Primary Reconstruction Research Articles

No increased complication rate with the use of soft tissue quadriceps tendon autograft for primary ACL reconstruction – a systematic review

BackgroundThe autograft of choice for anterior cruciate ligament reconstruction (ACLR) remains debateable. Recently there has been increased popularity of soft tissue quadriceps tendon (s-QT) autograft due to less donor site morbidity, reduced anterior knee pain and comparable re-operation and complication rates. The aim of this review was to analyse functional outcomes of primary ACLR using s-QT in adult population without the bone plug and to report its complication profile against other autografts. Patient and methodsThis systematic review was performed in accordance with PRISMA guidelines and a review of literature was conducted on four online databases (Medline, EMBASE, Cochrane and Google Scholar). Clinical studies reporting on patients undergoing primary ACLR with s-QT autograft or in comparison to BPTB or HS autografts with a minimum of 6 months follow-up were included. The studies were inclusive of only all soft tissue QT autograft regardless of the implants or fixation method used. Critical appraisal of studies was conducted using the Methodological Index for Non-Randomized Studies (MINORS) tool. ResultsFourteen studies were eligible. There were three randomised control studies (RCT) and 11 non-randomised comparative studies with 1543 patients who underwent ACLR. 682 underwent s-QT, 498 had hamstring tendon (HT) and 174 had bone-patellar tendon-bone (BPTB). 60% (n = 930) were males and mean follow up was 23.6 months (6–65). Eight studies reported post-operative patient reported outcome measures (PROMs). The mean International Knee Documentation Committee (IKDC) score was 91.5 ± 15.1 whereas mean Lysholm score was 90 ± 3.9. Five studies reported on laxity with mean anterior tibial translation (ATT) of 1.28 ± 1.09 mm. Overall complication rate of s-QT ACLR was 6% with 3% graft failure, 0.52% arthrofibrosis, 0.2% infection, 0.75% revision ACLR. There was no significant difference in functional outcome scores, knee stability and range of motion (ROM) between s-QT, HT and BPTB. Conclusions-QT for ACLR has a comparable functional outcome, laxity, failure and with overall graft failure rate of 3%. Level of evidenceIII; Systematic review and meta-analysis.

Temporal changes in tibiofemoral relationship following anterior cruciate ligament injury: Implications for rotational dynamics and clinical outcomes.

This study aims to elucidate changes in the tibiofemoral relationship over time following anterior cruciate ligament (ACL) injury, and investigate the correlation between the tibiofemoral relationship and patient-related outcome measures (PROMs). Overall, 203 primary ACL reconstructions were performed using autologous hamstring grafts. Medial and lateral anterior tibial translation (ATT) in the sagittal plane and tibial tubercle-trochlear groove (TT-TG) distance in the axial plane were measured using pre-operative magnetic resonance imaging and post-operative computed tomography. The difference between pre-operative and post-operative values for each parameter was calculated: ΔMesdial ATT, ΔLateral ATT and ΔTT-TG distance. The correlation between each calculated value and the time elapsed since ACL injury, and the correlation between each calculated value and PROMs-evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS)-were assessed. Sixty-four patients were enroled. Medial ATT, lateral ATT and TT-TG distance were significantly different pre-operatively compared to post-operative values, with the tibia translating anteriorly and rotating internally relative to the femur. ΔMedial ATT, ΔLateral ATT and ΔTT-TG distance were 1.6, 8.8 and -4.8 mm, respectively. A negative correlation was observed between the ΔTT-TG distance and the time elapsed since the injury (r = -0.44, p < 0.01). No correlation was found between ΔMedial ATT and the time elapsed since the injury, nor between ΔLateral ATT and the time elapsed since the injury. Neither the ΔMedial ATT, ΔLateral ATT, nor ΔTT-TG distance correlated with the pre-operative or post-operative KOOS subscale scores. The tibia underwent internal rotation relative to the femur over time following ACL injury, highlighting the importance of assessing rotational changes in ACL-injured knees. Level Ⅲ.

Younger age, hyperextended knee, concomitant meniscectomy and large prerevision anterior tibial translation are associated with graft failure after the revision anterior cruciate ligament reconstruction.

Graft failure following revision anterior cruciate ligament (ACL) reconstruction is higher than after primary ACL reconstruction. However, data regarding revision surgery is scarce. We aimed to evaluate the associated factors for failure after revision ACL reconstruction. Fifty-four patients (mean age: 24.7 ± 10.0 years) who underwent revision ACL reconstruction at our hospital with ≥1 year follow-up were retrospectively examined. Patients were divided into Group F (graft failure) and Group N (no graft failure) groups. Univariate analysis was conducted to identify factors associated with graft failure. Receiver operating characteristic (ROC) curve analysis was performed to determine the optimal thresholds for differentiating between the two groups. Graft failure was observed in 7 of 54 patients (13.0%). In the univariate analysis, significant differences were observed for age at the initial surgery (Group F: 15.6 ± 1.5, Group N: 20.9 ± 8.1), age at the revision surgery (Group F: 18.0 ± 2.8, Group N: 25.7 ± 10.3), presence of hyperextended knee (Group F: 85.7%, Group N: 14.9%), concomitant meniscectomy (Group F: 42.9%, Group N: 14.9%), prerevision space for the ACL (sACL) (Group F: 7.2 ± 3.4 mm, Group N: 13.4 ± 4.7 mm) and preoperative anterior tibial translation (ATT) (Group F: 5.0 ± 1.4 mm, Group N: 2.7 ± 3.1 m). ROC analysis of preoperative sACL and preoperative ATT on one-leg standing plain radiograph showed that cutoff values of 6.9 and 4.2 mm were the optimal thresholds, respectively. Younger patients with a hyperextended knee, concomitant meniscectomy, small sACL and large ATT before revision ACL reconstruction are predisposed to graft failure. Level IV.

Effect of Sampling Rate, Filtering, and Torque Onset Detection on Quadriceps Rate of Torque Development and Torque Steadiness.

Quadriceps rate of torque development (RTD) and torque steadiness are valuable metrics for assessing explosive strength and the ability to control force over a sustained period of time, which can inform clinical assessments of knee function. Despite their widespread use, there is a significant gap in standardized methodology for measuring these metrics, which limits their utility in comparing outcomes across different studies and populations. To address these gaps, we evaluated the influence of sampling rates, signal filtering, and torque onset detection on RTD and torque steadiness. Twenty-seven participants with a history of a primary anterior cruciate ligament reconstruction (N = 27 (11 male/16 female), age = 23 ± 8 years, body mass index = 26 ± 4 kg/m2) and thirty-two control participants (N = 32 (13 male/19 female), age = 23 ± 7 years, body mass index = 23 ± 3 kg/m2) underwent isometric quadriceps strength testing, with data collected at 2222 Hz on an isokinetic dynamometer. The torque-time signal was downsampled to approximately 100 and 1000 Hz and processed using a low-pass, zero-lag Butterworth filter with a range of cutoff frequencies spanning 10-200 Hz. The thresholds used to detect torque onset were defined as 0.1 Nm, 1 Nm, and 5 Nm. RTD between 0 and 100 ms, 0 and 200 ms, and 40-160 ms was computed, as well as absolute and relative torque steadiness. Relative differences were computed by comparing all outcomes to the "gold standard" values computed, with a sampling rate of 2222 Hz, a cutoff frequency in the low-pass filter of 150 Hz, and torque onset of 1 Nm, and compared utilizing linear mixed models. While all combinations of signal collection and processing parameters reached statistical significance (p < 0.05), these differences were consistent between injured and control limbs. Additionally, clinically relevant differences (+/-10%) were primarily observed through torque onset detection methods and primarily affected RTD between 0 and 100 ms. Although measurements of RTD and torque steadiness were generally robust against diverse signal collection and processing parameters, the selection of torque onset should be carefully considered, especially in early RTD assessments that have shorter time epochs.

Relationship between hamstring strength and hop performance at 8 and 12 months after ACL reconstruction with hamstring tendon autografts

BackgroundThe relationship between hamstring strength and hop performance after anterior cruciate ligament (ACL) reconstruction with hamstring tendon (HT) autografts has not been well elucidated. The aim was to investigate the relationship between eccentric hamstring strength, assessed with the NordBord, and concentric hamstring strength, assessed with the Biodex, with hop performance at 8 and 12 months after ACL reconstruction.MethodsRegistry study. Patients ≥ 16 years who had undergone primary ACL reconstruction with HT autograft, followed by muscle strength and hop tests at 8 and 12 months were included. Correlations of the relative hamstring strength (Nm/kg or N/kg) and limb symmetry index (LSI) with hop performance were analyzed. Pearson’s correlation coefficient, and coefficient of determination (r2) were used for statistical analysis.ResultsA total of 90 patients were included, of which 48 (53%) were women. The mean age at ACL reconstruction was 27.0 ± 8.0 years. Relative hamstring strength had significant positive correlations with hop performance, ranging from r = 0.25–0.66, whereas hamstring strength LSI had significant positive correlations which ranged from r = 0.22–0.37 at 8 and 12 months after ACL reconstruction. At 12 months, the relative hamstring strength in the Biodex explained 32.5–43.6% of the hop performance in vertical hop height, hop for distance relative to height, and the total number of side hops, whereas the relative hamstring strength in the NordBord explained 15.2–23.0% of the hop performance.ConclusionThe relative hamstring strength in the Biodex test explained 32.5–43.6% of the hop performance, whereas the relative hamstring strength in the NordBord explained 15.2–23.0%. Thus, our findings suggest that relative hamstring strength, especially in the hip-flexed position may be a better indicator of hop performance at 8 and 12 months after ACL reconstruction in patients treated with HT autograft.

Acute and post-acute soft tissue reconstruction

The precise analysis of the injured structures requiring reconstruction in complex wound defects is aprerequisite for successful restoration. The fundamental reconstructive strategies for soft tissue defects of the extremities including injuries to vessels, nerves and burn wounds in the context of the acute and post-acute trauma phases are presented. The different phases of soft tissue reconstruction are described. Recommendations for action with respect to the reconstruction of the functional structures are described. Two clinical case examples illustrate the approach. The acute reconstruction phase is defined as the period 0-72 h after the traumatic event and includes surgical debridement, primary reconstruction of nerves and vessels using interpositional grafts if necessary and temporary soft tissue reconstruction. Combined thermomechanical trauma requires early debridement combined with internal fixation of open fractures. In the post-acute reconstruction phase, which is generally defined as aperiod of up to 6weeks after the traumatic event, definitive soft tissue reconstruction is performed. In the case of long reinnervation distances, nerve transfer or motor replacement plastic surgery is performed in the post-acute phase. The reconstruction of soft tissue after trauma necessitates a stage-dependent approach. In the acute phase procedures aim at the immediate preservation of the limb. In the post-acute phase, definitive soft tissue reconstruction is performed to enable maximum functional preservation. Combined thermomechanical injuries require early surgical treatment in order to prevent infections.

Functional inferior canalicular reconstruction using a monocanalicular probe after tumor resection of the medial third of the lower eyelid

Purpose: To describe a surgical technique for functionally reconstructing a lacrimal drainage duct and to assess its long-term functionality.Methods: This observational review includes six cases involving reconstruction of the inferior canaliculus after surgical resection of lower eyelid carcinoma. Following lesion excision with safety margins, the epithelium of the distal portion of the inferior canaliculus is located and intubated with a monocanalicular probe. Subsequently, the eyelid lamellae are reconstructed without displacing the probe. The Monoka collarette is then sutured using a 10/0 nylon suture. Data collection included anatomic pathology of the lesion and data from ophthalmic examinations at each visit (including epiphora, inferior canalicular irrigation, and fluorescein dye disappearance test (FDDT)), as well as stent extrusion or other complications.Results: No complications were observed during the surgeries. The stents remained in place for an average of 4 months, with no extrusions prior to removal. The mean follow-up period was 4.8 years (SD=2.0), during which no other complications were noted. Only one patient experienced intermittent epiphora, also present in the fellow eye. At the final visit, FDDT was normal in all eyes, and all patients demonstrated patency of the inferior canaliculus upon irrigation.Conclusion: Primary reconstruction of an inferior lacrimal drainage duct following tumor resection can be successfully performed, resulting in favorable functional recovery.

Quadriceps Tendon Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: 3-Year Clinical and Patient-Reported Outcomes.

The rate of anterior cruciate ligament (ACL) rupture in active, skeletally immature patients is increasing. Although hamstring tendon autograft (HTA) was previously deemed the gold standard, recent studies have shown HTA to have a high failure rate in this high-risk population of young competitive athletes, and quadriceps tendon autograft (QTA) has yielded excellent preliminary outcomes in some studies examining this population. To evaluate 3-year clinical and patient-reported functional outcomes of primary ACL reconstruction (ACLR) with soft tissue QTA in skeletally immature patients. Case series; Level of evidence, 4. Skeletally immature patients who underwent ACLR with a full-thickness soft tissue QTA were included. Preoperative patient and surgical data were collected. The ACLR technique was selected predicated upon skeletal age and included all-epiphyseal and complete transphyseal techniques. Patients were followed for a minimum of 2 years with successive clinical visits or were contacted via telephone. Patients who did not have minimum 2-year follow-up after 3 contact attempts via telephone were excluded. Information regarding return to sports (RTS) and concomitant or subsequent surgical procedures was collected. Pediatric International Knee Documentation Committee (Pedi-IKDC), Hospital for Special Surgery Functional Activity Brief Scale (HSS Pedi-FABS), and Single Assessment Numeric Evaluation (SANE) scores were collected. Of 85 adolescent patients aged 11.1 to 17.6 years (mean age, 14.1 ± 1.2 years), 2 patients were determined to be lost to follow-up after 3 failed contact attempts. Of the patients included in this study (N = 83), 26 patients (31%) underwent all-epiphyseal and 57 patients (69%) underwent complete transphyseal ACLR. Additionally, 48 patients (58%) underwent concomitant lateral extra-articular tenodesis using the iliotibial band with a modified Lemaire technique. The mean follow-up time was 3.7 ± 1.2 years (range, 2-7 years). Twenty (24%) patients had subsequent surgical procedures, of which 3 (4%) were due to graft failures. At a mean 3-year follow-up, the mean Pedi-IKDC, HSS Pedi-FABS, and SANE scores were 90, 23, and 94 respectively; the RTS rate was 100%; and the rate of RTS at the previous level of performance was 93%. Use of a soft tissue QTA for ALCR in a high-risk skeletally immature population of athletes resulted in excellent postoperative outcomes with low rates of graft failure and high return to sport rates.

Athletes’ perspectives on return to sport after anterior cruciate ligament reconstruction and their strategies to reduce reinjury risk: a qualitative interview study

BackgroundInsights derived from athletes who have completed the final phase of rehabilitation and successfully returned to their respective sports after anterior cruciate ligament (ACL) reconstruction could potentially contribute to the enhancement of therapeutic strategies. Therefore, the aim of this study was to explore athletes’ experiences, thoughts, and behaviours of final phase rehabilitation and return to sport after ACL reconstruction and to describe their thoughts about the risk of reinjury.MethodsThis qualitative interview study included individual semi-structured interviews with 15 athletes after ACL reconstruction. All athletes were aged between 15 and 35 years (median, 23 years), had returned to their preinjury contact sport at elite or recreational competitive level, rehabilitated with different physioterapists (working in hospital, primary care or sport clinics), and had undergone primary ACL reconstruction between 14 and 59 months (median, 23 months) before the interviews. Data were analysed using qualitative content analysis.ResultsAnalysis of the data resulted in the following 4 main categories related to athletes’ experiences of the return to sport process and their thoughts about the risk of reinjury: Athletes’ strategies for safe return to sport; Support during rehabilitation and return to sport; The rehabilitation journey was worthwhile to be able to play again; and Reinjury is beyond one’s control.ConclusionsAthletes described strategies for a safe return to sport after ACL reconstruction, emphasizing continuous increased load, not forcing return to sport, injury prevention exercises, and seeking support from professionals and coaches. Despite loving their sport, the athletes had mixed feelings about undergoing additional rehabilitation if reinjured. The athletes recognized the high reinjury risk, attributing it to fate. These findings enhance understanding of athletes’ return to sport experiences after ACL reconstruction, their strategies to minimize reinjury risk, which might help optimizing care for this patient group.

Secondary Meniscectomy Rates and Risk Factors for Failed Repair of Ramp Lesions Performed at the Time of Primary ACL Reconstruction: An Analysis of 1037 Patients From the SANTI Study Group

Background: Studies evaluating secondary meniscectomy rates and risk factors for failure of ramp repair are sparse and limited by small numbers and heterogeneity. Purposes/Hypothesis: The purposes were to determine the secondary meniscectomy rate for failure of ramp repair performed using a posteromedial portal suture hook at the time of anterior cruciate ligament reconstruction (ACLR) and to identify risk factors for secondary meniscectomy. It was hypothesized that patients who underwent ACLR combined with a lateral extra-articular procedure (LEAP) would experience significantly lower rates of secondary meniscectomy compared with those undergoing isolated ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: Patients undergoing primary ACLR and ramp repair between 2013 and 2020 were included in the study. Final follow-up for each patient was defined by his or her last appointment recorded in a prospective database (with a study end date of March 2023). The database and medical records were used to determine whether patients had undergone secondary meniscectomy for failure of ramp repair. Survivorship of ramp repair (using secondary meniscectomy as an endpoint) was determined using the Kaplan-Meier method. Multivariate analysis was used to investigate possible risk factors. Results: A total of 1037 patients were included in the study. The secondary meniscectomy rate after ramp repair was 7.7% at a mean final follow-up of 72.4 months. Patients without combined ACLR + LEAP were >2-fold more likely to undergo a secondary medial meniscectomy compared with those with combined ACLR + LEAP (hazard ratio, 2.455; 95% CI, 1.457-4.135; P = .0007). Age, sex, preoperative Tegner score, and time between injury and surgery were not significant risk factors for failure. Conclusion: The rate of secondary meniscectomy after ramp repair performed through a posteromedial portal at the time of primary ACLR was low. Patients who underwent isolated ACLR (rather than ACLR + LEAP) were >2-fold more likely to undergo a secondary medial meniscectomy for failure of ramp repair. Additional risk factors for failure of ramp repair were not identified.

Reduced preoperative serum choline esterase levels and fecal peritoneal contamination as potential predictors for the leakage of intestinal sutures after source control in secondary peritonitis

BackgroundThe high rate of stoma placement during emergency laparotomy for secondary peritonitis is a paradigm in need of change in the current fast-track surgical setting. Despite growing evidence for the feasibility of primary bowel reconstruction in a peritonitic environment, little data substantiate a surgeons’ choice between a stoma and an anastomosis. The aim of this retrospective analysis is to identify pre- and intraoperative parameters that predict the leakage risk for enteric sutures placed during source control surgery (SCS) for secondary peritonitis.MethodsBetween January 2014 and December 2020, 497 patients underwent SCS for secondary peritonitis, of whom 187 received a primary reconstruction of the lower gastro-intestinal tract without a diverting stoma. In 47 (25.1%) patients postoperative leakage of the enteric sutures was directly confirmed during revision surgery or by computed tomography. Quantifiable predictors of intestinal suture outcome were detected by multivariate analysis.ResultsLength of intensive care, in-hospital mortality and failure of release to the initial home environment were significantly higher in patients with enteric suture leakage following SCS compared to patients with intact anastomoses (p < 0.0001, p = 0.0026 and p =0.0009, respectively). Reduced serum choline esterase (sCHE) levels and a high extent of peritonitis were identified as independent risk factors for insufficiency of enteric sutures placed during emergency laparotomy.ConclusionsA preoperative sCHE < 4.5 kU/L and generalized fecal peritonitis associate with a significantly higher incidence of enteric suture insufficiency after primary reconstruction of the lower gastro-intestinal tract in a peritonitic abdomen. These parameters may guide surgeons when choosing the optimal surgical procedure in the emergency setting.

A comparative study on quality of life of patients with breast cancer receiving subcutaneous gland resection combined with primary prosthesis implantation: Minimally invasive versus open surgery.

e12597 Background: Subcutaneous gland resection of the breast combined with primary prosthesis reconstruction is mostly used for reconstruction of early breast cancer (EBC) patients. In this study, we compared the long-term quality of life (QOL) of patients who underwent these procedures in a minimally invasive or open approach. Methods: The baseline data of EBC patients who underwent subcutaneous gland resection of breast combined with primary prosthesis reconstruction in a minimally invasive or open approach from 2008 to 2020 were retrospectively analyzed. The patients receiving minimally invasive surgery were regarded as minimally invasive group, and open surgery were regarded as open group. The BREAST-Q questionnaires were used to evaluate patients’ satisfaction with breasts, implants, animation deformity, psychosocial well-being, sexual well-being, physical well-being (chest) and breast sensation. Results: A total of 546 patients were enrolled, patients with local and regional recurrence, distant metastasis, death and prosthesis (44, 44, 22,12, respectively) were excluded, 423 patients were given questionnaires to evaluate their quality of life. Totally 226 questionnaires were recovered, with a response rate of 53.43%. Except 5 questionnaires with incomplete answers, 221 questionnaires were finally valid. There were 105 cases in the minimally invasive group, with an average follow-up time of 107.48 months (range 39-185 months), and 115 cases in the open group, with an average follow-up time of 77.97 months (range 36-188 months). The age was 43.0 [37.0, 47.0] years in all patients, 43.0[38.0, 47.0] years in the minimally invasive group and 42.5[36.8, 47.0] years in the open group. The patients in stage T1-2 accounted for 96.19% in the minimally invasive group and 97.42% in the open group, stage N0-1 accounted for 90.48% and 93.97, respectively. Prosthetic implant size showed no significant difference between two groups (220 [180, 240] cm3 vs 200 [180, 245] cm3, p=0.083). No significant difference was observed in patients’ race, education, marital status, income, job and breast size between the two groups ( p&gt;0.05). The scores of the minimally invasive group in satisfaction with breasts (54.0 [47.0, 59.0] vs 49.0 [44.8, 55.0], p&lt;0.01), animation deformity (70.0 [59.0, 100.0] vs 62.0 [57.0, 84.0], p=0.016), psychosocial well-being (66.0 [53.0, 93.0] vs 62.0 [49.0, 83.0], p=0.027), and physical well-being(chest) (48.0 [32.0, 56.0] 42.0 vs [32.0, 52.0], p=0.038) were significantly higher compared with the open group. There was no significant difference in implants, sexual well-being and breast sensation between the two groups. Conclusions: Minimally invasive subcutaneous gland resection combined with primary prosthetic implantation may improve postoperative quality of life in patients with EBC.

Liposomal Bupivacaine Analgesia in Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Retrospective Cohort Study

Background: Liposomal bupivacaine (LB) can be used for postsurgical analgesia after breast reconstruction. We examined real-world clinical and economic benefits of LB versus bupivacaine after deep inferior epigastric perforator (DIEP) flap breast reconstruction. Methods: This retrospective cohort study used the IQVIA claims databases to identify patients undergoing primary DIEP flap breast reconstruction in 2016–2019. Patients receiving LB and those receiving bupivacaine were compared to assess opioid utilization in morphine milligram equivalents (MMEs) and healthcare resource utilization during perioperative (2 weeks before surgery to 2 weeks after discharge) and 6-month postdischarge periods. A generalized linear mixed-effects model and inverse probability of treatment weighting method were performed. Results: Weighted baseline characteristics were similar between cohorts (LB, n = 669; bupivacaine, n = 348). The LB cohort received significantly fewer mean MMEs versus the bupivacaine cohort during the perioperative (395 versus 512 MMEs; rate ratio [RR], 0.771 [95% confidence interval (CI), 0.677–0.879]; P = 0.0001), 72 hours after surgery (63 versus 140 MMEs; RR, 0.449 [95% CI, 0.347–0.581]; P &lt; 0.0001), and inpatient (154 versus 303 MMEs; RR, 0.508 [95% CI, 0.411–0.629]; P &lt; 0.0001) periods; postdischarge filled opioid prescriptions were comparable. The LB cohort was less likely to have all-cause inpatient readmission (odds ratio, 0.670 [95% CI, 0.452–0.993]; P = 0.046) and outpatient clinic/office visits (odds ratio, 0.885 [95% CI, 0.785–0.999]; P = 0.048) 3 months after discharge than the bupivacaine cohort; other all-cause healthcare resource utilization outcomes were not different. Conclusions: LB was associated with fewer perioperative MMEs and all-cause 3-month inpatient readmissions and outpatient clinic/office visits than bupivacaine in patients undergoing DIEP flap breast reconstruction.

Variability Between Full-Length Lateral Radiographs and Standard Short Knee Radiographs When Evaluating Posterior Tibial Slope in Revision ACL Patients.

Increased posterior tibial slope (PTS) has been identified as a risk factor for failure after anterior cruciate ligament (ACL) reconstruction. Correction of PTS may improve outcomes after revision ACL reconstruction. There are conflicting reports demonstrating the measurement of the PTS on standard short knee (SSK) radiographs versus full-length lateral (FLL) radiographs including the entire tibia. To compare PTS measurements between SSK and FLL radiographs in patients who failed primary ACL reconstruction. It was hypothesized that there would be high variability between the SSK and FLL radiographic measurements. Cohort study (diagnosis); Level of evidence, 2. The medial and lateral PTS were measured on the SSK and FLL radiographs of 33 patients with failed primary ACL reconstructions. All measurements were performed by 2 trained independent observers (A.A.M., J.S.), and inter- and intraobserver reliability were calculated using the intraclass correlation coefficient (ICC). Measurements recorded by the observer with the higher intraobserver ICC were used for comparison of the PTS on SSK versus FLL radiographs. Both the inter- and the intraobserver reliability values of the PTS measurements were excellent. There was a significant difference in mean PTS on the medial plateau as measured on the SSK and FLL radiographs (11.2°± 5.3° vs 12.5°± 4.6°; P = .03), with the FLL radiographs demonstrating higher PTS. There was also a significant difference in the mean PTS on the lateral plateau as measured on SSK versus FLL radiographs (10.7°± 4.3° vs 12.2°± 4°, respectively; P = .01), with the FLL radiographs demonstrating higher PTS. Notably, 66.67% of the absolute measurements for PTS on the medial plateau differed by ≥2°, with variability as high as 8.5°. Results indicated that FLL and SSK radiographs are not interchangeable measurements for PTS associated with failed ACL reconstruction. Because FLL radiographs demonstrate less variability than SSK radiographs, we recommend obtaining them to evaluate these complex patients.

Patient’s Height and Sex Predict Graft Diameter. A Cohort Study of 4,519 Patients With Primary Anterior Cruciate Ligament Reconstruction Using Semitendinosus Autograft

To determine whether anthropometric measurements (height and weight), sex, age and pre-injury Tegner activity scale (TAS) were predictors of the quadrupled semitendinosus (ST) graft diameter in primary anterior cruciate ligament reconstruction (ACLR). A total of 4,519 patients who underwent primary ACLR with a quadrupled ST autograft were included. Anthropometric measurements (height and weight), sex, age, pre-injury TAS were collected. Correlation coefficients and multiple linear regression analysis were used to determine the relationship between graft diameter and anthropometrics measurements (height and weight), sex, age and pre-injury TAS. The diameter of the quadrupled ST graft was correlated positively to height (r =.021, P <.001), age (r =.005, P <.001) and weight (r =.004, P =.001) and negatively to female sex (r = -.297, P <.001). A regression equation was estimated to predict the ST graft diameter for men as 4.245 + 0.021 x height (cm) + 0.004 x age (years) + 0.005 x weight (kg) and for women as 3.969 + 0.021 x height (cm) + 0.004 x age (years) + 0.005 x weight (kg). Height, age and weight were positively correlated, whereas female sex was negatively correlated to the diameter of the quadrupled ST graft. Knowledge of these factors can be used for the preoperative estimation of the graft diameter which can be helpful for appropriate graft choice.

A High Grade of Postoperative Knee Laxity Is Associated With an Increased Hazard of Revision Surgery: A Cohort Study of 4697 Patients With Primary ACL Reconstruction

Background: There is still debate regarding the association between arthrometric knee laxity measurements and subjective knee outcome and revision surgery after primary anterior cruciate ligament reconstruction (ACLR). Purpose: To assess whether arthrometric knee laxity (measured with the KT-1000 arthrometer) 6 months after primary ACLR was associated with the 1-, 2-, and 5-year subjective knee outcomes or revision ACLR at a 5-year follow-up. Study Design: Cohort study, Level of evidence 3. Methods: Patients who underwent primary ACLR with a hamstring tendon autograft at the authors’ institution between January 1, 2005, and December 31, 2017, with no concomitant ligamentous injuries, were identified. Anterior knee laxity (KT-1000 arthrometer, 134 N) was assessed 6 months postoperatively. The Knee injury and Osteoarthritis Outcome Score (KOOS) was collected preoperatively and 1, 2, and 5 years postoperatively. Patients who underwent revision ACLR at any institution in the country within 5 years of primary surgery were identified through the Swedish National Knee Ligament Registry. Results: A total of 4697 patients (54.3% male) with available KT-1000 arthrometer measurements were included (normal: side-to-side [STS] ≤2 mm, 3015 [64.2%]; nearly normal: STS 3-5 mm, 1446 [30.8%]; abnormal: STS >5 mm, 236 [5.0%]). The only significant difference in subjective knee outcome between the groups was for the KOOS Symptoms subscale at the 1-year follow-up (STS ≤2 mm, 79.9 ± 16.2; STS 3-5 mm, 82.5 ± 14.8; STS >5 mm, 85.1 ± 14.2; P < .001). No other significant differences between the groups were found preoperatively or at 1, 2, or 5 years postoperatively for any of the KOOS subscales. The hazard for revision ACLR within 5 years of the primary surgery was significantly higher for the groups with an STS of 3 to 5 mm (6.6%; 95/1446) (hazard ratio [HR], 1.42; 95% CI, 1.07-1.87; P = .01) and an STS >5 mm (11.4%; 27/236) (HR, 2.61; 95% CI, 1.69-4.03; P < .001) compared with the group with an STS ≤2 mm (3.8%; 116/3015). Conclusion: A high grade of postoperative knee laxity (STS 3-5 mm and STS >5 mm) 6 months after primary ACLR was associated with an increased hazard of revision ACLR within 5 years, but it was not associated with an inferior subjective knee outcome.

Validating the capture rate of revisions by the New Zealand ACL Registry: An analysis of all-cause reoperation following primary ACL reconstruction.

To validate the New Zealand Anterior Cruciate Ligament(ACL) Registry's capture rate of revisions by cross-referencing Registry data with reoperations data recorded by the Accident Compensation Corporation (ACC) and identify risk factors for all-cause reoperation. Primary ACL reconstructions performed between April 2014 and September 2019 were individually matched on a record-by-record basis between the two databases. The ACC database was used to identify patients who underwent a reoperation with manual review of operation notes to identify whether a revision or other procedure was performed. This was combined with the number of revisions separately recorded in the New Zealand ACL Registry, which was used as the denominator value to calculate the Registry's capture rate of revisions. Patient and surgical data recorded in the Registry were analysed to identify independent predictors for all-cause reoperation. A total of 8046 primary ACL reconstructions were matched between the New Zealand ACL Registry and the ACC databases. The reoperation rate was 8.9% (n = 715) at a mean follow-up of 2.5 years. Meniscal-related procedures were the most common reoperation (n = 299, 3.7%), followed by revision ACL reconstruction (n = 219, 2.7%), arthrofibrosis (n = 185, 2.3%), cartilage (n = 56, 0.7%)and implants (n = 32, 0.4%). The New Zealand ACL Registry captured 96% of revisions. Younger age (hazard ratio [HR] > 1.4, p < 0.001), earlier surgery (HR > 1.3, p = 0.05), concurrent meniscal repair (medial meniscus HR = 1.9, p < 0.001 and lateral meniscus HR = 1.3, p = 0.022)and hamstring tendon autografts (HR = 1.4, p = 0.001) were associated with a higher risk of reoperation. The New Zealand ACL Registry captured 96% of revisions. Risk factors for all-cause reoperation included younger age, earlier surgery, meniscal repairand hamstring tendon autografts. Level III.

Is Polyetheretherketone an Effective Alloplastic Material in Comparison to Titanium in Calvarial Reconstruction.

Polyetheretherketone (PEEK) and titanium (Ti) cranioplasty implants ideal outcomes are good esthetics, long-term stability, and protection of the fragile brain tissue. However, it is unclear whether PEEK implants can offer an equal alternative to Ti implants. This work aimed to critically review papers and case series published on both Ti and PEEK Cranioplasty regarding complications, clinical outcomes, ease of use, esthetics, manufacture and availability, cost and time-saving factors, postoperative quality of life (QOL), as well as their suitability for the fronto-orbito region reconstruction. PubMed database was sourced for published literature in the period 2007 to the end of 2023; a further manual search for articles was carried out on the reference lists of each paper. A total of 48980 papers were found during the initial search, but only 33 articles met the inclusion criteria. A total of 6023 cranial implants, with 3879 being Ti and 1205 PEEK. Titanium was the material of choice in over 64.4% of cases; however, Ti has been in application for many years compared to PEEK. Out of the 33 papers, there was 27 retrospective cohort/analysis/case series and reviews: 1 meta-analysis, 2 systematic reviews and 3 randomized control trials. Four articles commented on the QOL, 15 on esthetics, 7 discussed cost and time-saving without measurable variables, and 7 articles looked explicitly at the complex fronto-orbito region, of which 49% were primary 1-stage surgical reconstructions, 54% were reconstructed with PEEK and 7% Ti (CAD/CAM). There is no absolute consensus for the preference of either material, however, in the fronto-orbito region, PEEK is the material of choice for ease of use, esthetics, and time-saving. However, there are no long-term studies on PEEK cranioplasty, and fewer in comparison with Ti implants. Further research is required in this field. No reliable or measurable data was found to determine the QOL, esthetics, cost, or time-saving elements.

App-based analysis of the femoral tunnel position in ACL reconstruction using the quadrant method.

The purpose of this study was to examine the intra- and interobserver variability of an app-based analysis of the femoral tunnel position using the quadrant method in primary anterior cruciate ligament reconstruction. Between 12/2020 und 12/2021 50 patients who underwent primary anterior cruciate ligament reconstruction were included in this retrospective study. Intraoperative strictly lateral fluoroscopic images of the knee with marked femoral tunnel were analyzed by four observers using the quadrant method. For retest reliability analysis, measurements were repeated once by 2 observers after 4 weeks. The femoral tunnel position of all included patients averaged 27.86% in the depth relation and 15.61% in the height relation. Statistical analysis showed an almost perfect intra- and interobserver reliability in the depth and height relation. The ICC was 0.92 in the depth relation and 0.84 in the height relation. The Pearson's correlation coefficient in the depth and height relation of observer 1 (0.94/0.81) was only slightly different from the Pearson's correlation coefficient of observer 2 (0.92/0.85). The app-based tunnel analysis took on average 59 ± 16s per measurement. The femoral tunnel analysis with the app-based quadrant method has an almost perfect intra- and interobserver reliability. By smartphone camera, a fast and highly accurate, if necessary also intraoperative, control of the tunnel position can be performed. Level 3-diagnostic retrospective cohort study.

Computer Patient-Specific 3D Modeling and Custom-Made Guides for Revision ACL Surgery.

Revision anterior cruciate ligament reconstruction (ACLR) is a challenging surgery occurring in 3 to 24% of primary reconstructions. A meticulous planning to study the precise size and location of both femoral and tibial bone tunnels is mandatory. The aim of the study was to evaluate the intra- and interoperator differences in the decision-making process between experienced surgeons after they were asked to make preoperative planning for ACL revision reconstruction with the use of both the computed tomography (CT) scan and a three-dimensional (3D)-printed model of the knee. Data collected from 23 consecutive patients undergoing revision of ACLR for graft failure at a single institute between September 2018 and February 2020 were prospectively reviewed. The double-blinded collected data were presented to three board-certificate attending surgeons. Surgeons were asked to decide whether to perform one-stage or two-stage revision ACLR based on the evaluation of the CT scan images and the 3D-printed custom-made models at two different rounds, T0 and T1, respectively, 7 days apart one from the other. Interoperator consensus following technical mistake was 52% at T0 and 56% at T1 using the CT scans, meanwhile concordance was 95% at T0 and 94% at T1 using the 3D models. Concordance between surgeons following new knee injury was 66% at T0 and 70% at T1 using CT scans, while concordance was 96% both at T0 and T1 using 3D models. Intraoperative variability using 3D models was extremely low: concordance at T0 and T1 was 98%. McNemar test showed a statistical significance in the use of 3D model for preoperative planning (p < 0.005). 3D-printed model reliability resulted to be higher compared with CT as intraoperator surgery technique selection was not modified throughout time from T0 to T1 (p < 0.005). The use of 3D-printed models had the most impact when evaluating femoral and tibial tunnels, resulting to be a useful instrument during preoperative planning of revision ACLR between attending surgeons with medium-high workflow.