Gracilis Tendon Research Articles

Smaller cross-sectional areas of the hamstring tendon measured from preoperative ultrasonography are likely to need additional gracilis harvesting for double-bundle anterior cruciate ligament reconstructions

Background/PurposeHamstring tendon autografts are commonly used for double-bundle anterior cruciate ligament reconstruction (DB-ACLR). If the volume of the semitendinosus (ST) tendon is insufficient, the gracilis (G) tendon is also harvested. Additional harvesting of the G autograft can affect patients’ short-term postoperative outcome, such as muscle recovery; thus, preoperative information about whether an additional G autograft is needed would be useful. The purpose of this study was to investigate whether preoperative measurement of the ST tendon using ultrasonography could inform the intraoperative decision to harvest the G tendon.MethodsWe enrolled 20 patients (13 men and seven women) who underwent DB-ACLR between October 2017 and March 2019. The mean patient age was 28.5 years. The ipsilateral ST tendon was measured using ultrasonography before surgery. Measurements included the diameter and breadth of the short-axis image. The cross-sectional area (CSA) was calculated from these measurements. During surgery, when two grafts with diameters of ≥ 5.0 mm could not be made, the G tendon was also harvested. Patients were categorized into two groups: the ST group where only the ST tendon was harvested, and the semitendinosus gracilis tendon (STG) group where the ST and G tendons were both harvested. The CSA value was compared between the two groups, and the cutoff value was calculated.ResultsIn the ST group (n = 8), the mean diameter and breadth of the semitendinosus tendon were 4.21 and 2.34 mm, respectively. In the STG group (n = 12), the mean diameter and breadth of the ST tendon were 3.39 and 1.78 mm, respectively. The CSAs calculated for the ST group and the STG group were 7.74 mm2 and 4.79 mm2, respectively. A cutoff value of 7.0 mm2 was found to correspond to a specificity and sensitivity to harvest the G tendon of 87.5% and 75.0%, respectively.ConclusionsThe preoperative CSA of the ST tendon determined using ultrasonography can, therefore, be informative for deciding whether to harvest the G tendon for DB-ACLR. The results of this study provide valuable information for graft selection in anterior cruciate ligament reconstruction.Level of EvidenceIV (Retrospective case series design).

A Practical Pre-Operative Predictive Model for Determining Hamstring Autograft Size for Anterior Cruciate Ligament Reconstruction in Children and Adolescents

Objectives:The most commonly used graft for pediatric and adolescent anterior cruciate ligament (ACL) reconstruction is the hamstring autograft. Recent evidence has suggested that graft sizes less than 8 mm and age less than 20 years old are the most significant factors influencing graft failure. Additionally, studies examining the role of augmenting smaller grafts with allograft have demonstrated mixed results and potentially increased failure rates. Efforts to predict hamstring size preoperatively using MRI and ultrasound in the adult population have shown promise. However, there have been no studies in an entirely pediatric population. The purpose of this study was to evaluate the predictive value of MRI in determining hamstring autograft size preoperatively for pediatric ACL reconstructions.Methods:Children and adolescents from 10-20 years old that had undergone ACL reconstruction using hamstring autograft were identified from 2017-2018. Semitendinosus and gracilis cross-sectional area and diameter were measured on preoperative knee MRIs using the field of interest (FOI) and distance measurement tools. The slice used for measurement was identified as the largest section by the measuring surgeon. Two surgeons independently measured all MRIs. Preoperative demographic data (height, weight, body mass index (BMI), gender) and operative data (graft size) was collected. Data was analyzed by an independent statistician. Ordinal regression analysis was performed to determine the relationship between demographic data and graft size. A Classification and Regression Tree (CART) was constructed to identify predictors for the pre-determined graft sizes of 8 mm. Receiver operating characteristics (ROC) analysis were then created to assess the performance of the predictive model and determine sensitivity and specificity. All analyses were performed using SPSS v. 24 with alpha set at p<0.05 to declare significance.Results:One hundred and ten children (54 boys, 56 girls) were included in this study with an average age of 15.93 years (range 11.81-20.22) and average BMI of 25.98 (range 16.02-40.08). CART analysis determined that if the sum of the cross-sectional areas of the semitendinosus and gracilis tendons were greater than 31.17 mm then 87.5% of children had graft sizes of 8 mm or greater. The ROC analysis determined the model to have an 80% sensitivity and 74% specificity for predicting a graft size of 8 mm or larger.Conclusion:A preoperative summation of the cross-sectional areas of the semitendinosus and gracilis tendons greater than 31.17 mm predicts an intraoperative graft size of 8 mm or larger in 87.5% of children.Figure 1.Table 1:Magnetic resonance imaging (MRI) measurements comparing children with graft sizes less than 8 mm with those 8 mm or greater. 95% Confidence Interval Mean Lower Upper P-value Height (cm)<8162.28159.66164.908+169.02166.56171.47<0.001Weight (kg)<867.3562.2772.438+76.8871.1682.600.014BMI<825.3823.7726.998+26.5725.1228.020.274Age (years)<815.8915.3916.388+15.9715.5716.370.793Semitendinosus<815.8314.8616.81 Cross-sectional Area8+19.1518.1420.16<0.001Semitendinosus Diameter<84.824.664.99 (Anteroposterior)8+5.174.975.370.009Semitendinosus Diameter<84.023.844.21 (Medial/lateral)8+4.494.334.65<0.001Gracillis<89.849.2210.46 Cross-sectional Area8+11.3310.6811.980.001Gracillis Diameter<84.224.094.36 (Anteroposterior)8+4.584.364.800.01Gracillis Diameter<82.872.752.99 (Medial/lateral)8+3.102.973.220.013Semitendinosus + Gracillis<825.6724.3227.02 Cross-sectional Area8+30.4829.0331.93<0.001Diameter Sum<815.9415.5516.338+17.3316.9017.77<0.001

Combined medial patellofemoral and patellotibial reconstruction with soft tissue fixation in recurrent patellar dislocation

IntroductionThe medial patellofemoral and patellotibial ligaments (MPFL and MPTL) are the main passive restraints to lateral patellar translation. When nonoperative management of patellofemoral dislocations fails, surgical options can be considered to restore patellofemoral stability. Several reconstruction procedures of the MPFL with semitendinosus, gracilis, quadriceps tendon, and synthetic grafts have been described. No clear superiority of one surgical technique over another is evident. Materials and methodsPatients who suffered at least two documented episodes of unilateral patellar dislocation, confirmed radiographically and at clinical examination, underwent combined MPFL and MPTL reconstruction. Patients were regularly followed-up postoperatively at 2, 4, 8, 12, and 24 weeks, and then annually for a minimum of 2.5 years. Clinical and functional evaluations were performed using the modified Cincinnati rating system and the Kujala score, while anthropometry values including thigh volume and cross-sectional area of the thigh were measured before the operation and at the latest follow-up bilaterally. ResultsThere were 7 males and 27 females with a mean age of 26.5 ± 10.7 years (range, 13–39 years). The mean follow-up was 3.1 years (range, 2.5–4 years). The mean modified Cincinnati score Increased from 51 ± 22 preoperatively to 90 ± 19 (P = .001). The mean Kujala scores increased from 47 ± 17 preoperatively to 82 ± 17 (P = .02), with no significant differences between patients with or without osteochondral lesions (P ≥ .05), and between male and female patients (P ≥ .08). The Insall-Salvati index was 1.1 preoperatively and remained within normal range (P = .05) at the latest follow-up. ConclusionCombined reconstruction of MPFL and MPTL using an ipsilateral autologous gracilis tendon is satisfactory and effective and can be considered as suitable management option to treat recurrent dislocation of the patella. However, randomized studies are needed to compare different techniques. Study designCase series.

Femoral Nerve Palsy following Medial Patella Femoral Ligament Reconstruction

A 29-year-old teacher, presented with right medial patellofemoral ligament (MPFL) tear. This was identified and confirmed by magnetic imaging resonance and MPFL was reconstructed with gracilis tendon. She had femoral nerve palsy that recovered fully after prolonged rehabilitation.

NON-FREE GRAFTS IN ANTERIOR CRUCIATE LIGAMENT AND LATERAL EXTRA-ARTICULAR TENODESIS RECONSTRUCTION

Introduction. The modern development of technologies of ACL-R allows us to take a fresh look at the methods for recovery of anterior and rotational knee instability of the knee joint, which were used in the middle of the XX century. The objective was to evaluate the non-free tendon grafts while maintaining their anatomical attachment point for the isolated and complex ACL-R. Methods and materials. From 2014 to 2018, 128 patients were operated on the isolated ACL injuries (102 patients – 79.7 %) and complex ACL injuries (26 patients – 20.3 %). 26 (20.3 %) patients were operated on the rupture of a previously installed ACL graft. There were 72 men (56.3 %) and 56 women (43.7 %). The average age was (34.7±2.5) years. The average body weight was (82.7±1.6) kg; 24 (18.8 %) patients weighed over 85 kg. In 87 (68.0 %) cases, an anatomic single bundle ACL-R was performed by non-free graft either from the tendon of semitendinosus or in combination with the gracilis tendon. In 41 (32.0 %) cases, ACL-R was supplemented by LEAT (non-free iliotibial tract or free gracilis tendon grafts). The results were evaluated clinically, radiologically, and using the 2000 IKDC, KOSS and Lysholm Knee Scoring Scale integrated scales. In all cases, high stability of the knee joint was noted. Lachman and the pivot shift test recorded only 0 and 1 degrees. By the KOSS scale: «pain» was (86.7±2.3) points, «pathological symptoms» – (88.5±1.6) points, «daily activity» – (93.1±2.8) points, «sports activity» – (73.9±2.1) points, «quality of life» – (84.6±1.9) points. The average values of knee function by the Lysholm Knee Scoring Scale was 95.1±2.1. According to the 2000 IKDC, 117 (91.4 %) patients were included in group A, and 11 (8.6 %) in group B. Patients with moderate or severe impaired knee function (C and D) were not observed. The average time of the ACL-R was (82.1±2.4) min., ACL-R and LEAT – (94.7±6.9) min. The mean hospital stay was (3.2±1.8) days and (3.8±1.3) days, respectively. Conclusion. Non-free grafts for ACL-R and LEAT have an anatomically reliable fixation point, which allows to achieve high functional results of the knee joint. The proposed techniques can be reproduced with standard instruments and implants, taking into account the average operating time and blood loss, and without significant infection complications, persistent synovitis, contractures and hypotrophy of the thigh muscles.

Clinical and Radiographic Outcomes of Double-Bundle Anterior Cruciate Ligament Reconstruction for Asian Patients with Bone-Patellar Tendon-Bone and Gracilis Tendon Grafts: A Matched-Control Comparison.

For anterior cruciate ligament (ACL)-deficient patients, using a single bone-patellar tendon-bone (BPTB) graft for the double-bundle concept is one of the suitable approaches for acquiring better stability and reducing bone tunnel enlargement compared with the use of hamstring grafts. At least 10-mm width of BPTB autograft is needed to achieve this concept; however, it is larger than one-third of the patellar tendon width for small or middle physique patients. This study aimed to assess the clinical and radiographic outcomes of BPTB and gracilis (G) composite autografts for primary double-bundle ACL reconstruction in Asian athletes. Thirty-two Asian patients undergoing double-bundle ACL reconstruction with 7.0 to 7.5 mm of BPTB and 5.0 to 5.5 mm of G composite grafts were compared with 43 double-bundle ACL reconstruction with hamstring graft cases. The BPTB graft was used for the anteromedial bundle (AMB), with the G graft for the posterolateral bundle (PLB). Percentage of femoral bone tunnel enlargement compared with the original size was determined by computed digital radiographs on the first postoperative day and at 12 months in the anteroposterior (AP) and lateral views. Standard clinical evaluations, including the limb symmetry index (LSI), were also performed. Less PLB tunnel enlargement was found in the BPTB + G group than in the hamstring group in the AP (101.9 ± 22.9 vs.113.7 ± 20.6%, p = 0.031) and lateral views (104.4 ± 18.1 vs. 120.6 ± 23.4%, p < 0.01).There was no significant difference between the groups in 12-month postoperative clinical outcomes (Lysholm's score, Tegner's activity level scale, and International Knee Documentation Committee subjective knee evaluation score).The side-to-side difference was significantly less in the BPTB + G group (0.2 ± 1.3 vs. 0.9 ± 1.1 mm, p = 0.026). Despite the small sizes of the BPTB and G grafts, there was no significant difference in the knee extensor LSI between the groups (92.9 ± 10.1 vs. 93.3 ± 12.2%, p = 0.707), whereas the knee flexor LSI was significantly higher in the BPTB + G group (97.7 ± 14.8 vs. 90.1 ± 13.3%, p = 0.033). Double-bundle ACL reconstruction with a small size BPTB and G composite graft procedure provided good clinical outcomes and significantly less femoral bone tunnel enlargement than the hamstring procedure 12 months after surgery. It is thus a useful surgical option for ACL-deficient Asian athletes. This study reflects level of evidence III.

A Randomized Controlled Trial of Bone–Patellar Tendon–Bone Anterior Cruciate Ligament Reconstruction With and Without Lateral Extra-articular Tenodesis: 19-Year Clinical and Radiological Follow-up

Background: Arthroscopic anterior cruciate ligament (ACL) reconstruction (ACLR) with a bone–patellar tendon–bone graft (BTB) is a reliable surgical option for the control of anterior knee laxity after ACL injury. The addition of a lateral extra-articular tenodesis (LET) may improve control of rotation knee laxity and improve short-term graft survival in high-risk patients. Purpose: The aims of this study were to compare long-term patient-reported outcomes, graft survival, and risk of osteoarthritis between ACLR with and without LET. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: This study included 121 consecutive knees (120 patients) presenting to a single center with an ACL rupture between 1998 and 1999. In total, 61 knees were randomized to an isolated BTB ACLR, and 60 knees were randomized to a BTB ACLR with an extra-articular lateral tenodesis with gracilis tendon (modified Lemaire). Results: Eighty knees in 79 patients (66%) were available for follow-up at a postoperative mean of 19.4 years (range, 19-20.2). Of those patients, 43 had a clinical examination and completed patient-reported outcome questionnaires, and the other 37 patients were evaluated through the questionnaires alone. Standard radiographs were available for 45 patients and laximetry (TELOS) for 42 patients. Mean subjective International Knee Documentation Committee score at last follow-up was 81.8, and no differences were noted between the BTB and BTB-LET groups (P = .7). Two-thirds of patients were still participating in pivoting sports. A total of 17 knees (21%) experienced a graft failure, 5 of which (6%) underwent revision ACLR. There was no significant difference in graft failure risk between the BTB group (29%) and the BTB-LET group (13%; P = .1). Lateral tibiofemoral osteoarthritis was significantly more frequent in the BTB-LET group (59%) as compared with the BTB group (22%; P = .02). Lateral compartment osteoarthritis was correlated with partial lateral meniscectomy. Conclusion: There were no significant differences in long-term patient-reported outcomes after ACLR with or without an LET. LET may increase the risk of lateral compartment osteoarthritis at long-term follow-up. There was a trend toward decreased graft failure risk with the addition of LET but this study was underpowered to assess this outcome.

Can we predict the graft diameter for autologous hamstring in anterior cruciate ligament reconstruction?

To achieve in the reconstruction of the anterior cruciate ligament a graft with strength, tension and low comorbidity is fundamental.An emerging concept is that a graft diameter of less than 7mm carries a greater risk of re-rupture and instability. Consequently, different methods are being sought to predict intra-surgical size.The objective is to predict the size of the hamstring graft by measuring the area of the semitendinous and gracilis tendon with magnetic resonance imaging (MRI). MethodologyWe carried out an observational retrospective study of 56 patients. They underwent anterior cruciate ligament reconstruction with 4-GST hamstring graft. The parameters evaluated were anthropometric data, hamstring graft diameter, area of gracilis and semitendinosus tendon in MRI. The measurements were made by three independent evaluators. ResultsThe mean diameter of the intrasurgical graft was 8.46mm, in the MRI the area of the gracilis was 8875mm and the semitendinosus area was 13,068mm. Their mean was 22.12 for the automatic measurement and 21.53 for the manual measurement. The interobserver correlation was regular for the automatic measurement (ICC=.595) and low for the manual measurement (ICC=.446). The result of the intraobserver correlation was excellent (ICC=.917). We did not obtain a statistical correlation between the measurement of areas and the increase of the graft diameter (R=.069, P=.63). ConclusionWe determined with our results that the intrasurgical graft size is not predictable with the measurement of the area of the gracilis and semitendinosus tendon on the MRI.

Hamstring autograft and anatomical footprint evaluation for anterior talofibular ligament reconstruction: Cadaveric study.

The aim of the study was to evaluate whether or not there was any incompatibility between two-strand hamstring tendons taken from the same knee and the ATFL and it was the determination of suitable footprint points in the fibula and talus for anatomical ATFL reconstruction. 16 fresh frozen cadaver specimens were dissected to gracilis and semitendinosus tendons and the anterior talofibular ligament. The origins, insertions, distances from osseous landmarks of fibular talus of ATFL were determined. The diameters of gracilis, semitendinosus and ATFL were calculated. There was a moderate correlation between body height and the distance between the distal of inferior lateral malleolus and the fibular adhesion site of ATFL (r: 36.5 p: 0.036). There was a weak correlation between body height and the distance between the apex of the lateral talar process and the talus adhesion site of ATFL in a single bundle (r: 28.4 p: 0.002). There was no correlation between the distance from proximal and distal adhesion side of ATFL and body height in the double bundle (p: 0.241). There was no significant relationship between ATFL diameter and gracilis, semitendinosus and both hamstring in women. A significant relationship at 80.5% was determined between the ATFL and the gracilis diameter in man. A significant relationship at 92.6% was determined between the ATFL and the semitendinosus diameter in man. It was determined that there is not compatibility between the gracilis tendons, the semitendinosus tendon and ATFL in women. It should be supported by biomechanical and clinical studies whether this incompatibility has a clinical effect or not.

Isolated reconstruction of medial patellofemoral ligament with an elastic femoral fixation leads to excellent clinical results.

The primary objective was to compare the functional outcomes after an isolated MPFL reconstruction using either a quasi-anatomical technique (group A) or an anatomical MPFL reconstruction (group B). The secondary objectives were to compare the rates of redislocation, range-of-motion and subjective patellar instability (Smillie test). A multicenter longitudinal prospective comparative study was performed. Group A had 29 patients and 28 were included in Group B. Patients with trochlear dysplasia types C and D and patients who had undergone a trochleoplasty, a distal realignment or patella distalization concurrently with MPFL reconstruction were excluded. The main evaluation criterion was the Kujala functional score. The mean postoperative Kujala was 90.4 (89.4 in group A and 92.1 in group B). Upon comparing the mean difference between pre- and post-operative values, no differences were detected between the two groups (n.s). Isolated quasi-anatomical MPFL reconstruction using a gracilis tendon autograft for recurrent patellar dislocation provides outcomes as good as the isolated anatomical MPFL reconstruction in patients with no trochlear dysplasia up to those with trochlear dysplasia type A and B at the 2-5years follow-up. Level IV.

Reconstruction of massive knee defects with extensor mechanism deficiency through concurrent anterolateral thigh flap and autogenous hamstring tendon: A report of two cases

Reconstruction of an infected knee joint with a large defect and extensor mechanism deficiency is challenging. In this study, we aim to describe a one-stage reconstruction surgery and provide its surgical outcome. Two patients had patellar open fracture and subsequent septic arthritis; in addition, a large soft tissue defect, loss of patella, and shortening of the patellar tendon were observed. The semitendinosus-gracilis tendon formed a loop to stabilize the patella. A free or supercharged reverse pedicle myocutaneous anterolateral thigh flap with fascial extension is designed to fill the defect and eradicate the infection. Mean clinical follow-up was 18 months. Although some limitation in the knee range of motion was observed, the dynamometer showed only partial loss in peak concentric power and eccentric power. We developed an innovative surgical procedure to alleviate infection and reconstruct a complex knee defect with extensor mechanism deficiency; this procedure resulted in favorable clinical outcomes.

Isolated MPTL reconstruction fails to restore lateral patellar stability when compared to MPFL reconstruction.

To biomechanically evaluate MPTL reconstruction and compare it with two techniques for MPFL reconstruction in regard to changes in patellofemoral contact pressures and restoration of patellar stability. This is an experimental laboratory study in eight human cadaveric knees. None had patellofemoral cartilage lesions or trochlear dysplasia as evaluated by conventional radiographs and MRI examinations. The specimens were secured in a testing apparatus, and the quadriceps was tensioned in line with the femoral shaft. Contact pressures were measured using the TekScan sensor at 30°, 60° and 90°. The sensor was placed in the patellofemoral joint through a proximal approach between femoral shaft and quadriceps tendon to not violate the medial and lateral patellofemoral complex. TekScan data were analysed to determine mean contact pressures on the medial and lateral patellar facets. Patellar lateral displacement was evaluated with the knee positioned at 30° of flexion and 9N of quadriceps load, then a lateral force of 22N was applied. The same protocol was used for each condition: native, medial patellofemoral complex lesion, medial patellofemoral ligament reconstruction (MPFL-R) using gracilis tendon, MPFL-R using quadriceps tendon transfer, and medial patellotibial ligament reconstruction (MPTL-R) using patellar tendon transfer. No statistical differences were found for mean and peak contact pressures, medial or lateral, among all three techniques. However, while both techniques of MPFL-R were able to restore the medial restraint, MPTL-R failed to restore resistance to lateral patellar translation to the native state (mean lateralization of the patella [mm]: native: 9.4; lesion: 22; gracilis MPFL-R: 8.1; quadriceps MPFL-R: 11.3; MPTL-R: 23.4 (p < 0.001). MPTL-R and both techniques for MPFL-R did not increase patellofemoral contact pressures; however, MPTL-R failed to provide a sufficient restraint against lateral patellar translation lateral translation in 30° of flexion. It, therefore, cannot be recommended as an isolated procedure for the treatment of patellar instability.

Arthroscopically-assisted treatment of acute and chronic dislocations of the acromioclavicular joint : Aprospective clinical trial

Injuries of the acromioclavicular joint (ACJ) are frequent and often occur during sports. While arthroscopically-assisted stabilization of acute injuries of the ACJ is awell-established procedure, there is not much data available for arthroscopically-assisted stabilization of chronic injuries of the ACJ. This study assesses clinical and radiological results of arthroscopically-assisted stabilization of acute and chronic injuries of the ACJ. Thirty-six patients with acute and chronic injuries of the ACJ were assessed in aprospective clinical trial. Twenty-five patients with acute injuries (groupA) and eleven patients with chronic injuries (groupB) were included in this study. Patients of groupA were operated using two suture-button systems, while patients of groupB received one suture-button system and an autologous gracilis tendon graft. In groupA, the mean preoperative Constant score rated 38, and the ASES score rated 34. At follow-up the Constant score(92) and the ASES score(89) had improved. Panorama views revealed an increased coracoclavicular distance of the affected shoulder (15.8 mm) in comparison to the contralateral shoulder (10.9 mm). In groupB, the preoperative Constant score measured 57. It improved to 72points at follow-up. The ASES score improved from 39 to 72points in the same period. Panorama views revealed an increased coracoclavicular distance of the affected shoulder (18.9 mm) in comparison to the contralateral shoulder (12.4 mm). Stabilization of acute injuries of the ACJ with two suture-button systems is related to very good shoulder function after one year. The native coracoclavicular distance cannot be restored with this procedure. Stabilization of chronic injuries of the ACJ with asuture-button system and an autologous gracilis tendon graft is related to improved shoulder function after one year. However, shoulder function cannot be fully restored with the stabilization technique presented.

Tendon regeneration and muscle hypotrophy after isolated Gracilis tendon harvesting - a pilot study

PurposeThe gracilis tendon (GT) is a commonly used autologous graft in Orthopaedic surgery. The majority of information on knee function and outcomes after hamstring harvest is related to both semitendinosus and GT harvest. Little is known regarding isolated harvest of a GT. It was hypothesized that isolated GT harvest would lead to altered gait patterns (e.g. augmented anterior-posterior translation or rotation in the tibiofemoral joint) and consequently a higher prevalence of cartilage lesions and meniscal tears in knees.MethodsGT harvesting was performed on patients with chronic acromioclavicular joint instability without previous knee injuries or surgeries. MRI of both knees and thighs were performed. Knee MRI were evaluated using the Whole-Organ Magnetic Resonance Imaging Score (WORMS). Inter- and intraobserver reliabilities, cross-sectional areas of different muscles, fatty infiltration of the gracilis muscle (GM) and GT regeneration were evaluated. The contralateral limb served as reference. The observers were blinded towards the identity of the patients and the operatively treated side.ResultsAfter a mean time of 44 months after surgery testing was performed on 12 patients. No significant side-to-side differences were found using WORMS, although there was a trend towards increased cartilage lesions after GT harvest (median healthy knee 4.8 and GT harvested knee 7.8 p = 0.086). Inter- and intraobserver repeatability was high with 0.899 (95% confidence interval (CI) 0.708–0.960) and 0.988 (95% CI 0.973–0.995), respectively. A significant hypotrophy of the GM with a mean decrease of 25.3%, 18.4% and 16.9% occurred at 25% (p = 0.016), 50% (p = 0.007) and 75% (p = 0.002) of the length of the femur from distal. No compensatory hypertrophy of other thigh muscles or increased fatty infiltration of the GM was found. Tendon regeneration took place in eight out of 12 patients. In case of regeneration, the regenerated tendon inserted in a more proximal place.ConclusionIsolated harvest of the GT for shoulder procedures did not affect knee MRI significantly indicating therefore in general suitable graft utilization for surgeries outside of the knee. GT regenerated in most patients with just a more proximal insertion and a hypotrophy of the muscle belly.

Anterolateral Ligament Reconstruction and Modified Lemaire Lateral Extra-Articular Tenodesis Similarly Improve Knee Stability After Anterior Cruciate Ligament Reconstruction: A Biomechanical Study

To determine the stabilizing role of anterolateral ligament reconstruction (ALLR) and modified Lemaire lateral extra-articular tenodesis (LET) performed in combination with anterior cruciate ligament reconstruction (ACLR) and to determine whether either procedure was superior to the other. Six nonpaired, human, fresh-frozen cadaveric knees were tested with a 6-df robotic system. Internal rotation and anterior translation of the knee were recorded from 0° to 90° of flexion after application of a 5-Nm internal rotation torque and a 134-N anterior load, respectively. A full kinematic assessment was performed in each of the following conditions: (1) intact knee, (2) after sectioning of the anterior cruciate ligament (ACL), (3) after sectioning of the ACL and anterolateral ligament, (4) after isolated ACLR, and (5) after combined ACLR and Lemaire LET and combined ACLR and ALLR. ALLR was performed using the gracilis tendon, whereas the modified Lemaire procedure was performed using the central strip of the iliotibial band. The different states were compared using a Tukey paired comparison test. In knees with combined deficiency of the ACL and anterolateral structures, anterior translation and internal rotation remained significantly increased after isolated ACLR compared with the intact knee (+2.33 ± 1.44 mm and+1.98° ± 1.06°, respectively; P < .01). On the other hand, the addition of ALLR or modified Lemaire LET to ACLR restored anterior translation and internal rotation to values similar to those in the intact knee. The 2 anterolateral procedures did not show statistically significantly different values for both tests. This difference was 0.67 ± 1.46 mm for anterior translation (P= .79) and 0.11° ± 1.11° for internal rotation (P=.99). In knees with ACL and anterolateral deficiency, combined ACLR and anterolateral reconstruction restored the native knee stability in anterior translation and internal rotation contrary to isolated ACLR. In addition, both types of extra-articular reconstruction-ALLR and modified Lemaire LET-were similar in terms of restoring knee kinematics, and neither overconstrained the knee. In knees with deficiency of the ACL and anterolateral structures, combined ACLR and anterolateral reconstruction increased knee stability at time zero after surgery. This biomechanical improvement could be responsible for the protective effect on ACL graft and meniscal repair reported in the literature after the combined procedure.

A PRACTICAL PRE-OPERATIVE PREDICTIVE MODEL FOR DETERMINING HAMSTRING AUTOGRAFT SIZE FOR ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN CHILDREN AND ADOLESCENTS

Background:The most commonly used graft for pediatric/adolescent anterior cruciate ligament (ACL) reconstruction is the hamstring autograft. Recent evidence has suggested that graft sizes less than 8 mm and age less than 20 years old are the most significant factors influencing graft failure. Additionally, studies examining the role of augmenting smaller grafts with allograft have demonstrated mixed results and potentially increased failure rates. Efforts to predict hamstring size preoperatively using MRI and ultrasound in the adult population have shown promise. However, there have been no studies in an entirely pediatric population.Hypothesis/Purpose:The purpose of this study was to evaluate the predictive value of MRI in determining hamstring autograft size preoperatively for pediatric ACL reconstructions.Methods:Children and adolescents from 10-20 years old that had undergone ACL reconstruction using hamstring autograft were identified from 2017-2018. Semitendinosus and gracilis cross-sectional area and diameter were measured on preoperative knee MRIs using the field of interest and distance measurement tools. The slice used for measurement was identified as the largest section by the measuring surgeon. Two surgeons independently measured all MRIs. Preoperative demographic data (height, weight, body mass index (BMI), gender) and operative data (graft size) was collected. Ordinal regression analysis was performed to determine the relationship between demographic data and graft size. A Classification and Regression Tree (CART) was constructed to identify predictors for the pre-determined graft sizes of 8 mm. Receiver operating characteristics (ROC) analysis were then created to assess the performance of the predictive model and determine sensitivity and specificity.Results:One hundred and ten children (54 boys, 56 girls) were included in this study with an average age of 15.93 years (range 11.81-20.22) and average BMI of 25.98 (range 16.02-40.08). CART analysis determined that if the sum of the cross-sectional areas of the semitendinosus and gracilis tendons were greater than 31.17 mm then 87.5% of children had graft sizes of 8 mm or greater. The ROC analysis determined the model to have an 80% sensitivity and 74% specificity for predicting a graft size of 8 mm or larger.Conclusion:A preoperative summation of the cross-sectional areas of the semitendinosus and gracilis tendons greater than 31.17 mm predicts an intraoperative graft size of 8 mm or larger in 87.5% of children.Table 1:Demographic data comparing children with graft sizes less than 8 mm with those 8 mm or greater. Table 2:Magnetic resonance imaging (MRI) measurements comparing children with graft sizes less than 8 mm with those 8 mm or greater. Figure 1:Magnetic resonance imaging (MRI) of a right knee cross-section demonstrating the measurement technique for determining the cross-sectional area of the semitendinosus and gracillis tendons using the field of interest (FOI) tool.

¿Podemos predecir el tamaño de la plastia de los isquiotibiales para la reconstrucción del ligamento cruzado anterior mediante resonancia magnética?

To achieve in the reconstruction of the anterior cruciate ligament a graft with strength, tension and low comorbidity is fundamental.An emerging concept is that a graft diameter of less than 7mm carries a greater risk of re-rupture and instability. Consequently, different methods are being sought to predict intra-surgical size.The objective is to predict the size of the hamstring graft by measuring the area of the semitendinous and gracilis tendon with magnetic resonance imaging (MRI). MethodologyWe carried out an observational retrospective study of 56 patients. They underwent anterior cruciate ligament reconstruction with 4-GST hamstring graft. The parameters evaluated were anthropometric data, hamstring graft diameter, area of gracilis and semitendinosus tendon in MRI. The measurements were made by three independent evaluators. ResultsThe mean diameter of the intrasurgical graft was 8.46mm, in the MRI the area of the gracilis was 8,875mm and the semitendinosus area was 13,068mm. Their mean was 22.12 for the automatic measurement and 21.53 for the manual measurement. The interobserver correlation was regular for the automatic measurement (ICC = 0.595) and low for the manual measurement (ICC = 0.446). The result of the intraobserver correlation was excellent (ICC = 0.917). We did not obtain a statistical correlation between the measurement of areas and the increase of the graft diameter (R = 0.069, P = .63). ConclusionWe determined with our results that the intrasurgical graft size is not predictable with the measurement of the area of the gracilis and semitendinosus tendon on the MRI.

All-Inside Arthroscopic Anterior Talofibular Ligament Anatomic Reconstruction With a Gracilis Tendon Autograft for Chronic Ankle Instability in High-Demand Patients

The goal of this study was to evaluate the surgical technique and clinical outcome of all-inside arthroscopic anterior talofibular ligament anatomic reconstruction with a gracilis tendon autograft for chronic ankle instability in high-demand patients. Fifteen consecutive patients (14 [93.3%] males and 1 [6.7%] female, mean age 31.9 ± 7.8 [range 21 to 48] years) with chronic ankle instability were enrolled in this study. Under direct arthroscopic visualization, bone tunnels were created in the fibula and talus by a 4.5-mm cannulated drill system. The gracilis tendon autograft was passed through the tunnels and secured by 5.0-mm interference screws. At the final follow-up, functional evaluation was carried out according to the Ankle-Hindfoot Score by the American Orthopaedic Foot and Ankle Society, Sefton grading system, and visual analog scale score. Complications were also recorded. Mean follow-up was 19.5 ± 1.8 (range 18 to 24) months. No complications of wound infection and nerve injury were noted. No patients experienced recurrent ankle instability. Radiologically, the mean varus tilting angle was 15.2° ± 1.5° before surgery and 4.3° ± 1.2° at the last follow-up (p ≤ .001). The anterior drawer distance was 13.2 ± 1.5 mm before surgery and 4.8 ± 1.1 mm at last follow-up (p ≤ .001). The mean American Orthopaedic Foot and Ankle Society and visual analog scale scores were 56.8 ± 10.5 and 5.7 ± 1.3 before surgery, which became 90.2 ± 6.2 and 0.5 ± 0.8 after surgery. Fourteen (93.3%) patients reported excellent/good functional results according to the Sefton grading system (6 [40.0%] excellent, 8 [53.3%] good, and 1 [6.7%] fair). From our clinical experience, all-inside arthroscopic anterior talofibular ligament anatomic reconstruction with a gracilis tendon is an effective treatment for chronic ankle instability in high-demand patients.

Factors that Predicts the Size of Autologous Hamstring Tendon Graft for Double-Bundle ACL Reconstruction.

To evaluate the effectiveness of demographic data and radiographic measurements for predicting the diameter and length of autologous semitendinosus (ST) and gracilis (GR) graft. Fifty-four cases were included to measure the size of 3 or 4 strands of ST and GR tendons retrospectively. The hamstring length on radiograph was defined as the length from the lowest point of ischial tuberosity to intercondylar notch of the femur. The linear and logistic regression analysis was used to assess the roles of the predictor variables, as demographic and radiologic data, in the outcome variables, as diameter of tendon grafts. The cross-validation with hold-out samples and concordance correlation coefficient (CCC) were also calculated. The hamstring and leg length measurement and gender were associated with the diameter of 4-stranded ST tendon graft. The hamstring length measurement, age and BMI were the factors associated with the diameter of 3-stranded ST tendon graft. The hamstring length measurement was found as a common factor for predicting diameters of hamstring tendon with reliable predictability. Moreover, the equation of multivariate regression analysis for the diameter of 4-stranded ST tendon graft showed the most validated power of prediction. All of the cross-validated R 2 values were calculated as similar results of multivariate model, but CCC between the measured diameter and estimated value on the predictive equation showed moderate agreement only (CCC = 0.694). Combining radiographic length measurements with demographic data showed reliable prediction in identifying the risk of inappropriate graft diameters. Level IV retrospective cohort study.

A biomechanical study after combined reconstruction of the anterior cruciate and anterolateral ligaments: Comparison between anatomic anterolateral ligament reconstruction and lateral tenodesis using the modified Lemaire technique

Objectives:To determine the stabilizing role of the anterolateral ligament reconstruction (ALLR) and the modified Lemaire lateral extraarticular tenodesis (LET) performed in combination with anterior cruciate ligament reconstruction (ACLR) and to determine if one of these two procedures was superior to the other.Methods:Six non paired cadaveric knees were tested with a 6 degrees of freedom robotic system (KUKA Robotics). Internal rotation and anterior tibial translation were measured between 0 and 90° knee flexion after applying 5 N-m Torque and a 134-N anterior load, respectively. A full kinematics assessment was performed in each following conditions: intact knee, after section of the anterior cruciate ligament (ACL), after section of the ACL and anterolateral ligament (ALL) and Kaplan fibers, after isolated ACLR, after combined ACLR+LET and ACLR+ALLR. ALLR was performed using Gracilis tendon while central strip of the ilio-tibial band was used for the modified Lemaire procedure.These different states were compared using a Tukey paired comparison test.Results:In combined ACL and anterolateral deficient knee, anterior translation and internal rotation remained significantly increased after isolated ACLR compared to intact knee (+2.33 ± 1.44 mm and +1.98 ± 1.06°; p > 0.01). On the other hand, the addition of an ALLR or a modified Lemaire LET to the ACLR allowed to restore anterior translation and internal rotation to values similar to the intact knee. Finally, the two anterolateral procedures had not significantly different values in both tests. This difference was 0.67 ± 1.46 mm for anterior translation (p=0.79) and 0.11 ± 1.11° for internal rotation (p=0.99).Conclusion:In ACL and anterolateral deficient knee, combined ACLR and anterolateral reconstruction allowed restoration of native stability of the knee in anterior translation and internal rotation contrary to isolated ACLR.Additionally, both types of extra-articular reconstruction, ALLR or modified Lemaire procedure, were similar in terms of restoring knee kinematics and neither overconstrained the knee.