Standard Anterior Cruciate Ligament Reconstruction Research Articles

Periosteal wrapping of the hamstring tendon autograft improves graft healing and prevents tunnel widening after anterior cruciate ligament anatomic reconstruction.

The periosteum is a readily available tissue at the hamstring harvest site that could be utilized to enhance graft healing and prevent tunnel widening without additional cost or morbidity. This study aimed to compare graft healing using magnetic resonance imaging (MRI) and functional clinical outcome scores in a matched cohort of patients who underwent anterior cruciate ligament (ACL) reconstruction with hamstring autografts with or without periosteal augmentation. Forty-eight patients who underwent ACL reconstruction (ACLR) were prospectively enrolled: 25 with standard ACLR (ST-ACLR) and 23 with periosteal augmented grafts (PA-ACLR). The same surgical techniques, fixation methods, and postoperative protocol were used in both groups. Signal-to-noise quotient (SNQ), graft healing at the bone-graft interface, graft signal according to the Howell scale, and femoral tunnel widening were evaluated using MRI after 1 year of follow-up. International knee documentation score (IKDC), Lysholm, Tegner activity scale, and visual analog scale for pain were used for functional evaluation at a minimum of 2years postoperative. The mean SNQ of the proximal part of the graft was 9.6 ± 9.2 and 2.9 ± 3.3 for the ST-ACLR and PA-ACLR groups, respectively (P = 0.005). The mean femoral tunnel widening was 30.3% ± 18.3 and 2.3% ± 9.9 for the ST-ACLR, PA-ACLR groups, respectively (P < 0.001). Complete graft tunnel healing was observed in 65% and 28% of cases in the PA-ACLR and ST-ACLR groups, respectively. Both groups showed marked improvements in functional scores, with no statistically significant differences. Periosteal wrapping of hamstring tendon autografts is associated with better graft healing and maturation and lower incidence of femoral tunnel widening based on MRI analysis 1year after ACL reconstruction. However, patient-reported outcomes and measured laxity were similar between the two groups at 2years follow up. Trail registration number: PACTR202308594339018, date of registration: 1/5/2023, retrospectively registered at the Pan African Clinical Trial Registry (pactr.samrc.ac.za) database.

Comparison of the Clinical Outcomes between All-inside and Standard Technique in Anterior Cruciate Ligament Reconstruction with 6-strand Hamstring Tendon Autograft.

All-inside and standard techniques with 4-strand hamstrings graft have been widely used in anterior cruciate ligament (ACL) reconstruction. However, the graft diameter of less than 8 mm will significantly increase the rate of surgical failure, and the 6-strand graft can solve this problem. The purpose of this study is to compare all-inside ACL reconstruction using suspensory cortical button fixation on both tibia and femur with standard ACL reconstruction using suspensory femoral fixation and a bioabsorbable tibial interference screw with a 6-strand hamstring tendon autograft in postoperative clinical outcomes. From January 2020 to December 2020, 48 patients performed ACL reconstruction were divided into the all-side group and the standard group according to the different surgical techniques. Magnetic resonance imaging (MRI) and subjective function scores was used to assess clinical outcomes at least 24 months following ACL reconstruction. MRI was used to measure the value of bone tunnel widening in articular and middle portions. Subjective function scores included the Lysholm knee score, the International Knee Documentation Committee (IKDC) score, the Knee Society Score (KSS) for pain and function, and KT-1000. The t-test was used assuming the distribution of the patients which follows the normal distribution and we used non-parametric tests if these two conditions were not satisfied. At the final follow-up, there were 22 patients in the all-inside group and 24 patients in the standard group. No significant differences were found with respect to femoral tunnel widening and subjective function scores. However, a significant increase in tibial tunnel widening was found in the middle portion of the standard group (2.25 ± 0.74) compared to the all-inside group (0.76 ± 0.24) (p < 0.01) and also in the articular portion of the standard group (2.07 ± 0.77) compared to the all-inside group (1.52 ± 0.54) (p = 0.02). In addition, the value of the KT-1000 was 1.81 ± 0.45 for the all-inside group and 2.12 ± 0.44 in the standard group (p = 0.016). The objective stability of the knee was relatively better in the all-inside group than in the standard group. And tunnel widening after ACL reconstruction was significantly greater in the standard technique when compared to the all-inside technique on the tibia side.

A comparative analysis of suture-augmented and standard hamstring autograft single-bundle ACL reconstruction outcomes: short-term functional benefits without long-term impact

BackgroundAugmentation of the biologic graft with nonabsorbable suture material during anterior cruciate ligament reconstruction (ACLR) is a relatively new technique to enhance its biomechanical properties and add additional support to the critical process of healing. We aimed to compare the short-term functional patient-reported outcome measures (PROMs) and complication rates of patients treated with either standard single-bundle four-strand hamstring ACLR or added suture augmentation (SA).MethodsPatients undergoing arthroscopic ACLR between February 2015-January 2017 and in the standard ACLR group, and between February 2017-September 2019 in the SA-ACLR group operated by adding a no.5 FiberWire® (Arthrex, Naples, FL, USA) braided suture to the hamstring autograft, were retrospectively reviewed and the PROMs were compared. Patients were followed up for a 24-month period and PROMs were assessed by the International Knee Documentation Committee (IKDC) Subjective Knee Form and Tegner-Lysholm knee score. Patients’ demographic and clinical characteristics, and postoperative complications including graft retear requiring revision surgery, deep vein thrombois, and surgical site infection were recorded and analyzed.ResultsWe included 79 patients with mean age of 31.6 ± 8.3 years in the standard ACLR group, and 90 patients with mean oge of 30.5 ± 7.6 in the SA-ACLR group. There was no statistically significant difference between the two groups in terms of age, sex, body mass index, and medical comorbidities. The values of the IKDC scores increased to 75.8 ± 18.9 in the standard ACLR group, and 85.6 ± 12.6 in the SA-ACLR group, 24 months after the operation (P < 0.05). The 24-month postoperative Tegner-Lysholm scores escalated to 79.3 ± 21.0 in the standard ACLR group and 91.0 ± 13.7 in the SA-ACLR group (P < 0.05). Four (5.1%) patients in the standard ACLR group and 4 (4.4%) in the SA-ACLR group experienced graft retear requiring revision surgery (P > 0.05). Incidence of surgical site infection and deep vein thrombosis showed no significant differences between the two groups, 24 months after ACLR.ConclusionSA-ACLR is associated with improved short-term functional PROMs compared to the standard hamstring ACLR. Although SA did not reduce the retear rate, and infection and DVT rates did not differ between study groups, superior improvement of PROMs in SA approach, leverages this method for ACLR.

What's New in Sports Medicine.

What's New in Sports Medicine.

Tibial graft fixation in anterior cruciate ligament reconstruction: multiple tibial tunnel technique (collateral tunnel technique).

This study aimed to compare the outcomes of patients with an anterior cruciate ligament (ACL) rupture who underwent tibial fixation using the multiple tibial tunnel fixation (MTTF) and standard tibial fixation methods. This retrospective study was conducted between January 1, 2020, and August 1, 2021. MTTT was applied to 43 patients diagnosed with ACL rupture. Of the 43 patients who met the study criteria, 38 were classified as Group 1. In the clinic where the study was conducted, 40 of 57 patients who underwent standard ACL reconstruction by opening a single tibial tunnel were assigned to Group 2. The Endobutton technique was used for fixation of the graft to the femur in both groups. Bioabsorbable and postfix screws were used for the tibial fixation of the patients in Group 2. For patients in Group 1, a bioabsorbable screw, a postfix screw, and an additional MTTT fixation were performed for tibial fixation. Lachman, anterior drawer, Pivot-Shift test results, Lysholm and IKDC knee evaluation scores of the patients in both groups were compared. In this study, there was no significant difference between the groups for the anterior drawer, Lachman, and Pivot-Shift test results at the final control (p > 0.05). There was a significant difference between the two groups for the Lysholm and IKDC scores at the final controls (p < 0.05). There was a significant difference in the Lysholm and IKDC scores between the groups (p < 0.05). In conclusion, ACL reconstruction was performed using the MTTF technique in this study. Due to the additional fixation, it was observed that the patients had a more successful knee function after the surgery.

Anterolateral Extraarticular Stabilisation of the Knee: Modified Lemaire Procedure.

The anterolateral aspect of the knee is prone to laxity or symptomatic instability, if the anterior cruciate ligament (ACL) is torn. It is necessary to address this issue in patients with general joint hyperlaxity, overextension of the knee, massive anterolateral instability, or re-tear of the ACL with chronic instability. In these cases, and in addition to a preoperative bony workup and revision ACL reconstruction, anterolateral stabilisation should be considered to avoid persistent anterolateral rotation instability and failure of the ACL reconstruction.To stabilise the anterolateral corner of the knee, the modified Lemaire procedure as presented and illustrated here is a straight forward surgical technique that can be performed right after standard ACL reconstruction surgery, if indicated. It is independent from the graft choice for the ACL reconstruction, and the surgical setting in the operating room remains unchanged.

Randomized controlled trial of all-inside and standard single-bundle anterior cruciate ligament reconstruction with functional, MRI-based graft maturity and patient-reported outcome measures

BackgroundAll-inside anterior cruciate ligament reconstruction (ACLR) is a novel technique that has gained attention due to its minimally invasive and graft-saving properties. However, studies comparing MRI-based graft maturity between all-inside and standard ACLR are lacking.PurposeThis study focused on the functional, knee laxity, and MRI-based graft maturity characteristics of all-inside and standard single-bundle ACLR.Study DesignRandomized controlled trial (RCT).MethodsFifty-four patients were randomly assigned to an all-inside reconstruction group (n = 27) or standard reconstruction group (n = 27). Using the same rehabilitation strategy. The Tegner, International Knee Documentation Committee, and Lysholm scores were recorded at postoperative months 3, 6, and 12 to assess functional recovery. MRI was conducted to measure the signal/noise quotient (SNQ) of the intra-articular graft to assess the maturity. A higher SNQ indicates lower graft maturity. Knee laxity was assessed using GNRB arthrometer at the postoperative month 12.ResultsThe graft SNQ of the all-inside group was significantly higher than that of the standard group at postoperative month 6 (p < 0.05). There was no statistical difference in graft SNQ between the two groups at postoperative months 3 and 12 (p > 0.05). Both groups exhibited the highest SNQ in the middle region of the graft, followed by the proximal region, and the distal region. Functional scores improved significantly for both groups and had no statistical difference (p > 0.05). The knee laxity was higher in the all-inside group (p < 0.05) at postoperative month 12. There was no correlation between the functional scores and graft maturity in both groups (p > 0.05).ConclusionsAll-inside and standard single-bundle ACLR show good functional outcomes; however, knee laxity was relatively higher in the all-inside ACLR group than in the standard ACLR group. Moreover, both techniques exhibited poor maturity in the middle graft region and the best in the distal region. Graft maturity with all-inside ACLR is inferior to that with standard ACLR in the early postoperative stages. There is no correlation between knee function and graft maturity.Trial registrationClinical trial registration numbers: ChiCTR1800018543.Date of registration: 09/23/2018.

The importance of continuous remnant preservation in anterior cruciate ligament reconstruction.

Selective anteromedial or posterolateral bundle reconstruction is recognized as a treatment modality in partial anterior cruciate ligament (ACL) reconstruction (ACLR) with a biomechanically sufficient ACL remnant. However, there is paucity in literature investigating clinical outcomes of standard ACLR with preservation of residual continuous but biomechanically insufficient ACL tissue. The aim of this study was to investigate the influence of preservation of residual continuous but biomechanical insufficient ACL tissue in standard ACLR on complication and repeat surgery rate, and patient reported and clinical outcome. The retrospective cohort comprised 134 patients (age 23 ± 7years; Tegner 6 ± 3) with an isolated acute ACL tear. In 67 patients, residual continuous but biomechanically insufficient ACL tissue was present and preserved based on visual inspection, probing of the ACL tissue and Lachman test under arthroscopic view (standard reconstruction with tissue preservation; SRTP). These patients were matched to 67 patients that underwent ACLR where no residual ACL tissue could be preserved (standard reconstruction; SR) based on gender, age and chondral and/or meniscal status. Clinical failure (recurrent instability, pathological ACL graft laxity and/or ACL graft discontinuity), other complication and repeat-surgery rate within index surgery and 1-year and within index surgery and 2-year follow-up, and patient reported and clinical outcomes at 1-year and at 2-year follow-up were compared. A statistically significant lower clinical failure rate within index surgery and 1-year (SRTP, 3%; SR, 13%; P = 0.028) and within index surgery and 2-year follow-up (SRTP, 3%; SR, 23%; P = 0.001), and revision ACL surgery rate within index surgery and 1-year (SRTP, 2%; ST, 10%; P = 0.029) and within index surgery and 2-year follow-up (SRTP, 2%; SR, 18%; P = 0.001) was found in the SRTP group. No statistically significant differences were found for other investigated outcomes in patients that were without clinical failure. This study shows that in ACLR surgery, preservation of residual continuous but biomechanical insufficient ACL tissue might lead to lower clinical failure rate and ACL revision surgery rate within index surgery and 1-year, and within index surgery and 2-year follow-up compared to standard ACLR where no residual continuous ACL tissue could be preserved. III.

CLEARANCE BASED ON STANDARDIZED RETURN TO SPORTS ASSESSMENT FOLLOWING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN PEDIATRIC AND ADOLESCENT PATIENTS

Background:Return to sports (RTS) is often the primary concern of patients following anterior cruciate ligament reconstruction (ACLR). Unfortunately, RTS at the preinjury level is not commonplace in pediatric patients despite advances in rehabilitation and measures of recovery, and second injury rates are highest among the young adolescent population. RTS criteria have become more rigorous in recent years. The impact of these new RTS assessments (RTSA) is still unfolding, and their application in a mixed pediatric and adolescent population is unclear.Purpose:To assess whether adolescent patients who undergo standard ACLR pass a rigorous RTSA sooner than those undergoing pediatric ACLR.Methods:This study was a retrospective chart review of patients ages >5 and <18 with primary, unilateral ACL tear who underwent ACLR from January 2017 to December 2019. Subjects were identified using current procedural terminology codes from the hospital electronic medical record then grouped based on ACL reconstruction technique: Adolescent (transphyseal approach) and Pediatric (complete or partial physeal-sparing approach). All subjects underwent a rigorous and standardized RTSA used by the operating surgeons to guide clearance to RTS. The primary outcome measure was post-operative time to clearance for RTS, with secondary analyses controlling for sex, concomitant pathology at the time of ACLR, number of RTSAs prior to clearance, and physical therapy provider. Parametric and nonparametric statistical comparisons were respectively performed via unpaired Student t-tests and Mann-Whitney U tests (p<0.05).Results:Of 426 identified ACLR patients, 97 (84 Adolescent, 13 Pediatric) met the inclusion criteria for the final analysis (39 M, 58 F; Adolescent mean age 16.44 ± 1.7 years, Pediatric mean age 13.21 ± 1.4 years). There were no significant differences in gender distribution or concomitant pathology between the groups. Median post-operative time to clearance for RTS was 12.2 months in the Pediatric group (95% CI: 10.9-12.7) and 9.3 months in the Adolescent group (95% CI: 8.9-9.8) (p<0.001). This difference in time to RTS between groups remained statistically significant after adjusting for the secondary variables described above (all p≤0.002).Conclusions:When applying a rigorous and standardized RTSA to determine readiness for RTS, Pediatric subjects who underwent a partial or complete physeal-sparing technique took nearly 3 months longer to be cleared than Adolescent subjects who underwent a standard transphyseal approach. Notably, Adolescent subjects averaged more than 9 months of rehabilitation prior to RTS. These findings help inform patient expectations for a safe recovery period following ACLR.

Early clinical and neuromuscular properties in patients with normal or sub-normal subjective knee function after anterior cruciate ligament reconstruction.

To determine clinical and neuromuscular properties in patients with normal or sub-normal subjective knee function after finalisation of 6months' post-operative rehabilitation following anterior cruciate ligament reconstruction (ACLR). Sixty patients after primary anatomical single-bundle hamstring ACLR were prospectively enrolled. Demographics, subjective, clinical and functional status of the injured knee were recorded at baseline, 6 and 12months post-operatively. Return to pre-injury activities time (months) was monitored. Tensiomyography and isokinetic dynamometry of thigh muscles were performed at 6months, when standard ACLR rehabilitation is finalized. Based on their IKDC Subjective Knee Evaluation scores at 6months, they were assigned into "Normal" or "Sub-normal" group. All the above measured parameters were then compared between the two groups. At 6months' timeline, 21 patients (35%) perceived their knee function as "Normal", while 39 (65%) were "Sub-normal". There were no differences in clinical status between both groups, but patients in Normal group achieved higher IKDC, Lysholm, Tegner scores as well as higher single-leg hop test. They were taller, had lower body mass index and more of them achieved their preinjury level of activity at 12months (67% vs. 33%). Tensiomyography revealed higher biceps femoris as well as semitendinosus and semimembranosus radial displacement values on the operated leg in Normal group. Isokinetic dynamometry showed significantly higher normalised peak torque and average power of knee extensor muscles. Patients who perceive their knee function as normal at 6months following ACLR presented with better neuromuscular properties of the thigh muscles. Decreased hamstring stiffness seems to be the key to higher return-to-preinjury activity. Postoperative rehabilitation should be more focused on reducing hamstring stiffness in addition to improving knee extensor muscle strength. Level of evidence II (prospective cohort study).

Is Remnant Preservation in Anterior Cruciate Ligament Reconstruction Superior to the Standard Technique? A Systematic Review and Meta-Analysis.

Purpose This is a systematic review and meta-analysis of current evidence that aims at comparing the clinical outcomes of remnant-preserving anterior cruciate ligament reconstruction (ACLR) and standard ACLR. Methods A systematic review of randomized controlled studies and cohort studies comparing remnant-preserving ACLR with standard ACLR with a minimum level of evidence of II was performed. Studies were included by strict inclusion and exclusion criteria. Extracted data were summarized as preoperative conditions, postoperative clinical outcomes, and postoperative complications. When feasible, meta-analysis was performed with RevMan5.3 software. Study methodological quality was evaluated with the modified Coleman methodology score (CMS). Results Eleven studies (n = 466 remnant-preserving and n = 536 standard) met the inclusion criteria. The mean modified CMS for all included studies was 85.8 (range: 77–92 on a 100-point scale). In total, 466 patients underwent remnant-preserving ACLR by 3 different procedures: standard ACLR plus tibial remnant tensioning (n = 283), selective-bundle augmentation (n = 49), and standard ACLR plus tibial remnant sparing (n = 134). Remnant-preserving ACLR provided a superior outcome of postoperative knee anterior stability (WMD = −0.42, 95% CI, −0.66, −0.17; P < 0.01) and Lysholm score (WMD = 2.01, 95% CI, 0.53 to 3.50; P < 0.01). There was no significant difference between the two groups with respect to second-look arthroscopy (OR = 1.38, 95% CI, 0.53, 3.62; P=0.51), complications (OR = 1.24 95% CI, 0.76, 2.02; P=0.39), International Knee Documentation Committee (IKDC) subject scores, IKDC grades, Lachman test, and pivot-shift test. Summary/conclusion Remnant-preserving ACLR promotes similar graft synovial coverage and revascularization to standard ACLR. Equivalent or superior postoperative knee stability and clinical scores were observed for remnant-preserving ACLR compared with standard ACLR. No significant difference in the total complication rate between the groups was evident.

Suture Augmented Versus Standard Anterior Cruciate Ligament Reconstruction: A Matched Comparative Analysis

To compare outcomes between standard anterior cruciate ligament reconstruction (ACLR) using hamstring grafts with and without suture augmentation (SA). Patients who underwent ACLR with hamstring autografts or allografts with minimum 2-year follow-up were retrospectively reviewed. Patients undergoing ACLR with SA were matched 1:1 by age, gender, body mass index, graft type, and revision status to standard ACLR. Range of motion, pain, postoperative activity, patient-reported outcome measures (PROMs), and complications were collected. Paired 2-tailed Student's t-tests and Pearson's χ2-tests were used for continuous and categorical variables, respectively. A multivariate analysis of variance was conducted. Return to preinjury activity level was assessed using Spearman's rho and Pearson's χ2-tests. Sixty patients at a mean age of 29.50 ± 6.60years, 43.4% male, body mass index 26.27 ± 3.37, and follow-up of 29.54 ± 5.37months were included. Preoperative PROMs were not significantly different (P >. 05). Postoperative range of motion was similar between groups (P= .457). Postoperative average daily (0.60 ± 1.25 vs 1.66 ± 1.90) and maximum daily pain (1.57 ± 1.83 vs 3.35 ± 2.28) were significantly lower for SA (P < .014). SA predicted improvement in PROMs (P < .05) and maximum pain scores (P= .001). SA was significantly correlated with improved time to return to preinjury activity level (9.17 ± 2.06 vs 12.88 ± 3.94months; P= .002) and percentage of preinjury activity level (93.33% ± 13.22% vs 83.17% ± 17.69%; P= .010). There was a trend toward improved rate of return to preinjury activity level for SA (76.7% vs 56.7%; P=.100). Our study demonstrates that SA hamstring ACLRs were associated with improved PROMs, less pain, and a higher percentage of and earlier return to preinjury activity level when compared with standard hamstring ACLRs without evidence of overconstraint. Level III, retrospective comparative study.

Application of a Beta-Tricalcium Phosphate Graft to Minimize Bony Defect in Bone–Patella Tendon–Bone Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament (ACL) reconstruction with a bone–patellar tendon–bone autograft yields good clinical outcomes. Despite appropriate clinical outcomes, the most common complaint after reconstruction with a bone–patellar tendon–bone autograft is anterior knee pain at the donor graft sites. Synthetic bone grafts, such as beta-tricalcium phosphate (β-TCP), have been previously used to fill the bony defect in fractures as well as removal of bony tumors, and have shown positive utility in improving anterior knee pain after ACL reconstruction. In this Technical Note, we describe the technique of placing a β-TCP graft in the donor graft site after bone–patellar tendon–bone ACL reconstruction. After standard arthroscopic ACL reconstruction, the β-TCP is appropriately sized with an osteotome and sagital saw before being placed into the patellar and tibial donor sites. A 0-Vicryl suture is used to suture the periosteum to secure the β-TCP graft at the donor sites. This described technique allows for appropriate sizing and secure placement of the graft to maximize bone regeneration at the donor site.

Outcomes and Complications After All-Epiphyseal Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients.

Background:The safest and most effective technique for anterior cruciate ligament (ACL) reconstruction in skeletally immature patients is currently unknown.Purpose:To evaluate the functional and patient-reported outcomes of a specific all-epiphyseal ACL reconstruction technique in which the graft, bone tunnels, and fixation do not cross the knee growth plates.Study Design:Case series; Level of evidence, 4.Methods:Twenty-seven patients (23 boys, 4 girls; mean age, 11 years; range, 8-15 years) underwent an all-epiphyseal ACL reconstruction with a single femoral transverse epiphyseal tunnel and primarily split tibial epiphyseal tunnels. Outcomes were evaluated in terms of the manual Lachman test, range of motion, pain, return to activity, angular or leg-length deformity on imaging, and International Knee Documentation Committee (IKDC) or Pedi-IKDC score an average of 3.8 years postoperatively, with a minimum 2-year follow-up.Results:The mean IKDC score was 94 ± 11. There were no growth arrests, but 3 patients had knee overgrowth, and 2 required a subsequent guided growth procedure. The ACL graft failed in 4 patients (15%), and 2 patients had contralateral ACL tears (7%). There were 5 subsequent ipsilateral meniscal tears, 4 of which were retears of a repaired meniscus. Ipsilateral knee reinjury significantly correlated with the number of associated injuries at the time of index surgery (P = .040) and the number of sports played (P = .029).Conclusion:All-epiphyseal ACL reconstruction resulted in excellent long-term functional outcomes, despite a high rate of complications (48%) and secondary procedures (37%) in this highly active cohort. The incidence of graft failure was similar to other standard ACL reconstruction techniques for patients younger than 20 years.

Femoral-Side ACL Rupture: Arthroscopic Transosseous Refixation Technique and Early Outcomes

Background: Many different surgical techniques are nowadays performed in Anterior Cruciate Ligament (ACL) lesions. Several studies demonstrated that native ACL contains mechanoreceptors that are fundamentals for the proprioception of the knee, which are removed during the standard arthroscopic ACL reconstruction. Material and Methods: This article shows a new arthroscopic way to reinsert an ACL, through a Vycril® #2 wire using a modified Mason-Allen technique, combined with the “healing response technique”, described by Steadman. We recommend this technique for patients with an ACL lesion, detached from his femoral insertion, as suggested by MRI and confirmed by arthroscopic view. Postoperatively the patient must have a knee brace locked at 15-degrees of flexion for the first two weeks with partial weight bearing and prophylaxis of thrombosis with low-molecular-weight heparin until the complete weight bearing; then gradually the flexion will be increased during the next month. Discussion: This new technique permits to maintain the native ACL, reinserted into his anatomical insertion and the mechanoreceptors that are fundamentals for the proprioception, associated with the healing power of the bone marrow cells and blood.

Combined Intra-articular and Extra-articular Reconstruction in Anterior Cruciate Ligament–Deficient Knee: 25 Years Later

To determine whether an anterior cruciate ligament (ACL)-reconstructed knee with hamstring autograft has a greater incidence of degenerative changes when an extra-articular reconstruction is added and to determine the effect of the combined reconstruction on knee stability and function at long-term follow-up. For this retrospective study, patients who underwent ACL reconstruction between January 2002 and December 2003 were selected and classified into 2 groups, I and II. Group I consisted of patients operated by a standard ACL reconstruction, and group II consisted of patients in whom, owing to the presence of risk factors (severe pivot shift graded+++ or high-risk sports), an extra-articular reconstruction performed with ileo-tibial tract according to McIntosh as modified by Cocker Arnold technique, was used in conjunction with intra-articular ACL reconstruction. At final follow-up, Lysholm, International Knee Documentation Committee (IKDC), and Tegner scores were used. An arthrometric KT-1000 evaluation was done. Comparative weight-bearing radiographs were taken, including a skyline view for the patellofemoral joint and analyzed according to Fairbank, Kellgren, and IKDC classification. Seventy-two of the 75 (96%) patients in group I and 68 of the 75 patients in group II were available at the final follow-up (minimum 10years). Subjective scores improved significantly in both groups, with no significant difference. Objectively, the number of patients receiving C and D IKDC objective activity scores in group I (7/56; 12.5%) was significantly higher than in group II (0/60) (P= .01). Considering as a failure a side-to-side arthrometric difference more than 5mm or a pivot shift test graded as++ or+++, or any giving way episode occurring postoperatively, we found 8 cases in group I and no cases in group II (P= .01) despite the presence of risk factors that group I did not include. Radiologic evaluation showed less arthritic changes in group II in both tibiofemoral and patellofemoral joints. On the basis of the results of this study, adding an extra-articular reconstruction to an anatomically placed intra-articular ACL reconstruction, followed by a modern rehabilitation protocol, does not increase the risk of osteoarthritis and may be able to reduce the rate of failure. Level III, retrospective comparative study.

Is anterior cruciate ligament preservation surgery better than reconstructing both bundles?

Rupture of the anterior cruciate ligament (ACL) is one of the most common ligamentous injuries of the knee, with an incidence of 35 out of 100,000. An ACL reconstruction is now a routine procedure. Generally, good outcomes are expected from the surgery, with return to preinjury level of sports activity in most patients. Debate, however, continues regarding the advantages of preserving the ACL remnant and augmenting it with a graft as opposed to debridement of the remnant in a standard ACL reconstruction. The purpose of this article is to consider the scientific basis of ACL preservation surgery (remnant preservation and selective bundle reconstruction) and to compare the outcomes between an ACL-preserving surgery and a double-bundle reconstruction. Both techniques provide anteroposterior laxity control and some degree of control on rotational laxity. Although superior Lysholm and subjective International Knee Documentation Committee (IKDC) scores have been documented with double-bundle reconstructions, remnant-preserving procedures have several advantages and seem to have a valuable contribution either on single-bundle, selective, and double-bundle reconstructions. Based on our experience, we recommend the remnant preserving technique. However, longer follow-up is necessary to ascertain which procedure could restore the normal knee kinematics, thus providing better clinical outcomes.

Anterior Cruciate Ligament Reconstruction of the Knee Using Double Bundle Hamstring Autograft - Is the Remnant Preservation Technique Superior to the Standard Procedure in Terms of Long-Term Graft Failure Rate, the Need for Revision Operation, and Associated Clinical Dysfunction?

Background:Anterior cruciate remnant preservation may be beneficial in Anterior Cruciate Ligament Reconstruction (ACLR). Gohil, Annear & Breidahl (Sept, 2007) used a grade 1 randomised controlled trial to compare the two methods and at short term follow-up, the minimal debridement technique demonstrated earlier revascularisation within the ACL graft at 2 months, and suggested improved strength at 6 months based on radiological imaging. Unfortunately, this did not translate through to clinical benefits in the early 12 month post operative period. Zhang, L et al. (May, 2013) and Naylor, AJ et al. (2013) reiterated that remnant preservation may improve graft revascularization and knee proprioception. Takazawa Y et al. (Sept, 2013) demonstrated that minimal debridement may facilitate recovery of function and decreased graft rupture at two years post primary reconstruction. However, studies have yet to show consistent significant clinical advantages and follow-up has only been analysed over 1-2 years.Purpose:This current study reported results over a long-term follow-up of 10 years post operation for the same participants from the Gohil, Annear & Breidahl (2007) study.Study Design:The review was based on level 1 randomised controlled trial chart review.Methods:All 49 participants (25 standard – group 1, and 24 remnant preserving group – group 2) from the previous study have been included for investigation. The chart review recorded demographic data, graft rupture, re-operation rates, and associated clinical failures of the ACLR. The review presents comparative data between the two groups.Results:At 10 year follow-up, the remnant retention ACLR group only had better outcomes for ipsilateral graft rupture (2 patients versus 3 patients). Standard ACLR group had improved outcomes for contralateral graft rupture (2 versus 3), ipsilateral other knee post operative surgery (5 versus 10), ipsilateral knee post operative complaints (7 versus 12), and other non-knee post operative issues (3 versus 4). Non of the differences were statistically significant.Conclusion:Overall our results suggested no statistically significant difference between the remnant retaining and standard technique for ACLR in these 49 subjects using chart review endpoints of graft revision and knee reoperation rates. The review is limited by a small study group and a chart only review. A larger study group with long term clinical outcome measures may offer more definitive conclusions as to the advantages of remnant sparing ACLR. In this 10 year follow-up post ACL reconstruction there has been no distinct advantage identified for either procedure.

Comparison of Clinical Outcome of Autograft and Allograft Reconstruction for Anterior Cruciate Ligament Tears.

Background:Hamstring (HS) autograft and bone-patellar tendon-bone allograft are the most common choice for reconstruction of anterior cruciate ligament (ACL). There was a little report about the clinical outcome and difference of arthroscopic ACL reconstruction using allograft and autograft. This study aimed to compare the clinical outcome of autograft and allograft reconstruction for ACL tears.Methods:A total of 106 patients who underwent surgery because of ACL tear were included in this study. The patients were randomly divided into two groups, including 53 patients in each group. The patients in group I underwent standard ACL reconstruction with HS tendon autografts, while others in group II underwent reconstruction with bone-patellar tendon-bone allograft. All the patients were followed up and analyzed; the mean follow-up was 81 months (range: 28–86 months). Clinical outcomes were evaluated using the International Knee Documentation Committee (IKDC), Lysholm scores, physical instability tests, and patient satisfaction questionnaires. The complication rates of both groups were compared. Tibial and femoral tunnel widening were assessed using lateral and anteroposterior radiographs.Results:At the end of follow-up, no significant differences were found between the groups in terms of IKDC, Lysholm scores, physical instability tests, patient satisfaction questionnaires, and incidences of arthrofibrosis. Tibial and femoral tunnel widening was less in the HS tendon autografts. This difference was more significant on the tibial side.Conclusions:In the repair of ACL tears, allograft reconstruction is as effective as the autograft reconstruction, but the allograft can lead to more tunnel widening evidently in the tibial tunnel, particularly.

Anterior Cruciate Ligament Repair Revisited. Preliminary Results of Primary Repair with Internal Brace Ligament Augmentation: A Case Series

Background: There is renewed interest in ACL repair following rupture with the development of new repair techniques. The aim of the audit was to assess outcomes and complications of ACL repair with Internal Brace Ligament Augmentation (IBLA) at minimum one year follow-up. Materials and methods: 68 consecutive patients who underwent Anterior Cruciate Ligament (ACL) repair with IBLA were followed for a minimum of one year following surgery. Knee Injury and Osteoarthritis Outcome Score (KOOS) and Western Ontario and McMaster osteoarthritis index (WOMAC) scores were collected at set time points via an online outcomes system. Improvements in scores from baseline were recorded and effect sizes for the five KOOS and three WOMAC domains were calculated. Patients suffering from re-rupture or undergoing re-interventions were identified and Kaplan-Meier survivorship calculated. Results: Improvement was seen over the study period in all KOOS and WOMAC domains with the majority of improvement seen in the first three months. The results were comparable to the literature on ACL reconstruction. In the KOOS score, the greatest effect size at one year was seen in the Quality of Life (QoL) (2.82, 95% CI 2.25 to 3.39) and Sport domains (2.60, 95% CI 2.09 to 2.12). The lowest KOOS effect size was seen in the Activities of Daily Living (ADL) domain (1.1, 95% CI 0.68 to 1.51), with similar smaller improvements seen in the WOMAC domains. There were four re-interventions including one for re-rupture, and one each for surgery for arthrofibrosis, meniscal tear and chondral parthology. Conclusions: This audit provides early functional outcome and failure data that demonstrates the technique of ACL repair with IBLA is comparable with early results from ACL reconstruction, with the greatest improvements seen in return to sporting activity. Further randomised studies are required to directly compare repair against standard ACL reconstruction techniques.