Anterior Cruciate Ligament Reconstruction Techniques Research Articles

Comparative Results of Anterior Cruciate Ligament Reconstruction with Full Tibial Tunnel: Quadrupled Semitendinosus Suspensory Femoral and Tibial Fixation versus Quadrupled Semitendinosus and Gracilis Suspensory Femoral and Tibial Screw and Staple Fixation.

This study compared the clinical outcomes of patients treated with described "modified all-inside" anterior cruciate ligament reconstruction (ACLR) technique with those of patients treated with suspensory femoral fixation and a bioabsorbable tibial interference screw with the ACLR technique. From 2017 to 2019, 98 patients who underwent ACLR surgery by two surgeons using either of the techniques were included in this study. Patients in group 1 were treated with the "modified all-inside" ACLR technique. In this technique, only the semitendinosus tendon was harvested as a four-strand graft and fixed to the tibia and femur with suspensory buttons. Patients in group 2 were treated with suspensory femoral fixation and a bioabsorbable tibial interference screw ACL reconstruction technique. Patients' functional outcomes were evaluated by the Lysholm score, Tegner activity scale, and International Knee Documentation Committee (IKDC) subjective score. Postoperative knee stability of the patients was evaluated using the Lachman test and the pivot-shift test. The mean ages of the patients were 31.1 (16-55) and 28.7 (18-48) years in groups 1 and 2, respectively. The average follow-up durations were 26 (20-30) and 25.9 (22-30) months for both groups. There was no significant difference between the preoperative and postoperative Lysholm's score, Tegner's activity score, and IKDC subjective score in groups 1 and 2. There were no major complications or reruptures in either group. ACLR incorporating the "modified all-inside" ACLR technique obtained significant clinical outcomes compared to ACLR with a suspensory femoral fixation and a bioabsorbable tibial interference screw.

Outcomes, Including Graft Tears, Contralateral Anterior Cruciate Ligament Tears, and All-Cause Ipsilateral Knee Operations, are Similar for Adult-type, Transphyseal, and Partial Transphyseal Anterior Cruciate Ligament Reconstruction Using Hamstring Autograft in Pediatric and Adolescent Patients

PurposeTo compare hamstring autograft primary anterior cruciate ligament reconstruction (ACLR) techniques including adult-type/anatomic, transphyseal, and transphyseal techniques by (1) ACL graft tear, (2) contralateral ACL tear, and (3) all-cause ipsilateral reoperation.MethodsA retrospective, single-surgeon review was performed including all ACLR with hamstring autograft in pediatric and adolescent patients from 2011 to 2019. Minimum 2-year follow-up was required for patients unless a tear or reoperation was sustained before that time point. Data collected included demographics and baseline surgical variables, type of reconstruction, sporting activity, and deviations from rehabilitation protocols. Comparisons were made among hamstring autograft reconstruction groups (adult-type/anatomic, transphyseal, and partial transphyseal) for primary outcomes of graft tear, contralateral ACL tears, and all-cause ipsilateral knee reoperations, including hardware removal. Secondary surgeries performed with different surgeons were noted.ResultsIn total, 214 patients of age 15.2 ± 2.0 years with 4.1 ± 1.7-year follow-up were included. Overall graft tear rate was 11.7% (11.0% adult-type vs 19.1% transphyseal vs 5.6% partial transphyseal; P = .18). On univariate analyses, all-cause ipsilateral reoperation did not differ by technique (21.3% vs 31.0% vs 33.3%; P = .20), and neither did contralateral ACL tear (8.1% vs 9.5% vs 0%; P = .17). 21.7% of ipsilateral revision ACLRs (all adult-type) and 16.7% of patients with any reoperations had subsequent procedures performed with a different surgeon.ConclusionsThe graft tear rates in primary hamstring autograft ACLRs in the adolescent population did not significantly differ by technique (11.0% vs 19.1% vs 5.6% in adult-type, transphyseal, and partial transphyseal reconstructions, respectively). Furthermore, contralateral ACL tears (8.1% vs 9.5% vs 0%) and all-cause (including > 1/4 hardware removal) ipsilateral knee reoperations (21.3% vs 31.0% vs 33.3%) did not statistically differ. Higher powered studies may detect statistical significance in the observed differences in this study.Level of evidenceLevel IV, therapeutic case series.

Comparative study of functional outcomes of arthroscopic anterior cruciate ligament reconstruction using anteromedial portal and translateral all-inside technique

BackgroundAnterior Cruciate Ligament (ACL) injuries are common in the active population of the Armed Forces. Symptomatic instability prompts individuals to seek a cure or a sheltered appointment. Despite the increasing numbers of ACL reconstructions performed, the outcomes have not been so spectacular with only a meager percentage of our patients returning to preinjury levels of activity. With the premise that an all-inside ACL reconstruction is likely to result in better functional outcomes, the aim of this study was to compare the short-term functional outcomes of a large consecutive series of patients undergoing ACL reconstruction using the translateral all-inside ACL reconstruction technique (AI) and standard anteromedial portal technique (AM) with a minimum follow-up of one year. MethodsA total of 240 patients with isolated ACL tear underwent ACL reconstruction via the AI or AM technique. Their preoperative and postoperative scores were compared to look for any significant differences in functional outcomes. ResultsThe two groups were matched for age, BMI, mechanism of injury, and interval from injury to surgery. There was no difference in their preoperative scores. Postoperatively, although there were significant improvements across both groups, there was no significant difference between the groups at any point of time. ConclusionThe AI technique has garnered interest in recent literature in addressing ACL injuries. This study found no discernible benefit of the AI technique when compared to the AM technique in terms of functionality following an ACL reconstruction at any point of time up to 1 year following surgery.

Poster 263: Distance to Neurovascular Bundle During Iliotibial Band ACL Graft Passage: A Cadaveric Study

Objectives:For patients with significant growth remaining, the Micheli (iliotibial band) ACL reconstruction technique has proven to be a reliable procedure with minimal risk for growth disturbance. Recent cadaveric studies have demonstrated that graft passage over the top of the femur may bring the graft and surgical instrument close to the critical neurovascular structures. The purpose of this study was to evaluate the Micheli over-the-top, graft passage technique for ACL reconstruction using pediatric cadaveric knees, and measure the distance between surgical instrument tip and the peroneal nerve, tibial nerve, and popliteal artery.Methods:Gross dissection was performed on seventeen skeletally immature cadaveric knees (12 male and 5 female) between the ages of 4 and 12 years old. A 5.5” curved-tip hemostat clamp was used to create a path through the posterior capsule, after the posterior neurovascular structures were identified. The tip of the clamp was passed from an anterior medial portal through the notch postero-superiorly, towards the proximal lateral capsule, with the knee flexed to 90-100 degrees or more. Once passed, the clamp was positioned in the popliteal fossa and clinical photographs were taken from the posterior aspect of the dissected knee, visualizing the tip of the clamp and the neurovascular structures. A metric ruler was included in all photographs. Digital imaging software was used to measure the distance in centimeters from clamp tip to peroneal nerve laterally, and the popliteal artery and tibial nerve medially for all specimens, FIGURE 1. Distances were averaged and stratified to assess differences in age and sex FIGURE 2.Results:The average distances from clamp to neurovascular bundle were 0.875cm (range: 0.468-1.737cm), 0.968cm (range: 0.312-1.819cm), and 1.149cm (range: 0.202-2.409cm) for tibial nerve, popliteal artery and peroneal nerve, respectfully. Means were further calculated for age groups ≤8, 9-10, and 11-12 years old. The average distance from clamp tip to peroneal nerve was 1.400cm larger for 11–12-year-old patients vs. patients ≤8 after adjusting for sex (95% CI=[0.6, 2.2], p=0.005).Conclusions:Iliotibial band graft ACL reconstruction is one of the best options in the skeletally immature, as it has the lowest risk of growth plate complications and growth arrest. The neurovascular structures are very close to the path for over-the-top graft clamp placement with distances <1 cm in many subjects. When passing the graft through the posterior knee there may be greater accessibility on the lateral cortex of the knee among older patients who are closer in age to physeal closure. The current study provides detailed measurements of instrument proximity to the neurovascular bundle in the posterior compartment of the knee. This knowledge is important to help surgeons who perform the Micheli pediatric ACL reconstruction avoid damage to the nerves and vessels in this region. Careful instrument and graft passage, with awareness of proximity to critical structures, are important to reduce the risk of neurovascular injury.Figure 1.Measurements (cm) from clamp tip to neurovascular bundle structures in right Knee model.Figure 2.Average distance from clamp from tip to neurovascular bundle by age Error bars represent 95%CI,**p<0.01

Poster 265: ACL Reconstruction in Skeletally Immature Patients: Do ACL Graft Tear and Complication Rates Differ Based on Surgical Technique? A Systematic Review

Objectives:Despite a notable increase in studies investigating outcomes following ACL reconstruction (ACLR) in pediatric patients in the last decade, there remains a dearth of comparative studies designed to elucidate the optimal technique(s) for this active, high-risk sub-population. The obejctive of the current study was to compare the rates of ACL graft tear, complications, and return-to-sport (RTS) between categories of ACLR techniques in skeletally immature patients. Our hypothesis was that complication rates would be similar between techniques, while ACL graft tear rates would be greater in transphyseal (adolescent) ACLR than physeal-sparing (pediatric) ACLR.Methods:A literature search indexed from the earliest available date to January 5, 2021 was performed using the PubMed/MEDLINE, Embase, and Cochrane databases for relevant journal articles with standard inclusion/exclusion criteria utilized for systematic reviews. Further exclusions were studies of ACL repair, revision ACLR, ACLR with allograft or bone-patellar tendon-bone (BTB) autograft. Cohorts of adolescent patients undergoing transphyseal ACLR were distinguished from those of pediatric patients undergoing physeal-sparing techniques, which were further sub-classified as all-epiphyseal (AE), iliotibial band (ITB)/modified Macintosh, and partial transphyseal (PTP). Transphyseal ACLR was further classified based on graft type (hamstring vs. quadriceps autograft). Primary outcomes included reoperation for ACL graft tear, non-ACL/meniscus complications, and RTS rates. Meta-analysis for each outcome incidence rate was conducted within each subgroup, and overall, using a random effects generalized linear mixed model with logit link.Results:44 studies published between 2001 and 2021 from 15 different peer-reviewed journals were included. The total number of patients within each subgroup were as follows: Transphyseal, 2,130 patients; AE, 232 patients; ITB, 274 patients; PTP, 99 patients. The mean age of the adolescent/transphyseal group was 13.4 years (range, 11.0-14.8), compared to 12.3 years (range, 11.0-14.8) in the pediatric/physeal-sparing group (AE, 12.6 years; ITB, 11.5 years; PTP, 12.6 years). Mean duration of follow-up was reported in 93.2% of the studies and was 4.0 years (range, 1.6-10.6 years). ACL graft tear, contralateral ACL tear, complications, and RTS were not significantly different between transphyseal and physeal-sparing techniques (all p>0.05) (Table 1). ITB reconstruction was not associated with any significant differences in ACL graft tear or RTS rates compared to other physeal-sparing techniques, but did demonstrate a significantly lower complication rate (ITB, 2.9%; AE, 10.8%; PTP, 15.3%; p=0.005). The most reported non-ACL/meniscus complications were arthrofibrosis (n=35) and growth disturbance (including angular deformity and leg length discrepancy, n=23).Conclusions:Unlike the findings of smaller, single-center clinical series, we found no differences in the clinical results of younger pediatric patients undergoing physeal-sparing ACLR and relatively older, skeletally immature adolescents undergoing transphyseal ACLR when the pediatric ACLR literature was analyzed in a pooled fashion. Amongst physeal-sparing techniques, the ITB/modified-MacIntosh ACLR demonstrated a significantly lower complication rate than all-epiphyseal and partial-transphyseal ACLR. Further prospective comparative research is required to directly compare ACLR techniques for differences in ACL graft tear rates.Table 1.Rates of ACL Graft Tear, complications, and Return to Sports in Skeletally Immature Sub-Populations

Bone Grafting Technique in Revision ACL Reconstruction: Coring Reamer and Dowel Trick

One- or two-staged bone grafting is sometimes required for tunnel malposition and/or tunnel widening in revision anterior cruciate ligament (ACL) reconstruction. The aim of this procedure is to restore the correct position of the ACL graft in the revision setting to provide a stable and functional ACL, thereby reproducing normal knee kinematics. We present a technique that allows for a cost-effective, convenient tunnel grafting of a femoral head allograft bone dowel into both femoral and tibial defects in revision ACL reconstruction.

Evaluation of a smartphone application for self-rehabilitation after anterior cruciate ligament reconstruction during a COVID-19 lockdown

BackgroundRehabilitation after surgery is a crucial process that governs the final functional outcome. The self-rehabilitation smartphone application Doct’up (Healing SAS, Lyon, France) is designed for patients who have had anterior cruciate ligament (ACL) reconstruction surgery. In France in the spring of 2020, the lockdown mandated due to the COVID-19 pandemic prevented patients from seeing their physiotherapists for 2 months. The objective of this study was to compare the clinical outcomes in two groups of patients who underwent ACL reconstruction surgery: in one group, surgery performed before the lockdown was followed by standard in-person physiotherapy while, in the other, surgery was done just before the lockdown and rehabilitation was performed by the patients themselves using the phone application. HypothesisUsing a self-rehabilitation smartphone app limits the negative effects of not receiving physiotherapist rehabilitation after ACL reconstruction. Material and methodsWe performed a case-control study involving the retrospective analysis of prospectively collected data from two groups of patients who had undergone ACL reconstruction surgery. Patients in the App group had surgery just before the 2-month COVID-19-related lockdown that started in France on March 17, 2020,and used only the smartphone app for rehabilitation. The standard-care group was composed of matched controls who had surgery 1 year before the cases and received rehabilitation therapy during in-person physiotherapist visits. The ACL reconstruction technique was the same in the two groups. The primary outcome measure was extension lag 6 weeks after surgery. The secondary outcome measures were extension lag 3 weeks and 6 months after surgery, quadriceps muscle activation, knee extension locking 3 and 6 weeks after surgery, and the 6-month rate of surgical revision for cyclops syndrome. ResultsWe included 32 cases managed using only self-rehabilitation guided by the phone app, and we identified 101 matched controls managed using standard care. We found no significant between-group difference in extension lag after 6 weeks: 9.4% (28/32) vs. 4.6% (87/101), p=0.39. After 3 weeks, the App group had a higher proportions of patients with quadriceps activation (94% [30/32] vs. 73% [74/101], p=0.015) and extension control using canes (78.1% [25/32] vs. 40.6% [41/101], p=0.0002). None of the other measured outcomes differed significantly between the two groups (extension lag after 3 weeks: 12.5% [4/32] vs. 13.8% 14/101]; extension lag after 6 months: 3.2% [1/32] vs. 1% [1/101]; quadriceps activation after 6 weeks: 97% [31/32] vs. 99% [100/101]; extension locking with canes after 6 weeks: 96.9% [31/32] vs. 93.1% [94/101]; extension locking without canes after 3 weeks: 53.2% [17/32] vs. 47.5% [48/101]; extension locking without canes after 6 weeks: 93.7% [30/32] vs. 82.2% [83/101]; and surgery for cyclops syndrome (3.1% [1/32] vs. 1% [1/101]). DiscussionThe use of a self-rehabilitation phone app after ACL reconstruction during a COVID-19 lockdown limited the adverse effects of not receiving in-person physiotherapy. The 6-month outcomes were similar to those seen with standard rehabilitation. The study results demonstrate the usefulness of self-rehabilitation after ACL reconstruction surgery. Self-rehabilitation guided by a phone app could be used as a complement to the protocols generally applied by physiotherapists. Level of evidenceIV, single-centre retrospective case-control study.

How to Avoid Knee Tunnel Convergence When Performing a Modified Lemaire Extra-Articular Tenodesis

There has been a significant increase in the number of anterior cruciate ligament (ACL) reconstruction (ACLR) procedures being performed with a lateral extra-articular procedure (LEAP). However, tunnel convergence in combined ACLR and LEAP techniques has been described and can lead to damage to the graft or graft failure. This technical note describes how to avoid knee tunnel convergence when performing a modified Lemaire extra-articular tenodesis using a knotless suture anchor.

Functional results of multiple revision anterior cruciate ligament with anterolateral tibial tunnel associated with anterolateral ligament reconstruction

BackgroundRevision anterior cruciate ligament (ACL) reconstructions are usually complex owing to previous tunnels. The objective of this study is to report the results of a revision ACL reconstruction technique with a tibial tunnel performed from the anterolateral plateau associated with an anterolateral ligament (ALL) reconstruction.MethodsPatients with at least two ACL reconstructions that failed and who had significant enlargement and confluence of tunnels in the medial tibial plateau and underwent revision ACL reconstruction associated with ALL reconstruction with the tibial tunnel for the ACL performed from the lateral plateau between 2017 and 2019 were evaluated. All patients were evaluated by physical examination, International Knee Documentation Committee (IKDC), and Lysholm functional scales.ResultsSix patients who underwent this surgical procedure were evaluated. All patients were sports practitioners and presented a grade 3 pivot shift. The mean age was 28.5 ± 8.2 years, and the mean follow-up time was 34.1 ± 12.8 months. No patient had a new graft rupture, but three (50%) had grade 1 pivot shift. Four patients had minor complications with no clinical impact on the final result. All except one patient were able to return to pre-injury type of sports, at a mean time of 14.6 ± 2.3 months after surgery.ConclusionThe anterolateral tibial tunnel technique using an Achilles tendon allograft for revision ACL reconstruction after multiple failures associated with an ALL reconstruction showed good results and no major complications. The anterolateral tunnel can be considered a good alternative in cases of medial tibial confluence or significant enlargement of the medial tunnels in re-revision procedures.

Objective laxity and subjective outcomes are more influenced by meniscal treatment than anterior cruciate ligament reconstruction technique at minimum2 years of follow-up

ObjectiveThe purposes of this study were: (1) to compare three different surgical techniques for anterior cruciate ligament (ACL) reconstruction at a minimum 2 years of follow-up in terms of objective laxity and patient-reported outcomes; (2) to inspect the role of meniscal tears and treatment alongside with ACL reconstruction. Methods59 patients were randomly assigned to one of the three reconstruction groups according to the ACL reconstruction technique: Double Bundle, Single Bundle, Single Bundle with Lateral Plasty. Autologous hamstring tendons were used in all the ACL reconstruction techniques. Objective laxity tests and KOOS were collected before surgery as a baseline and at a minimum of 2 years of follow-up and compared through a Repeated measure ANOVA. Secondary analysis to evaluate the effect of meniscal treatment on laxity reduction and scores improvement was also conducted using ANOVA. Three laxity evaluations were performed: anterior/posterior displacement at 30° of knee flexion (AP 30), anterior/posterior displacement at 90° of knee flexion (AP 90), and pivot-shift test. ResultsObjective laxity and KOOS showed statistically significant improvement at follow-up in all three groups (p < 0.0001) without differences among the techniques. A higher AP 30 (mean difference 2.4 mm, p = 0.0333, ES = 0.66) was found at baseline for the patients with irreparable medial meniscal tear compared to the patients with isolated ACL tear; a statistically significant difference in pain score at two-year follow-up was found between patients who underwent lateral meniscectomy and patients with either meniscal repair (mean difference 6.9 ± 12.5) or isolated ACL tear (mean difference 6.8 ± 16.1); patients with reparable meniscal tear had a statistically significant pain score improvement compared to the patients who underwent medial and lateral meniscectomy (mean difference of 9.5 ± 14.53 and 23.4 ± 19.2 respectively). ConclusionComparable objective laxity and subjective outcomes were found among the three ACL reconstruction techniques at a minimum of 2 years of follow-up. The presence of irreparable medial meniscal tear increased pre-operative laxity (AP 30, mean difference 2.4 ± 3.6 mm). Patients with meniscal repair presented higher pain relief between baseline and follow-up compared with patients undergoing medial or lateral meniscectomy (mean difference of 9.5 ± 14.53 and 23.4 ± 19.2, respectively).

Outcomes of Quadriceps Tendon Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients:2-Year Follow-Up

Background:The quadriceps tendon (QUAD) autograft has recently become an alternative to the hamstring tendon autograft that demonstrates superior preliminary outcomes in pediatric anterior cruciate ligament reconstruction (ACLR).Purpose:To evaluate 2-year clinical and patient-reported functional outcomes of primary ACLR with soft tissue QUAD autograft in skeletally immature patients.Methods:Consecutive skeletally immature patients who underwent ACLR with QUAD autograft were included. All cases utilized full thickness soft tissue QUAD autograft without a bone plug and were performed on patients with open growth plates. Preoperative demographic and surgical data were collected (Table 1). The ACLR technique was selected predicated upon skeletal age and included all-epiphyseal (AE) and complete transphyseal (CT). Patients were followed for a minimum of 24 months with successive clinical visits or contacted via telephone. Information regarding the return to sports and concomitant or subsequent surgical procedures was collected. KT-1000 was performed post-operatively, and Pediatric International Knee Documentation Committee (Pedi-IKDC) and HSS Functional Activity Brief Scale (HSS Pedi-FABS) scores were collected for each subject at their 2-year follow-up appointment.Results:The final cohort included of 60 consecutive adolescent patients aged 11.1 to 17.1 (13.9 ±1.2) with a minimum follow-up of 2 years. One patient was lost to follow-up. Prior to surgery, 86% of patients reported playing team sports including soccer, basketball, football and lacrosse, with soccer being the most popular one. 21 (35%) patients underwent AE and 39 (65%) underwent CT ACLR. Additionally, 35 (58%) underwent an a lateral extra-articular tenodesis procedure using the iliotibial band (ITB) with a modified Lemaire technique, and 5 (8%) patients underwent simultaneous implant mediated guided growth with a plate for structural genu valgum, both procedures were performed for non-modifiable risk factors as previously published for hamstring autograft ACLR. The rate of graft failure was 0%, and 10 patients had additional surgical procedures, of which 4 were concomitant removal of hardware for hemi-epiphysiodesis, 3 were contralateral ACLR, 3 were meniscal injuries that required surgical intervention and 2 were lysis of adhesions. The mean KT-1000 at 2-year follow-up was -0.36 ±0.75. The median Pedi-IKDC score was 87, and the median HSS-Pedi FABS score was 25. At 2 years after surgery, 90% patients reported returning to sports.Conclusion:This study reveals that QUAD autograft ACLR had a low failure rate when compared to previously reported studies of ACLR with hamstring autograft. Based on these results, we recommend this technique for skeletally immature patients undergoing ACLR.Table 1.Demographic and Surgical data of included knees.

Distance to Neurovascular Bundle During Iliotibial Band Acl Graft Passage: A Cadaveric Study

Background:For patients with significant growth remaining, the Micheli-Kocher (iliotibial band) ACL reconstruction technique has proven to be a reliable procedure with minimal risk for growth disturbance. Recent cadaveric studies have demonstrated that graft passage over the top of the femur may bring the graft and instrument close to the critical neurovascular structures.Purpose:The purpose of this study was to evaluate the over-the-top graft passage technique using pediatric cadaveric knees, and measure the distance between instruments and the peroneal nerve, tibial nerve, popliteal artery.Methods:Seventeen skeletally immature cadaveric knees between the ages of 4 and 12 years old were dissected and prepared for visualization of iliotibial band graft passage procedure. A curved hemostat clamp was used, creating a path through the posterior capsule. To avoid neurovascular injury, the tip of the instrument was kept close to the posterior and lateral cortex of the femur. Once the clamp was safely positioned in the posterior knee joint, photographs were taken. Digital imaging software was used to measure the distance in centimeters from clamp tip to peroneal nerve laterally, and the popliteal artery and tibial nerve medially for all specimens, FIGURE 1. Distances were averaged and stratified to assess differences in age, FIGURE 2.Results:The average distances from clamp to neurovascular bundle were 0.875cm (range: 0.468-1.737cm), 0.968cm (range: 0.312-1.819cm), and 1.149cm (range: 0.202-2.409cm) for tibial nerve, popliteal artery and peroneal nerve, respectfully. Means were further calculated for age groups ≤8, 9-10, and 11-12 years old.Conclusion:Iliotibial band graft ACL reconstruction is one of the best options in the skeletally immature, as it has the lowest risk of growth plate complications and growth arrest. The neurovascular structures are very close to the path for over-the-top graft clamp placement with distances <1 cm in many subjects. The current study provides detailed measurements of instrument proximity to the neurovascular bundle in the posterior compartment of the knee. This knowledge is important to help surgeons who perform the Micheli-Kocher pediatric ACL reconstruction avoid damage to the nerves and vessels in this region. Careful instrument and graft passage, with awareness of proximity to critical structures, are important to reduce the risk of neurovascular injury.Figure 1.Measurements (cm) from clamp tip to neurovascular bundle in right knee model.Figure 2.Average distance from surgical instrument to neurovascular bundle are identified with respect to age.

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

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

ACL Reconstruction in Skeletally Immature Patients: Does Graft Retear and Complication Rates Differ Based on Surgical Technique? A Systematic Review

Background:Despite exponential increases in studies regarding ACL reconstruction (ACLR) in pediatric patients in the last two decades, there remains a dearth of comparative studies designed to elucidate the optimal technique(s) for this active, high-risk sub-population.Hypothesis/Purpose:The purpose was to compare the rates of ACL re-tear, contralateral ACL tear, complications, and return-to-sport (RTS) between categories of ACLR techniques in skeletally immature patients. The hypothesis was that complication rates would be similar between techniques, while ACL re-tear rates would be higher in transphyseal (adolescent) ACLR than physeal-sparing (pediatric) ACLR.Methods:A literature search indexed from the earliest available date to January 5, 2021 was performed using the PubMed/MEDLINE, Embase, and Cochrane databases for relevant journal articles with standard inclusion/exclusion criteria utilized for systematic reviews. Further exclusions were investigations of ACL repair, revision ACLR, and ACLR with allograft or BTB autograft. Cohorts of adolescent patients undergoing transphyseal ACLR were distinguished from those of pediatric patients undergoing physeal-sparing techniques, which were further sub-classified as all-epiphyseal (AE), iliotibial band (ITB)/modified Macintosh, and partial transphyseal (PTP). Transphyseal ACLR was further classified based on graft type (hamstring vs. quadriceps autograft). Meta-analysis for each outcome incidence rate was conducted within each subgroup and overall using a random-effects generalized linear mixed model with logit link.Results:44 studies published between 2001 and 2021 from 15 different peer-reviewed journals were included. The mean age of the adolescent/transphyseal group was 13.4 years (range, 11.0-14.8), compared to 12.3 years (range, 11.0-14.8) in the pediatric/physeal-sparing group (All-Epiphyseal, 12.6 years; ITB, 11.5 years; PTP, 12.6 years). Mean duration of follow-up was reported in 93.2% of the studies and was 4.0 years (range, 1.6-10.6 years). ACL re-tear, contralateral ACL tear, complications, and RTS were not significantly different between transphyseal and physeal-sparing techniques (all p>0.05) (Table 1). ITB demonstrated significantly lower complications (2.9%) than other physeal-sparing techniques (AE, 10.8%; PTP, 15.3%, p=0.005) and the lowest ACL re-tear rate (AE, 10.1%; ITB, 6.9%; PTP, 7.5%, p=0.20), though this difference was not significant.Conclusions:Unlike the findings of some single-center analyses, when the breadth of pediatric ACLR literature was analyzed in pooled fashion, no differences were seen between the clinical results of younger pediatric patients undergoing physeal-sparing ACLR and relatively older skeletally immature adolescents undergoing transphyseal ACLR. Amongst physeal-sparing techniques, the ITB/modified-Macintosh ACLR appears to have the lowest retear rate and a significantly lower complication rate than all-epiphyseal and partial-transphyseal ACLR.

ACL Reconstruction With Quadrupled ST Graft and Mini-Invasive Anterolateral Ligament Reconstruction

Anterior cruciate ligament (ACL) reconstruction with hamstring graft is the most common procedure around the world. More recently, the use of the semitendinosus (ST), in a quadrupled arrangement, has been described with great results. Having a thicker tendon instead of double gracilis, ST offers a graft with a diameter superior to 8 mm, thus more closely resembling the native ACL and decreasing the risk of graft failure. It has also been published that preservation of the ACL stump was paramount to obtain better graft vascularization and proprioception. In addition, reconstructing the anterolateral ligament is associated with better results. The aim of this technical note is to present an ACL reconstruction technique using a quadrupled ST graft with a double suspensory fixation associated with ACL stump preservation and a mini-invasive anterolateral ligament reconstruction.

Paediatric Anterior Cruciate Ligament (ACL) Injuries: Current Concepts Review.

Over the past two decades, there has been a documented increase in paediatric ACL injuries because of a rise in younger age sports participation at the competitive level, awareness about sports-related injuries, and advanced imaging modalities. A PubMed electronic database search was done, which revealed 1366 hits over the last five years (2016 - 2020). Finally, 37 articles that contributed to new findings were included. This review was conducted based on predefined research questions. Early surgical reconstruction is recommended in children due to the increasing demand for early return to sports and to prevent the instability that can lead to progressive cartilage and meniscal damage. With the evolution of several "physeal sparing" ACL reconstruction (ACLR) techniques, a favorable clinical outcome with less growth disturbance is achievable. Although different autograft options are available, hamstring autografts are most commonly preferred. A specific pattern of a bone bruise not extending into the metaphysis, and lateral meniscus tears are the most common associated injuries. Following paediatric ACLR, complications like graft rupture and contralateral ACL injuries are two to three folds higher than with adult ACLR. Unprepared early return to sports is one of the reasons for increased complication rates in children; thus, clearance criteria for return to sports need to be standardized, and early return to sports (< 9 months post ACLR) should be avoided. Neuromuscular training protocols are recommended to minimize complications like graft ruptures.

Outside-in technique versus inside-out semitendinosus graft harvest technique in ACLR: a randomised control trial

BackgroundParaesthesia after hamstring graft harvest is a ubiquitous complication in the early post-operative period, and its correlation with vertical versus horizontal skin incision are well documented. The purpose of the study is to evaluate the incidence and extent/area of sensory loss of saphenous nerve branches occurring with the outside-in (OI) versus inside-out technique (IO) of semitendinosus graft harvest from the sartorius fascia and to determine a better method of graft harvest.MethodsSixty patients who underwent isolated semitendinosus graft harvest during anterior cruciate ligament reconstruction (ACLR) between 2016 and 2017. Patients were randomised into two groups depending on the graft harvest technique: 30 in the OI group and 30 in the IO group. The area of sensory loss was mapped on the patients’ skin using tactile feedback from the patients at each follow-up (10 days, 1 month, 3 months, 6 months and 1 year). Then, the area of sensory changes for the infrapatellar branch (IPBSN) and sartorial branch (SBSN) of the saphenous nerve, incision length, graft harvest duration, and graft length were analysed statistically between the groups.ResultsIn groups 1 and 2, 18/30 (60%) and 19/30 (63%) of patients, respectively, developed sensory changes, with no significant difference between the groups (p = 0.79). Isolated SBSN and IPBSN paraesthesia occurred in 2/60 (3%) and 19/60 (32%), respectively. Combined SBSN and IPBSN paraesthesia was present in 16/60 (27%) of patients. There was no significant difference in the area of the sensory deficit between OI and IO groups on the 10th post-operative day or at 1-month, 3-month or 1-year follow-up (p = 0.723, p = 0.308, p = 0.478, p = 0.128, respectively). However, at 6-month follow-up, the area of paraesthesia was significantly higher in the IO group (p = 0.009). The length of incision and duration of graft harvest was higher in the OI group than in the IO group (p = 0.002 and p = 0.007, respectively), and the total length of the graft was greater in the IO group (p = 0.04).ConclusionIncidence is equally distributed, area of iatrogenic saphenous nerve injury gradually decreases, and recovery is seen in the majority of the patients in both graft harvest techniques. IO graft harvesting technique is better in terms of graft harvest time and cosmetics and yields longer graft; however, area of paraesthesia, though not significant, was two-fold higher than the OI technique at 1-year follow-up.Clinical relevanceIO graft harvest technique would enable the surgeon to adopt quicker graft harvest, smaller surgical scar and lengthier graft than the OI technique.Level of evidenceTherapeutic randomised controlled prospective study, Level II.

Comparison of Inside-Out and Outside-In Methods of Femoral Tunnel Preparation in Anterior Cruciate Ligament (ACL) Reconstruction Using 3D-CT.

IntroductionAnterior cruciate ligament (ACL) reconstruction techniques continue to evolve and the need to address the more anatomical femoral tunnel placement of the graft is critical, and in our study, we assessed the placement of femoral tunnel via transportal and retrograde drilling techniques.Material and methodsSixty patients where n=31 for retrograde, n=29 for transportal were assessed via CT knee for the femoral tunnel aperture on the intercondylar ridge via high low and deep shallow direction ratio and interpreted accordingly.ResultsIn our study, the femoral tunnel done via transportal method (n=29) has a deep shallow ratio range of 22%-47% and mean of 31.9±6.5, and graft is anatomical in 79%. The femoral tunnel done via the retrograde method (n=31) has a deep shallow depth ratio range of 11%-41% with a mean of 27.5±6.5 and graft is anatomical in 77% of the study group and the p-value means the ratio is 0.01 (significant). The femoral tunnel done via transportal method (n=29) has a high low ratio range of 19%-45% and mean of 32.9±6.3 and graft is anatomical in 72%. The femoral tunnel done via the retrograde method (n=31) has a deep shallow depth ratio range of 20%-38% with a mean of 33.9±4.1 and graft is anatomical in 94% of the study group with a p-value mean ratio being 0.51 (insignificant).ConclusionWatch out for the femoral tunnel placement in a deep shallow direction while going for standard transportal technique and high low direction while performing retrograde technique.

Post-Operative Results of ACL Reconstruction Techniques on Single-Leg Hop Tests in Athletes: Hamstring Autograft vs. Hamstring Grafts Fixed Using Adjustable Cortical Suspension in Both the Femur and Tibia.

Background and Objectives: Anterior cruciate ligament (ACL) tears are common injuries in the athletic population, and accordingly, ACL reconstruction (ACLR) is among the most common orthopedic surgical procedures performed in sports medicine. This study aims to compare the semitendinosus/gracilis (ST/G) and ACL hamstring grafts fixed using adjustable cortical suspension in both the femur and tibia (MAI) ACLR techniques. We aimed to compare the results of single-leg hop tests (SLHT) applied in different directions and limb symmetry indices (LSI) in athletes with a 6-month post-operative ACLR history. Materials and Methods: A retrospective cohort of 39 athletes from various sports branches who underwent MAI (n = 16) and ST/G (n = 23) ACLR techniques by the same surgeon were evaluated. The knee strength of the participants on the operated and non-operated sides was evaluated with five different SLHTs. The SLHT included the single hop for distance (SH), triple hop for distance (TH), crossover triple hop for distance (CH), medial side triple hop for distance (MSTH), and medial rotation (90°) hop for distance (MRH). Results: There was a significant improvement in the mean Lysholm, Tegner, and IKDC scores in the post-operative leg for both techniques (p < 0.05) compared to the pre-operative levels. When there was a difference between the SH of the operative and the non-operative legs in the ST/G technique (p < 0.05), there was no significant difference in the other hop distance for both ST/G and MAI (p > 0.05). There was no difference between the techniques regarding the LSI scores. Conclusions: The fact that our research revealed similar LSI rates of the SLHTs applied in different directions in the ST/G and MAI techniques assumes that the MAI technique can be an ACLR technique which can be functionally used in athletes.

All-Inside Anterior Cruciate Ligament Reconstruction: A Review of Advance and Trends.

Anterior cruciate ligament (ACL) injury is a common disease in orthopedics and mostly occurs as a noncontact injury in athletes. Patients' knee joint stability, which is crucial to their athletic ability, cannot be restored through conservative treatment; it can only be restored through ACLR (ACL reconstruction) surgery. The surgical techniques of ACLR are constantly evolving, from bone tendon bone (BTB) grafting combined with interface screw fixation to hamstring tendon autograft or allogeneic tendon and of suspension device constructs. In particular, the currently prevalent all-inside technique featuring good cosmetic results and quick recovery of early functions not only ensures the stable fixation of grafts but also reduces surgical trauma. This review compares the advantages and disadvantages of different aspects of all-inside ACLR, including graft selection and preparation, bone socket reconstruction, fixation methods, and surgical technique effects and limitations. It has been found that the all-inside technique excels both anatomically and clinically but still requires further development. Besides, it has some limitations, and high-quality randomized controlled trials are still required to compare the long-term effects of the all-inside technique and other ACLR techniques.