon (BTB) or hamstring (HS) autograft performed by a single surgeon. Skeletally mature or nearly mature patients in “high-risk” ACL injury sports (basketball, football, soccer, lacrosse, and gymnastics) were initially treated with hamstring autografts but the graft preference transitioned to BTB autografts as the preferred graft choice during the study period. This transition in graft preference for adolescents participating in “high risk” sports allows for a comparison of outcomes based on graft types. Inclusion criteria were ages 13 – 18 years, participation in a “high risk” sport, and minimum 24-month follow-up. The two cohorts of patients were matched by age, gender, and sport. The primary outcome measure was graft rupture.Results:One hundred twenty-six patients with an average age of 15.8 years (range 13 – 18 years) met inclusion criteria. There were 60 BTB reconstructions and 66 HS reconstructions. There were 55 females and 71 males. There was no difference in age, sex, BMI, or laterality between groups. There were more patients who played soccer in the BTB cohort (44%) vs HS cohort (22%) and fewer who played basketball in the BTB cohort (24%) vs HS cohort (38%), p = 0.005. There were no differences between the BTB and HS cohorts in terms of meniscus tears (60% v 68%, p = 0.34), meniscus repair (20% v 30%, p = 0.19), or partial meniscectomy (33% v 39%, p = 0.48). Mean duration of follow-up was 41 months (range 24-78 months). There was a difference in follow-up between cohorts (BTB 36 months and HS 50 months, p < 0.05). There were 16 graft ruptures (12.6%). There was no difference in the rate of graft rupture between cohorts (BTB 10.0% vs HS 15.2%, p = 0.45). Mean time to graft rupture was 21 months (range 8 – 35 months) and Kaplan-Meier survival curves demonstrated no difference between cohorts. The mean age of graft failures within the BTB cohort was 15.5 years as compared to 16.1 years for those that did not have a graft failure (p=0.268). The mean age of graft failures within the HS cohort was 14.9 years as compared to 15.9 years for those that did not have a graft failure (p<0.05).Conclusion:ACL reconstruction in adolescents returning to high-risk sports can be performed utilizing BTB or HS autografts with similar rates of graft rupture. Patients under the age of 15 years have a greater risk of failure associated with HS autograft as compared to patients 16 years of age and older with the same graft. In contrast, BTB grafts have similar failure rates regardless of age. There is a trend toward lower rates of graft rupture associated with BTB autografts, but additional patients will be necessary to determine if this trend will become a statistically significant difference.

Outcome of Single Stage Revision ACL Reconstruction. Retrospective Study and Review of Literature.

Pragmatic review of outcomes for single stage revision ACL reconstruction performed in a single center and the reasons for failure in primary surgery. Retrospective study included 59 patients with revision ACL reconstruction done by one surgeon from 2007 to 2017.Clinical records, operative notes and x-rays were assessed to find the reasons of failure. The cause of failure was traumatic in 26 (44.1%) patients after primary reconstruction, incorrect tunnel position in 18(30.5%) and biological failure in 15 (25.4%). All ACL revisions were done using autografts; patellar tendon grafts in 33 patients (55.9%), ipsilateral hamstrings in 12 (20.3%), contralateral hamstrings in 9 (15.3%) and quadriceps tendons in 5 (8.5%). Twenty-one patients were contactable as regards postoperative functional outcome scores. There was an average 18 point improvement in Oxford knee score (OKS) post-operatively, 1.6 point improvement in Tegner scores and 30 point improvement in Lysholm scores. One patient (1.7%) developed septic arthritis, 4 (6.8%) had superficial infection, while 6 (10.2%) had residual instability after revision but did not have further surgery. There was lack of full extension in 4 (6.8%) patients. In BTB grafts, 2 (6.1%) patients sustained a post-traumatic patellar fracture. 1. Good outcomes of single stage revision ACL reconstruction surgery are achievable as de-monstrated in our cohort. 2. There is need for good quality research to identify whether BTB, hamstrings or quadriceps autografts are better for ACL Reconstruction.