Ligament Graft Research Articles

Higher Posterior Tibial Slope and Lower Medial Proximal Tibial Angle of the Knee Are Associated with Delayed Graft Maturation after ACL Reconstruction Surgery with Hamstring Autograft

PurposeThis study aims to relate bone shape with anterior cruciate ligament (ACL) graft maturation, as evaluated by quantitative magnetic resonance imaging (MRI). MethodsWe retrospectively evaluated patients aged 18-60 years who underwent ACL reconstruction with a hamstring autograft with doubled semitendinosus and gracilis at our institution between 2018 and 2020 with isolated ACL injuries. All patients had a minimum follow-up period of 2 years. To evaluate alignment, radiographs of the knee were taken preoperatively. Postoperative 3T magnetic resonance imaging (MRI) and patient-reported outcomes (PRO) scores were acquired at 2 years after surgery. A combined T1ρ/T2 quantification sequence and a 3D multi-echo ultrashort echo-time (UTE) Cones sequence were obtained in a sagittal-oblique plane for better assessment of the ACL graft. After acquiring images, a manual segmentation for ACL graft was performed to assess T1ρ, T2 and UTE T2* relaxation times. Correlations between radiographic parameters or PRO scores and T1ρ, T2 and UTE T2* values were tested with Pearson correlation coefficients. Significance was defined as p<0.05. ResultsSubjects were 28 patients (12 males and 16 females) and had an average age of 34.3 years (SD=8.5 years) and a BMI of 24.4 kg/m2 (SD=4.5 kg/m2). A significant correlation was found between the preoperative PTS and the T1ρ, T2 and UTE T2* relaxation times (r=0.41; p=0.033, r =0.47; p=0.014 and r =0.41; p=0.030), indicating inferior graft maturation in patients with higher PTS. Furthermore, a negative correlation was identified between the preoperative MPTA and the T1ρ, T2 and UTE T2* relaxation times (r=-0.39; p=0.039, r =-0.46; p=0.018 and r =-0.43; p=0.024), indicating inferior graft maturation in patients with greater varus knee alignment. ConclusionThe study findings suggest that an increased PTS and lower MPTA are associated with inferior graft maturation as per T1ρ, T2 and UTE T2* imaging at 2 years post-ACL reconstruction. Level of EvidenceLevel IV retrospective case series

Biomechanical comparison of different surgical suture techniques for four-stranded all-inside cruciate ligament grafts

Biomechanical comparison of different surgical suture techniques for four-stranded all-inside cruciate ligament grafts

Evaluation of Return to Military Activities after Combining Anterior Cruciate Ligament Reconstruction with Modified Lateral Extra-articular Tenodesis Versus Anterior Cruciate Ligament Reconstruction Alone in Primary Anterior Cruciate Ligament Tear in Soldiers. A Randomized Comparative Study

Abstract Background: This study aimed to assess the clinical result, complications, failure rate, and return to resuming military duty of a single-stage anterior cruciate ligament reconstruction (ACLR) procedure utilizing quadrupled semitendinosus tendon graft joint with modified lateral extra-articular tenodesis (LET). This study evaluates the potential impact of combined modified LET with ACLR versus ACLR alone on the rate of return to high-impact military activities, which we call return to sports (RTSs), and the subsequent rate of the anterior cruciate ligament (ACL) graft failure. Materials and Methods: A total of 198 soldiers with primary ACL tears with a high-grade pivot test (grade 3) were included and randomized using the simple randomized method and divided into two groups. A consecutive cohort of military personnel with an isolated ACL tear undergoing ACLR with modified LET (group A, n = 116) and ACLR alone (group B, n = 82) were analyzed between 2016 and 2021. Both groups were followed up for a minimum of 2 years. Soldiers underwent a survey evaluating knee function (knee injury and osteoarthritis outcome score [KOOS]), RTS criteria (RTS type), symptoms (International Knee Documentation Committee [IKDC] subjective), activity level (Tegner score), and fear of movement (Tampa Scale of Kinesiophobia-11) to assess psychological readiness for sport participation. Results: Among these, a mean age of 32 ± 2.93 years underwent primary ACLR with modified LET (n = 116) or without LET (n = 82) procedure. A total of 31 soldiers (15.6%) experienced ACL graft failure, including 26 (31.7%) reconstructions without LET and 5 (4.3%) with LET. Combined with LET during primary ACLR, it lowered the risk of graft failure by 2.8 times. Multivariable analysis revealed a significant reduction in graft rupture risk (relative risk = 0.325, P = 0.029) associated with LET compared to ACLR alone after adjusting for age, anthropometric factors, and tibial slopes. 105 out of 113 (90.5%) soldiers were able to return to military duty in group A (combined ACLR with modified LET), whereas 51 of 81 (62.9%) of the soldiers who underwent ACLR alone (group B) returned to military duty (P = 0.05). Conclusion: At 24 months postoperatively, combined ACLR plus LET showed a significantly higher RTS rate than ACLR alone. The combined ACLR with the modified LET group also showed a lower failure rate than the ACLR alone group. No marked differences were observed in KOOS sub-scores, IKDCsubjective, and Tegner activity scores.

Non-tuberculous mycobacterial bone and joint infections - a case series from a tertiary referral centre in Australia.

Non-tuberculous mycobacteria (NTM) are rare causes of bone and joint infection (BJI) and there is limited evidence on which to base management decisions. This study describes 1 year of experience from a multi-disciplinary BJI team which collects data on all cases reviewed at a tertiary referral centre in Queensland, Australia. The database was interrogated for all cases in which NTM were recovered from operative samples. Individual chart review was performed to collect the details of each case. A total of seven cases were managed between 1st February 2021 and 28th February 2022, comprising one patient with chronic osteomyelitis, three with fracture-related infections, two with prosthetic joint infections, and one with infection of a synthetic ligament graft. In contrast to pulmonary NTM infections, most patients were clinically well and immunocompetent, and most infections were propagated by direct inoculation. Time to diagnosis was unknown in three patients, with 1, 2, 2, and 5 months for the remaining four. Rapid growing NTM were diagnosed on routine cultures and specific mycobacterial cultures were confirmatory. Management was characterized by multiple stage surgical procedures and prolonged antimicrobial regimens. Antimicrobial complications were common; however, all patients were infection free at their latest follow up. Despite the inherent limitations, these results suggest that routinely ordering mycobacterial culture is of low yield. There is potential for shorter-term oral antimicrobial treatments. Prospective research is required to optimize treatment regimens and durations.

Preservation of the MMPH and Status of the Notch Configurations Are Important Factors for Successful Revision ACL Reconstruction.

The aim of this study was to identify the differences in anatomical factors between the patients who underwent revision and primary anterior cruciate ligament reconstructions (ACLR) and compare the outcomes between the 2 surgeries. Retrospective cohort study. Single institution tertiary academic center between 2014 and 2020. A total of 84 matched patients who underwent revision (group I) or primary ACLR (group II). Radiological evaluations were performed using side-to-side differences (SS-D), femorotibial angle, and posterior tibial slope. The medial meniscus posterior horn status as width (MMPHW), medial tibial plateau width (MTPW), notch configurations, tunnel positions, and sagittal graft angle were measured using 3D-CT and magnetic resonance imaging (MRI). Graft signals were assessed using MRI. The clinical outcomes were assessed. Group I showed larger SS-D and higher mean Howell grade of anterior cruciate ligament (ACL) graft than group II (P = 0.002 and P = 0.004, respectively). Multivariate regression analyses showed that the decreased MMPHW/MTPW ratio (P = 0.010) and notch width index (P < 0.007) were significantly independent factors associated with the higher Howell grade of ACL grafts. The decreased MMPHW/MTPW ratio (P < 0.001) was a significantly independent factor associated with larger SS-D. In the subgroup analysis, all patients in the notchplasty group showed wider notches postoperatively (P < 0.001). Revision ACLRs resulted in worse ACL signal intensity and stability outcome. The results of this study suggest that it may be important to preserve the MMPHW as much as possible and check notch configurations, especially during a revision ACLR.

Superior Biological Healing of Hamstring Autografts Compared with Tibialis Allografts after Anterior Cruciate Ligament Reconstruction: A Propensity Score Matching Analysis Based on Second-Look Arthroscopy.

Background and Objectives: Remodeling and healing of the graft are crucial processes for long-term graft survival after anterior cruciate ligament reconstruction (ACLR). However, few studies have objectively evaluated the differences in graft healing between autografts and allografts. This study aimed to compare the status of the anterior cruciate ligament (ACL) grafts between hamstring tendon (HT) autografts and tibialis anterior tendon (TAT) allografts using second-look arthroscopy. Materials and Methods: The outcomes of 193 consecutive patients (153 males and 40 females, with an average age of 30.38 and BMI of 25.43 kg/m2) who underwent second-look arthroscopy following primary ACLR were retrospectively reviewed. Prior to participating in this study, all patients provided written informed consent. The patients were divided into two groups: those with HT autografts and those with TAT allografts. Confounding factors were matched between the two groups using propensity score matching (PSM). ACL graft status was assessed during second-look arthroscopy using a numeric scale system based on the degree of four parameters: graft tension, continuity, synovium coverage, and vascular marking. Clinical outcomes were assessed using the Lysholm and International Knee Documentation Committee (IKDC) scores. Graft status and clinical outcomes were compared between the two groups. Additionally, a subgroup analysis based on the timing of the second-look arthroscopy (12-24 months vs. >24 months after the initial ACLR) was conducted. Results: After PSM, 62 patients were included in each group. The second-look arthroscopy was conducted at 23.6 ± 6.6 months for the HT group and at 24.0 ± 7.9 months for the TAT group (p = 0.749). The continuity and tension of the ACL graft were not significantly different between the two groups (p = 0.146 and 0.075, respectively). However, the TAT group exhibited significantly inferior synovial coverage and vascular marking of the ACL graft compared with the HT group (p = 0.021 and 0.007, respectively). These findings were consistent regardless of the timing of the second-look arthroscopy. Clinical outcomes, according to the Lysholm and IKDC scores, significantly improved in both groups with no significant differences (p = 0.386 and 0.733, respectively). Conclusions: Although there were no differences in graft tension and continuity between HT autografts and TAT allografts, the biological healing of ACL grafts, in terms of synovialization and vascularization, was superior in HT autografts compared to TAT allografts.

Anterior Slope–Modifying Osteotomies Alter the Length Change Behavior of the Superficial Medial Collateral Ligament: A Biomechanical Study

Background: Increased tibial slope has been shown to lead to higher rates of anterior cruciate ligament graft failure. A slope-decreasing osteotomy can reduce in situ anterior cruciate ligament force and may mitigate this risk. However, how this procedure may affect the length change behavior of the medial ligamentous structures is unknown. Purpose/Hypothesis: The purpose of this study was to examine the effect of anterior slope–modifying osteotomies on the medial ligamentous structures. It was hypothesized that (1) decreasing the tibial slope would lead to shortening of the superficial medial collateral ligament (sMCL), (2) while the fibers of the posterior oblique ligament (POL) would be unaffected. Study Design: Descriptive laboratory study. Methods: Eight fresh-frozen cadaveric knee specimens underwent anatomic dissection to precisely identify the medial ligamentous structures. The knees were mounted in a custom-made kinematics rig with the quadriceps muscle and iliotibial tract loaded. An anterior slope–modifying osteotomy was performed and fixed using an external fixator, which allowed modification of the wedge height between −15 and +10 mm in 5-mm increments. Threads were mounted between pins positioned at the anterior, middle, and posterior parts of the tibial and femoral attachments of the sMCL and POL. For different tibial slope modifications, length changes between the tibiofemoral pin combinations were recorded using a rotary encoder as the knee was flexed between 0° and 120°. Results: All sMCL fiber regions shortened with slope reduction (P < .001) and lengthened with slope increase (P < .001), with the anterior sMCL fibers more affected than the posterior sMCL fibers. A 15-mm anterior closing-wedge high tibial osteotomy (ACWHTO) resulted in a 6.9% ± 3.0% decrease in the length of the anterior sMCL fibers compared with a 3.6% ± 2.3% decrease for the posterior sMCL fibers. A 10-mm anterior opening-wedge high tibial osteotomy (AOWHTO) increased anterior sMCL fiber length by 5.9% ± 2.3% and posterior sMCL fiber length by 1.6% ± 1.0%. The POL fibers were not significantly affected by a slope-modifying osteotomy. Conclusion: Tibial slope–modifying osteotomies changed the length change pattern of the sMCL such that an AOWHTO increased whereas an ACWHTO decreased the sMCL strain. This effect was most pronounced for the anterior fibers of the sMCL. The length change pattern of the POL remained unaffected by slope-modifying osteotomy. Clinical Relevance: Surgeons should be aware that anterior tibial slope–modifying osteotomies affect the biomechanics of the sMCL. After an extensive ACWHTO, patients may develop a medial or anteromedial instability, while an AOWHTO may overconstrain the medial compartment.

Autograft and Allograft Anterior Cruciate Ligament Reconstruction in Patients Older Than 40 Years Have Similar Short-Term Patient-Reported Outcomes With Greater Rates of Anterior Cruciate Ligament Graft Failure in Patients Who Receive Allograft

PurposeThe purpose of this study was to evaluate short-term patient-reported outcomes (PROs) in patients aged 40 and older after primary ACLR between patients that received allograft or autograft. Secondary aims included assessing the effect of pre-existing osteoarthritis on short-term PROs. MethodsA retrospective review of an ambulatory surgery center’s electronic medical record was conducted for patients who underwent primary ACLR between 2009 and 2022. Patients aged younger than 40, those who underwent index revision procedures and/or concomitant ligament repair/reconstructions, and those with incomplete baseline or short-term (1- or 2-year) KOOS scores were excluded. Allograft and autograft patients were matched according to sex and body mass index (BMI) in a 2:1 fashion. PROs used included KOOS and Single Assessment Numeric Evaluation (SANE) at baseline and short-term follow up (minimum of 1 year). Minimum clinically important difference was calculated in a distribution-based fashion. Osteoarthritis severity was determined based on Kellgren-Lawrence grading of perioperative knee x-rays. Preexisting osteoarthritis was defined as KL grade 1 or more. ResultsA total of 331 patients were included after matching (215 allograft and 116 autograft patients). The average age was 47.7 ± 6.0 (range: 40-66). Age differed significantly between the two groups, with the allograft cohort having an average age of 48.6 ± 6.0 years and the autograft cohort having an average age of 46.1 ± 5.7 years (p < 0.001). Short-term change in KOOS and SANE scores did not differ by graft type (p = 0.154, p = 0.556, respectively). Sixty-seven percent of all patients met MCID for KOOS and 82% of patients with complete baseline and short-term SANE scores met MCID for SANE. There was a statistically significant difference in rupture rates between the allograft and autograft cohorts (n = 9 allograft vs n = 0 autograft; p = 0.030). There was no difference in re-operation rates between the autograft and allograft cohorts (p = 0.453). Perioperative Kellgren-Lawrence grading did not affect outcomes for either graft type (allograft: p = 0.905 vs. autograft: p = 0.522). ConclusionMiddle-aged patients undergoing ACLR with allograft or autograft demonstrate similar short-term patient reported outcomes. Pre-existing osteoarthritis similarly did not significantly affect short-term outcomes. However, rerupture rates were significantly higher in the allograft cohort than the autograft cohort. Level of EvidenceLevel III - Therapeutic

Morphology and morphometry of the patella in a select Black South African sample

BackgroundFor many years, sex determination has been achieved through analysis of skeletal remains in forensic medicine. The patella can be utilized for sex determination in the absence (or damage) of the cranium, upper and lower limbs, and pelvic bones. Additionally, understanding the patella's morphology and morphometry is essential for diagnosing and treating injuries and disorders of the knee joint, as well as knee arthroplasty and patella ligament grafting (Medeiros et al., 2001). This study reviewed the morphology and morphometry of the patella in a Black African population of KwaZulu-Natal and determined if a correlation between the parameters of the patellae and sex exists. Materials and methods154 dry patellae belonging to a South African black population group were utilized to review their morphology and morphometry. The classifications of Wiberg (1941) and Borges et al. (2016) were adapted for the morphology. The seven morphometric measurements were adapted from Dayal and Bidmos (2005) and Borges et al. (2016). A p-value less than 0.05 was considered statistically significant. ResultsAccording to the Wiberg classification: Type 1 patellae were least prevalent (1.9 %), while Type 2 were most common with an incidence of 59.7 %. No statistical difference was recorded with sex (p-value = 0.517). According to Borges et al. (2016) classification: Type 1 (triangular-shaped) patellae were most prevalent in males and females (72.7 %) and Type 3 (irregular shape) patellae were least common in this study. A statistically significant difference between Borges et al. (2016) classification scheme (shape of the patella) and sexes was recorded (p-value = 0.003). A statistically significant relationship between morphometric parameters of the patella and sex was also recorded (p-value <0.001). Patella measurements were greater in males than in females. ConclusionIn this study, the patella displayed sexually dimorphic morphological and morphometric characteristics, which indicated that the patella may be used for sex determination in forensic cases with the KwaZulu-Natal population of South Africa, in addition to clinical applications such as knee arthroplasty, patellar ligament grafting, prosthesis synthesis, and patellar implants.

Single-bundle ACL combined with ALL reconstruction yields comparable outcomes in patients with varied anatomical risk factors for ACL graft failure

BackgroundAnterior cruciate ligament (ACL) graft failure is influenced by factors such as meniscal tears and tibial plateau slope. Combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction has reduced failure rates; however, its efficacy in high-risk patients remains unclear. This study hypothesized that combined ACL and ALL reconstruction would yield similar clinical outcomes in patients with varying risks of ACL failure.Patients and methodsA total of 76 patients who underwent primary single-bundle ACL reconstruction combined with ALL reconstruction between June 2018 and June 2021 were included. The medial tibial slope (MTS), lateral tibial slope (LTS), and anterior tibial translation (ATT) were measured using magnetic resonance imaging and plain radiography of the knee joint. The meniscal lesions were assessed during surgery. Preoperative clinical assessments and final follow-up were conducted using patient-reported outcome measurements (PROMs), including the International Knee Documentation Committee (IKDC) evaluation, Lysholm knee scoring scale, and Tegner Activity scale. PROMs were collected at least two years postoperatively.ResultsThe average follow-up was 32.5 ± 7.4 months. There were no significant differences in postoperative IKDC score, Lysholm score, or Tegner activity score between patients with or without medial meniscus injury (p = 0.155, 0.914, and 0.042, respectively), with or without lateral meniscus injury (p = 0.737, 0.569, and 0.942, respectively), medial tibial slope > 12° or ≤ 12° (p = 0.290, 0.496, and 0.988, respectively), or lateral tibial slope > 7.4° or ≤ 7.4° (p = 0.213, 0.625, and 0.922, respectively). No significant correlations were found between anterior tibial translation and postoperative IKDC (R = -0.058, p = 0.365), Lysholm (R = -0.017, p = 0.459), or Tegner activity scores (R = -0.147, p = 0.189).ConclusionOur study demonstrates that single-bundle ACL reconstruction combined with ALL reconstruction provides reliable and comparable clinical outcomes in patients with high-risk factors for ACL graft failure, such as increased tibial slope or meniscal injury. Our results suggest that the indications for ALL reconstruction may be expanded to include patients with a high tibial slope or meniscal injury, because these factors have been shown to contribute to increased rotational instability and high rates of ACL graft failure. Future prospective randomized controlled trials with large patient cohorts and long follow-up periods are needed to validate these findings and establish clear guidelines for patient selection and surgical decision-making.Level of evidenceLevel 3.

Patient Perception of Allograft Versus Autograft in ACL Reconstruction Using a Validated Online Survey Marketplace.

Little is known regarding the opinions of the general population on anterior cruciate ligament (ACL) graft options. To evaluate the general population's perception of the use of allografts versus autografts in ACL reconstruction using a previously validated online marketplace platform. A prospective 34-question survey was distributed via the online marketplace. After collecting baseline demographics, participant preferences for ACL reconstruction with an allograft or autograft were established. All respondents completed a preeducation survey, reviewed an evidence-based education sheet, and completed a posteducation survey to assess their understanding. Upon completion, participants were asked which graft they would prefer. Participants were then asked if they would be willing to change their preference based on surgeon recommendation. Finally, participants were asked to rank the factors from the education sheet that were most influential. Cross-sectional study. There were 491 participants that completed the survey (mean age, 39.9 years [range, 19-72 years]; 244 male, 241 female, and 6 nonbinary/third-gender participants). Before reading the education sheet, 276 (56%) reported no graft preferences, 146 (30%) preferred autograft, and 69 (14%) preferred allograft. After reading the provided sheet, 226 (46%) participants preferred autograft, 185 (38%) preferred allograft, and 80 (16%) had no preference. The mean score on the preeducation test was 45%, and the mean score on the posteducation test was significantly greater (61%; P < .01). Overall, 345 participants (83.9%) stated they would change their preference for autograft or allograft if their surgeon recommended it. Surgeon preference (n = 330; 67%), educational information provided (n = 117; 24%), and previous knowledge (n = 44; 9%) were the most important factors for making graft selections. The mean ages of the participants selecting each graft type before and after education were as follows: allograft (37.8 ± 10.1 vs 40.6 ± 11.8 years; P = .05), autograft (38 ± 11.5 vs 39.5 ± 10.1 years; P = .21), and no preference (41.5 ± 11.2 vs 39.4 ± 11.8 years; P = .16). Education resulted in a greater number of individuals' reporting a preference in graft type (either allograft or autograft) compared with preinformation questioning. In addition, 83.9% of the participants were willing to switch their graft choice if recommended by their surgeon.

Ligament augmentation and reconstruction system (LARS) synthetic grafts are safe and effective for medial collateral ligament and posterolateral corner reconstructions in elite athletes.

This study documents the efficacy and safety of using a Ligament Augmentation and Reconstruction System (LARS) ligament graft to augment extra-articular knee ligament reconstructions in elite athletes by reporting return-to-play(RTP) rates and levels, career longevityand complications. A consecutive series of all extra-articular knee ligament reconstructions augmented by LARS ligaments in elite athletes undertaken by three specialist sports knee surgeons between 2013 and 2020 were reviewed. Seventy-six elite athletes, aged over 16 years old, and more than 2 years postsurgery were included. RTPwas defined as competing at professional levelor national/international level in amateur sport. There were 64 medial collateral ligament (MCL) and 12 posterolateral corner (PLC) reconstructions. Fifty-two (68.4%) underwent concomitant autograft cruciate ligament(s) reconstruction. The mean age was 25.1 years (SD ± 4.5). Most were football (35, 46.1%) or rugby players (35, 46.1%). Sixty-seven athletes (88.2%) RTP with 65 (97.0%) of these playing at the same or higher Tegner level. Fifty-six (83.6%) of the athletes that RTP were still playing at 2 years postsurgery. Twenty (57.1%) of those who had RTP and were more than 5 years postsurgery were still playing at 5 years. Six (7.9%) players required further surgery relating to the LARS/metalwork. One case had soft tissue inflammation adjacent to the proximal end of the synthetic graft, but it is unknown if this was mechanical irritation or a biological reaction. One MCL reruptured 4 years after RTP. Utilising LARS to augment extra-articular knee ligament reconstructions allows 88.2% of athletes with a variety of knee ligament injuries to return to elite sport. The low morbidity rates coupled with 57% of athletes still playing 5 years postsurgery demonstrates that the LARS is safe and effective in these cases. Although there are reports of LARS ligaments being used in MCL and PLC reconstructions, there is very little evidence investigating if they are safe and effective. This study demonstrates that LARS synthetic grafts can be safely used for MCL and PLC reconstructions in elite athletes and they permit a high RTP with a low risk of complications. Level IV.

Four-year comparative analysis of return to sport and psychological recovery following ACL revision: Artificial ligament vs. anterior tibial tendon allograft

BackgroundResearch on return to sport and psychological recovery in anterior cruciate ligament (ACL) revision remains scarce. The clinical efficacy of artificial ligament in ACL revision requires further exploration. Our objectives were (1) to compare the midterm clinical outcomes of artificial ligament versus allogenic tendon graft in ACL revision and (2) to analyze the effects of employing artificial ligament on return to sport and psychological recovery in ACL revision. MethodsThis cohort study included the cases receiving ACL revision from 2014 to 2021 in Sports Medicine Department of Huashan Hospital. The grafts used were Ligament Advanced Reinforcement System (LARS) and ATT allograft. We recorded patients' baseline data. The final follow-up assessment included subjective scales, physical examination, and return to sport status. We recorded the rates and timings of return to sport. Subjective scales included the 2000 International Knee Documentation Committee (IKDC) subjective score, Lysholm Knee Scaling Score (LKSS), Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner activity score, Marx activity rating score, and Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI). Anterior knee stability was assessed using the KT-1000 arthrometer. ResultsFifty cases (LARS group: 27; ATT group: 23) enrolled and 45 (LARS group: 23; ATT group: 22) completed evaluations with a median follow-up period of 49 months. At recent follow-up, LARS group outperformed in knee stability (1.0 ± 1.9 mm vs. 2.6 ± 3.0 mm, P = 0.039), confidence (86.7 ± 12.4 vs. 69.4 ± 18.6, P < 0.001), emotion (82.7 ± 11.3 vs. 70.7 ± 16.2, P < 0.001), KOOS knee function (78.7 ± 8.8 vs. 69.5 ± 11.0, P = 0.003), quality of life (79.1 ± 16.1 vs. 66.4 ± 19.5, P = 0.014), Tegner score (6.3 ± 1.9 vs. 5.2 ± 2.1, P < 0.001), and Marx activity score (10.7 ± 3.7 vs. 7.9 ± 4.0, P = 0.012). The LARS group had significantly higher return rates: recreational (91.3 % vs. 63.6 %, P = 0.026), knee cutting and pivoting (87.0 % vs. 59.1 %, P = 0.035), competitive (78.3 % vs. 45.5 %, P = 0.023), and pre-injury (56.5 % vs. 27.3 %, P = 0.047). For return timings, the LARS group was earlier at recreational (11.2 ± 3.9 vs. 27.8 ± 9.0 weeks, P < 0.001), knee cutting and pivoting (17.2 ± 5.8 vs. 35.6 ± 13.8 weeks, P < 0.001), competitive (24.8 ± 16.2 vs. 53.2 ± 22.0 weeks, P < 0.001), and pre-injury levels (32.8 ± 11.0 vs. 72.8 ± 16.9 weeks, P < 0.001). ConclusionIn ACL revision, using LARS demonstrated improved joint stability and functionality compared to using allogenic ATT four years postoperative. Patients accepting the LARS procedure exhibited higher rates and earlier timings of return to various levels of sport, indicating enhanced confidence and emotional resilience. The translational potential of this articleIn ACL revision, the choice of artificial ligament to shorten recovery time, thereby enabling patients to return to sport more quickly and effectively, is thought-provoking. The research value extends beyond mere graft selection, guiding future clinical trials and studies. This research enhances our understanding of the application value of artificial ligament in ACL revision, emphasizing the importance of psychological recovery and updating our perceptions of return to sport levels post-revision. It stimulates exploration into personalized rehabilitation programs and treatment strategies, aiming to optimize clinical outcomes and meet the real-world needs of patients with failed ACL reconstruction.

Exploratory Anterior Cruciate Ligament Graft Stress during Medial Knee Rotation with and without Iliotibial Band–Intermuscular Septum Lateral Extra-Articular Tenodesis for Transtibial and Anteromedial Femoral Tunnels

Exploratory Anterior Cruciate Ligament Graft Stress during Medial Knee Rotation with and without Iliotibial Band–Intermuscular Septum Lateral Extra-Articular Tenodesis for Transtibial and Anteromedial Femoral Tunnels

Biomechanical and Histological Study of Retrieved LARS Synthetic Ligaments

Background: Synthetic grafts have been used for a number of years in anterior cruciate ligament (ACL) reconstruction surgery. One of the more recent additions to the stable of synthetic ligaments is the Ligament Augmentation and Reconstruction System (LARS) ligament. Purpose: To analyze the biomechanics and histology of LARS grafts retrieved due to failure of the device. Study Design: Descriptive laboratory study. Methods: A total of 22 LARS ligament grafts that were explanted from patients were sent for analysis. Five new, unused samples of the standard LARS ACL graft were also analyzed. Biomechanical testing was performed: ultimate tensile force, force versus displacement, and stress versus strain were recorded. Histopathological examination was performed looking for degree of fibrous tissue ingrowth as well as the presence of a foreign body reaction. Results: Of the 22 grafts retrieved, 14 were used for ACL grafts, 1 for a lateral collateral ligament graft, 2 for medial collateral ligament grafts, 4 for gluteal tendon augmentation, and 1 for a supraspinatus augmentation. A severe foreign body reaction was found in 86% of the grafts (18/22) and a mild foreign body reaction in the remaining 14% (4/22). Tissue ingrowth was minimal in the majority of ACL grafts; the other grafts showed moderate tissue ingrowth. Maximal tensile force was significantly higher for the new ACL grafts (mean ± SD, 1667 ± 845 N) compared with the retrieved grafts (897 ± 395 N; P < .05). Conclusion: This study demonstrated that the vast majority of retrieved LARS artificial ligaments had a florid foreign body reaction. There was minimal tissue ingrowth in ACL grafts and moderate ingrowth in other grafts. Retrieved grafts had a decreased ultimate tensile force, which increased their risk of rupture. Clinical Relevance: Surgeons should be cautious in choosing to use these grafts in reconstructive surgery for patients.

A novel surgical technique for revision anterior cruciate ligament reconstruction using an isolated rectus femoris tendon autograft.

Only a few anatomic studies have described an isolated rectus femoris tendon autograft for anterior cruciate ligament (ACL) reconstruction. This study aims to demonstrate a new surgical technique utilising the rectus femoris tendon for ACL reconstruction. This study hypothesises that the rectus tendon autograft will yield satisfying postoperative outcomes in terms of stability, with minimal complications at the harvest site. This retrospective study investigated the outcomes of 28 revision ACL reconstructions using a rectus tendon autograft with a mean follow-up of 41.7 (range, 24.0-64.8) months. A 3cm longitudinal incision was used to harvest the rectus tendon with an open tendon stripper. Intraoperative collected data included the length of the tendon and thickness of a 4-fold graft. Further outcome parameters include anterior cruciate ligament stability and range of motion. Additionally, postoperative complications, especially donor site morbidity, were documented in type and frequency. The mean tendon length measured 32.4cm (range, 30-35cm). After preparing a 4-fold graft, the mean diameter was 9.2mm (range, 8.0-10mm) at the tibial and 9.0mm (range, 7.5-10mm) at the femoral end. Stability evaluated by the Lachman test improved significantly from 2 (Interquartile range (IQR), 2-3) preoperatively to 0 (IQR, 0-1) postoperatively (p < .001). Rerupture of the anterior cruciate ligament graft was observed in 2 patients (7.1%). Four patients showed a persistent extension deficit of about 5 degrees postoperatively. Two of them underwent revision surgery due to a Cyclops lesion. Only one patient complained of prolonged pain at the harvest site (3.6%). The 4-fold rectus tendon represents a novel autograft technique in revision ACL reconstruction. This study provides evidence of appropriate graft dimensions and satisfying postoperative outcomes regarding stability. The technique is associated with a low complication rate at the harvest site. Case series; Level of evidence, IV.

The Efficacy of Anterior Cruciate Ligament Reconstruction with Peroneus Longus Tendon and its Impact on Ankle Joint Function.

Peroneus Longus Tendon (PLT), a viable anterior cruciate ligament (ACL) graft, shares similar biomechanics, making it suitable for reconstruction. Controversy exists over whether PLT transplants affects the donor ankle joint. The purpose of this study was to examine the recovery of knee joint function following arthroscopic ACL restoration using autologous PLT and its influence on the donor ankle joint. A retrospective analysis was conducted on 65 patients with ACL rupture who underwent PLT graft reconstruction in our hospital from January 2016 to December 2021. A three-dimensional gait analysis of the bilateral knee and ankle joints was performed postoperatively using an Opti_Knee three-dimensional motion measurement and analysis system-Yidong Medical Infrared Motion Gait Analyzer. Knee function scores and changes in the range of motion of the bilateral knee and ankle joints were collected. The analysis of preoperative and postoperative joint function scores, bilateral knee and ankle mobility was performed by t-tests. One year after surgery, the patients' International Knee Documentation Committee (IKDC) scores, Knee Injury and Osteoarthritis Outcome Scores (KOOSs), and Lysholm scores were significantly improved compared to preoperative scores, with statistically significant differences (p < 0.05). There was no statistical difference in the American Orthopedic Foot and Ankle Society (AOFAS) score of the donor ankle joint before and after surgery (p > 0.05). During different gait cycles, there was no statistical difference in knee joint mobility between the affected and healthy sides (p > 0.05), but there was a statistical difference in the inversion and eversion angle of the donor ankle joint during the support phase (p < 0.05). ACL reconstruction using the PLT can yield satisfactory knee joint function. However, it does affect inversion and eversion in the donor ankle joint, necessitating postoperative exercises. Similar subjective function ratings for both operated and non-operated feet, despite increased inversion-eversion motion in the operated foot, may be influenced by the subjective nature and margin of error in the AOFAS Ankle-hindfoot score, along with the relatively small variation in ankle inversion-eversion angles.

Vitrification cryopreservation of ligaments based on zwitterionic betaine

Ligament cryopreservation enables a prolonged shelf life of allogeneic ligament grafts, which is fundamentally important to ligament reconstruction. However, conventional cryopreservation techniques fail to eliminate the damage caused by ice crystal growth and the toxicity of cryopreservation agents (CPAs). Here, we report a novel CPA vitrification formulation primarily composed of betaine for ligament cryopreservation. Comprehensive optimization was conducted on the methods for vitrification and rewarming, as well as the loading and unloading conditions, based on the critical cooling rate (CCR), critical warming rate (CWR), and permeation properties of the cryoprotectant. Using biomechanical and histological level tests, we demonstrate the superior performance of our method in ligament cryopreservation. After 30 days of vitrification cryopreservation, parameters such as the Young's modulus, tensile stress, denaturation temperature, and glycosaminoglycans (GAGs) content of the ligament remained essentially unchanged. This work pioneers the application of ice-free cryopreservation for ligament and holds great potential for improving the long-term storage of ligament, providing valuable insights for future technique development.

The Influence of Tibial Tubercle–Sparing Slope-Reducing Osteotomy on Patellar Height in Patients Undergoing Revision ACL Reconstruction

Background: A posterior tibial slope (PTS) >12° is an independent risk factor for anterior cruciate ligament (ACL) graft rupture, and a high tibial osteotomy (HTO) for slope correction can help avoid it. Management of patellar height is of major concern when performing HTO. Purpose: To evaluate the effect of tibial tubercle–sparing anterior closing-wedge osteotomy on patellar height in revision ACL reconstruction (ACLR). Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent arthroscopic revision ACLR combined with retro–tibial tubercle anterior closing-wedge HTO (ACW-HTO) between January 1, 2016, and March 31, 2021, were assessed for eligibility. Patellar height was measured on full weightbearing lateral radiographs according to the Insall-Salvati index (ISI) and Caton-Deschamps index (CDI) or frontal radiographs using the femoral patellar height index. The PTS was evaluated using the proximal anatomic axis of the tibia on standard short lateral radiographs. The delta (postoperative – preoperative) and the ratio (preoperative/postoperative) of the 3 patellar height indices and PTS were calculated. Preoperative and postoperative patellar heights were compared using independent t tests for each index. Also investigated was whether patients changed patellar height category (baja, normal, or alta) after slope osteotomy. Results: Among 475 revision ACLRs, 47 tibial tubercle–sparing ACW-HTOs were retained for analysis. No significant difference in patellar height was found between pre- and postoperative radiographs regardless of the index (preoperative – postoperative) (ISI: 1.0 ± 0.2 – 0.9 ± 0.2, P = .1729; CDI: 1.0 ± 0.2 – 1.0 ± 0.2, P = .4034; femoral patellar height index: 1.5 ± 0.2 – 1.5 ± 0.2; P = .5130). Fifteen patients (31.9%) exhibited a postoperative change in their patellar height category when measured by the ISI (6 moved up a category, 9 moved down one), and 18 patients (38.3%) changed category according to the CDI (10 moved up a category, 8 moved down one). No significant difference was found between pre- and postoperative patellar height among these patients (ISI: P = .2418; CDI: P = .3005). Conclusion: Changes in patellar height ratio are common after tibial tubercle–sparing ACW-HTO in patients undergoing revision ACLR. The clinical effect of these changes is unknown, and further study is needed to investigate whether they may result in patellofemoral symptoms.

The terror of athletes - Anterior Cruciate Ligament Reconstruction, grafts and moden techniques

Introduction&#x0D; The anterior cruciate ligament (ACL) is a prevalent sports-related injury, constituting nearly half of knee injuries. This narrative review explores the evolution of ACL reconstruction surgeries, emphasizing graft types and their pros and cons.&#x0D; Current state of knowledgeThe ideal ACL graft choice depends on factors like age, lifestyle, and demands. Autografts are the current standard, with the Quadriceps Tendon graft offering similar outcomes and fewer complications. Allografts are a secondary option for older, low-demand patients due to a shorter recovery period. Artificial grafts have limited use, lacking strong evidence for clinical advantages but may be considered for suturing torn ACL stumps and in cases were quick recovery is essential.&#x0D; Summary&#x0D; Contemporary orthopedic practitioners must possess comprehensive knowledge of various ACL reconstruction graft types to tailor interventions precisely to individual patient requirements. The selection of a graft should be rooted in a profound comprehension of patients' lifestyles, medical histories, and specific demands, thereby mitigating the subjective impact of any associated limitations for the patient.