Tendon Anterior Cruciate Ligament Reconstruction Research Articles

No Clinical Advantage of Harvesting a Patellar Bone Block Compared to All Soft Tissue Graft in Primary Quadriceps Tendon Anterior Cruciate Ligament Reconstruction

PurposeTo compare patient-reported outcomes measurements (PROMs) and subsequent surgical interventions in patients treated with anterior cruciate ligament reconstruction (ACLR) using either quadriceps tendon autograft with a patellar bone block (bQT) or soft tissue only (sQT). MethodsAll ACLRs performed between 01.2010 and 03.2022 were prospectively followed for 24 months and retrospectively evaluated. All primary ACLRs with full 24 months of follow-up data, without any previous surgery or any additional ligamentous interventions, were matched for major ACL risk factors, including gender, age, Tegner activity level (TAL), pivoting sports, and concomitant injuries. PROMs (Lysholm score, Visual Analog Scale (VAS) for pain, and TAL) and subsequent surgical interventions were registered after 6, 12, and 24 months postoperative. Binary logistic regression was used to assess the influence of graft type, age, preinjury TAL, gender, pivoting sports and concomitant interventions on the need to undergo subsequent surgery. ResultsAfter matching, 246 patients were included in the final analysis. Both groups did not differ regarding any preoperative patient demographics or intraoperative details. At final follow-up, no significant difference in mean Lysholm score (sQT: 90.8±10.6, bQT: 91.8±10.6, p= .46), median TAL (sQT: 6 [1-10], bQT: 6 [1-10], p= .53) and VAS for pain (sQT: 0.7±1.1, bQT: 0.7±1.2, p= .70) was reported between both groups. 70.3% (sQT-A: 70.7%, bQT: 69.9%, p= .89) of patients returned to or exceeded their preinjury activity level. In terms of revision ACLR, there was no statistically significant difference between bQT (3.3%) and sQT (4.1%). Similarly, no difference was observed in contralateral ACLR (bQT: 7.3% sQT: 11.4%). Regression analysis indicated that none of the studied factors, including the use of a patellar bone block, influenced subsequent surgery, revision ACLR, or contralateral ACLR. ConclusionHarvesting an additional patellar bone block in quadriceps tendon ACL reconstruction does not seem to impact postoperative patient-reported outcomes, ACL revision- or contralateral ACL reconstruction rates. Level of EvidenceLevel 3 – Cohort Study

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.

Comparison of the biomechanical properties of grafts in three anterior cruciate ligament reconstruction techniques based on three-dimensional finite element analysis

ObjectiveTo evaluate the biomechanical characteristics of grafts from three different anterior cruciate ligament (ACL) reconstructive surgeries and to determine which method is better at restoring knee joint stability.MethodsA 31-year-old female volunteer was enrolled in the study. According to the magnetic resonance imaging of her left knee, a three-dimensional model consisting of the distal femur, proximal tibia and fibula, ACL, posterior cruciate ligament, medial collateral ligament and lateral collateral ligament was established. Then, the ACL was removed from the original model to simulate the knee joint after ACL rupture. Based on the knee joint model without the ACL, single-bundle ACL reconstruction, double-bundle ACL reconstruction, and flat-tunnel ACL reconstruction were performed. The cross-sectional diameters of the grafts were equally set as 6 mm in the three groups. The bone tissues had a Young’s modulus of 17 GPa and a Poisson’s ratio of 0.36. The ligaments and grafts had a Young’s modulus of 390 MPa and a Poisson’s ratio of 0.4. Six probes were placed in an ACL or a graft to obtain the values of the equivalent stress, maximum principal stress, and maximum shear stress. After pulling the proximal tibia with a forward force of 134 N, the distance that the tibia moved and the stress distribution in the ACL or the graft, reflected by 30 mechanical values, were measured.ResultsThe anterior tibial translation values were similar among the three groups, with the double-bundle ACL reconstruction group performing the best, followed closely by the patellar tendon ACL reconstruction group. In terms of stress distribution, 13 out of 30 mechanical values indicated that the grafts reconstructed by flat bone tunnels had better performance than the grafts in the other groups, while 12 out of 30 showed comparable outcomes, and 5 out of 30 had worse outcomes.ConclusionCompared with traditional single-bundle and double-bundle ACL reconstructions, flat-tunnel ACL reconstruction has advantages in terms of stress dispersion. Additionally, flat-tunnel ACL reconstruction falls between traditional double-bundle and single-bundle ACL reconstructions in terms of restoring knee joint stability and is superior to single-bundle ACL reconstruction.

Peroneus Longus Tendon Autografts have Better Graft Diameter, Less Morbidity, and Enhanced Muscle Recuperation than Hamstring Tendon in ACL Reconstruction.

Recently the peroneus longus tendon (PLT) gained popularity in anterior cruciate ligament (ACL) reconstruction and has been utilized with satisfactory outcomes. However, there are concerns regarding donor site morbidity. This study aims to compare the functional outcome of ACL reconstruction using hamstring (HT) and PLT autografts and evaluate the donor site morbidity. Patients who underwent ACL reconstruction were allocated to two groups (HT and PLT). Graft diameter was measured intraoperatively. Knee functional outcome was evaluated with IKDC and Tegner-Lysholm scores preoperatively, and postoperatively after 3 months, 6 months, and 1 year. Donor site morbidities were assessed with thigh circumference measurements, subjective evaluation of sensory disturbances, and ankle scoring with AOFAS and FADI scores. At 1-year follow-up, the PLT group showed comparable IKDC (p = 0.925) and Tegner-Lysholm (p = 0.600) scores with those of the HT group. The mean graft diameter in the PLT group (7.93 ± 0.52mm) was larger compared with the HT group (7.43 ± 0.50mm) (p < 0.001). The incidence of thigh atrophy (HT-16.7%, PLT-10%) and sensory disturbances (HT-73.3%, PLT-10%) was greater in the HT group. There was no significant ankle donor site morbidity in the PLT group (AOFAS-98.67 ± 3.45, FADI-99.23 ± 1.69). ACL reconstruction with PLT had comparable functional outcome with that of HT at 1 year. However, PLT demonstrated larger graft diameter, less donor site morbidity, and enhanced muscle recovery without significantly affecting the ankle function. PLT can be safely used as an acceptable alternative graft choice harvested from outside the knee for ACL reconstruction.

Four-Stranded Semitendinosus Tendon Anterior Cruciate Ligament Reconstruction With Mini-invasive Anterolateral Ligament Reconstruction

Anterior cruciate ligament reconstruction (ACLR) is presently acknowledged as a prevalent procedure within the field of sports medicine surgery. Among the various graft options available, autograft hamstring tendons have emerged as one of the frequently used choices. This selection is primarily driven by the advantages it offers, such as reduced postoperative knee pain and a comparatively smoother surgical recovery process, when compared with the use of bone–patellar tendon–bone autografts. Quadrupled (4-stranded) semitendinosus tendon grafts have gained substantial popularity in recent years. This graft option offers the advantage of preserving the gracilis tendon while simultaneously exhibiting exceptional biomechanical strength. Furthermore, clinical studies have shown that the combination of ACLR and anterolateral ligament reconstruction yields superior outcomes, circumventing the application of nonanatomic extra-articular procedures involving the use of the fascia lata. The objective of this technical note is to outline a meticulous approach for ACLR using a 4-stranded semitendinosus tendon graft, applying a double-suspensory fixation method, and incorporating a minimally invasive procedure for anterolateral ligament reconstruction.

Minimal differences in acute postoperative pain after anterior cruciate ligament reconstruction with quadriceps versus hamstring autograft.

Studies are lacking that evaluate early postoperative pain after all-soft-tissue quadriceps tendon anterior cruciate ligament reconstruction (ACLR), particularly in young patients. The purpose of this study was to investigate differences in early postoperative pain between adolescent patients undergoing ACLR with quadriceps tendon versus hamstring autograft. A retrospective review was performed of 60 patients (mean age, 15.6 ± 1.3 years) who underwent ACLR using either quadriceps tendon ( n = 31) or hamstring ( n = 29) autografts between January 2017 and February 2020. Intraoperative and postoperative milligram morphine equivalents (MMEs), postanesthesia care unit (PACU) length of stay and PACU pain scores were recorded. Pain scores and supplemental oxycodone use were recorded on postoperative days (POD) 1-3. Differences were compared between the two groups. There were no statistically significant differences in age, sex, body mass index or concomitant meniscus repairs between the two groups ( P > 0.05). There were no statistically significant differences in intraoperative MMEs, PACU MMEs or PACU length of stay between groups ( P > 0.05). There were no statistically significant differences in maximum PACU pain scores (3.7 ± 3.0 vs. 3.8 ± 3.2; P = 0.89). Maximum pain scores on POD 1-3 were similar between groups ( P > 0.05). There were no statistically significant differences in supplemental oxycodone doses between groups on POD 1-3 ( P > 0.05). Adolescent patients undergoing ACLR with quadriceps tendon and hamstring autografts have similar pain levels and opioid use in the early postoperative period.

Poster 324: Complications following Quadriceps Tendon Anterior Cruciate Ligament Reconstruction in Pediatric Patients: A Case Series

Objectives: The purpose of this study was to analyze the rate and type of complications and subsequent procedures encountered with soft tissue quadriceps tendon autograft (QTA) for anterior cruciate ligament reconstruction (ACLR) in pediatric patients ≤ 18 years old. Methods: After institutional review board approval, operative records of all pediatric patients ≤ 18 years old who underwent ACLR from June 2015 to December 2021 were retrospectively reviewed. A consecutive series of patients who underwent ACLR with a QTA with minimum 6 month-follow up were included in the study. Skeletally immature patients underwent an all-epiphyseal (AE) technique while patients nearing skeletal maturity or that were skeletally mature underwent a complete transphyseal (CT) procedure. All patients underwent ACLR by utilizing a full thickness soft tissue QTA without a bone plug. Additionally, patients who were determined to be at high risk of re-tear underwent a concomitant a lateral extra-articular tenodesis (LET) with a modified Lemaire technique. Preoperative demographic information, surgical details, associated diagnosis, and subsequent injuries and complications were collected. Complications associated with the quadriceps tendon harvest site and use of QTA including removal of non-absorbable sutures from the autograft donor site, quadriceps tendon rupture, and the subsequent development of a superior patellar osteochondritis dissecans lesions (OCD) were reported. Results: A total of 143 pediatric patients ≤ 18 years old underwent an ACLR with a soft tissue QTA during the study period. Of the 143 eligible patients, 137 patients had minimum 6-month follow-up and were included in the study. After 3 attempted contacts, six patients (4%) were deemed lost to follow-up and excluded from the study. The mean age was 14.8±1.6 (range 11-18 years) and 60% were male. The average follow-up time was of 2.0 ± 1.1 years (range 0.5-4.9 years). Of the 137 patients included in the study, 11 (8%) had a subsequent complication associated with the use a of a QTA. Baseline demographic characteristics of this cohort are summarized in (Table 1). Of the 11 patients with QTA related complications, 8 (6%) had a subsequent procedure to remove non- absorbable sutures used for the donor site closure. When we first began to perform QTA ACLR, non- absorbable sutures were used to close the donor site defect. We encountered a subset of patients that developed persistent donor site irritation and pain associated to the use of such sutures, and consequently changed our technique to use absorbable sutures. Interestingly, 2 (1%) patients developed OCD-like lesions in the superior aspect of the patella 1.2 ± 0.8 years on average following surgery (Fig 1). We speculate that the QTA harvest could have compromised the vasculature of the patella, thus resulting in the development of OCD and subsequent chondromalacia. Finally, 2 (1%) patients had quadriceps tendon ruptures following QTA ACLR. The first patient aged 16, slipped and fell onto a hyperflexed left knee 6 weeks after QTA ACLR and sustained a small boney avulsion injury of the superior pole of the patella. During repair, cultures were taken, and rare Staphylococcus aureus were identified. The patient was placed on Keflex for 4 weeks, however 2 weeks after finishing treatment they presented with sudden limited range of motion, increased pain, and a yellow appearing scab. An ultrasound guided aspirated was positive for Staphylococcus aureus, and the patient subsequently underwent an infection and debridement procedure. The second patient, aged 14, sustained a non-contact injury while playing football 7 months post- operatively prior to being cleared to return to sports. They sustained a complete tear of the distal quadriceps tendon, adjacent to the donor site. Of note, 1 patient underwent a concomitant removal of non-absorbable sutures and patellar chondromalacia debridement and is thus represented twice. In addition, 5 (4%) patients had a graft failure and underwent subsequent revision ACLR, 6 (4%) had a second meniscus related surgery, 8 (6%) had a subsequent lysis of adhesions procedure and 13 (9%) underwent ACLR for injuries sustained on the contralateral knee. Conclusions: In this study, we report complications encountered with soft tissue QTA for ACLR. The complication rate for quadriceps tendon graft harvest was 8%. However, given that the removal of non- absorbable sutures from the donor site was caused by the surgical technique used, the revised complication rate for quadriceps tendon graft harvest was 3%. To the authors’ knowledge, this is the first study to raise the suspicion that quadriceps tendon graft harvest could lead to the development of super patellar OCD as this occurred in two patients from this cohort. Although the use of a QTA has recently gained popularity due to its high return to sports and low graft failure rate, surgeons must be aware of the complications and risk associated with quadriceps tendon graft harvest. [Table: see text]

Poster 338: Analysis of Patient Reported Outcomes and Subsequent Surgery Rate following Quadriceps Tendon Anterior Cruciate Ligament Reconstruction and Lateral Extra-articular Tenodesis in Skeletally Immature Patients: Two Year Follow-Up

Objectives: The incidence of anterior cruciate ligament reconstruction (ACLR) in pediatric and adolescent patients 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. The purpose of this study is to evaluate the 2-year clinical outcomes of ACLR with soft tissue quadriceps tendon (QUAD) autograft and a lateral extra-articular tenodesis (LET) using a modified Lemaire technique in skeletally immature patients. Methods: A consecutive series of patients who underwent QUAD tendon autograft 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. Outcome measures included participants’ return to sports (RTS), 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: The final cohort included 50 consecutive adolescent patients aged 11 to 16 years (mean 14.2 ± 1 years) with a minimum follow-up of 2 years. Two patients were lost to follow-up. Of the patients included in the study (n=48), 98% participated in high-risk competitive sports (Table 1). Two patients (4%) were revision ACLR. Ten (21%) patients underwent AE and 38 (79%) underwent CT ACLR. Sixteen patients (33%) had subsequent surgical procedures, including 5 contralateral ACLR, 4 meniscus surgeries, 4 QUAD autograft scar revision, 4 irrigation and debridement (2 patients, 2 each) and 3 hardware removal procedures (2 for hemi-epiphysiodesis and 1 tibial socket button removal). The rate of graft failure was 0%. At two-year follow-up, mean SANE score was 93, mean Pedi-IKDC score was 90, and mean HSS-Pedi-FABS score was 23. RTS rate was 100%. Conclusions: A LET when performing an ACLR is safe and should be considered as a concomitant procedure for adolescent patients that are at high risk of re-tear. [Table: see text]

Poster 332: Return to Sport, Post-Operative Performance Testing, and Re-injury Rates Among Athletes Treated with Hamstring, Quadriceps, and Patellar Tendon Autograft ACL Reconstruction

Objectives: Anterior Cruciate Ligament (ACL) tears are a common sporting injury and optimal graft choice is of concern for both patients and surgeons. Few comparative studies have evaluated return to sport and reinjury rates across graft types. The purpose of the present study was to evaluate return to sport rates and reinjuries among hamstring tendon (HT), quadriceps tendon (QT), and patellar tendon (BPTB) ACL reconstructions. Methods: Recreational and competitive athletes ages 13-24 from 2010-2022 that underwent primary or revision ACL reconstruction were included. There were 837 total athletes comprised of 341 HT, 358 BPTB, and 138 QT autografts, of which 729 were primary and 108 were revision surgeries. Return to sport (RTS) rates, RTS testing results, clearance time, and reinjury rates were collected. RTS testing data included isokinetic testing of quadricep and hamstring strength and functional movement screening. A Kruskal-Wallis test was used to detect differences among continuous variables. A GLIMMIX procedure was completed for multivariate analysis to detect differences between groups after adjusting for age and activity level. Chi-square statistics and Fisher’s exact test were used for categorical variables. Odds ratio, adjusted odds ratio, and 95% confidence intervals were provided by logistic regression. All statistical analyses were performed using SAS 9.4 (Cary, NC). Statistical significance was measured at p&lt;0.05. Results: The median ages were 18 for HT and BPTB and 17 for QT (p= 0.0001). Females comprised 50.73% of HT grafts, 42.86% of BPTB grafts, and 41.30% of QT grafts. Return to previous level of play was observed in 118/130 (90.77%) HT, 124/136 (91.18%) BPTB, and 39/52 (75.00%) of QT grafts (p=0.0045); BPTB remained statistically more likely to return to previous level of play than QT after adjusting for age and activity level. RTS testing was completed in 28/341 (8.21%) HT, 142/358 (39.66%) BPTB, and 80/138 (57.97%) QT grafts (p&lt;0.001); after adjusting for age and activity level, the results remained significant. Median isokinetic quadriceps testing at 300 degrees per second was 92% for 26 HT athletes, 83% for 134 BPTB athletes, and 87% for 77 QT athletes (p= 0.0006); results remained significant following age and activity level adjustment. Median isokinetic hamstring testing at 60 degrees per second was 89% for 24 HT athletes, 101% for 135 BPTB athletes, and 100% for 79 QT athletes (p=0.0007); results remained significant after adjustment for age and activity level. The median single- leg hop ratio was 98% for 5 HT athletes, 85% for 12 BPTB athletes, and 96% for 14 QT athletes (p=0.044); after adjusting for age and activity level, results remained significant. Time to be cleared for RTS was 25.89 weeks for 179 HT athletes, 34.75 weeks for 186 BPTB athletes, and 35.74 weeks for 75 QT athletes (p &lt;0.0001) with the results remaining statistically significant following adjustment for age and activity level. ACL retear rates were 12.02% for HT, 3.07% for BPTB, and 5.07% for QT (p&lt;0.0001) with hamstring grafts remaining significantly more likely to suffer an ACL retear than BPTB grafts after adjusting for age and activity level. Conclusions: After adjusting for age and activity level, BPTB ACL autografts demonstrated a lower reinjury risk when compared to HT autografts. When comparing QT and BPTB, return to sport testing 6-9 months post-op was superior in the QT group; however, BPTB patients were more likely to return to sport. This data can help influence surgeon and patient shared decision-making models in athletes with ACL injuries.

Tape-Reinforced Graft Suturing and Retensioning of Adjustable-Loop Cortical Buttons Improve Quadriceps Tendon Autograft Biomechanics in Anterior Cruciate Ligament Reconstruction: A Cadaveric Study

To investigate the biomechanical effects of tape-reinforced graft suturing and graft retensioning for all-soft tissue quadriceps tendon (ASTQT) anterior cruciate ligament reconstruction (ACLR) in a full-construct human cadaveric model. Harvested cadaveric ASTQT grafts were assigned to either (1) double-suspensory adjustable-loop cortical button device (ALD) fixation in which both graft ends were fixed with a suspensory fixation device with (n= 5) or without (n= 5) tape-reinforced suturing or (2) single-suspensory distal tendon fixation in which only the patellar end was fixed with an ALD (n= 5) or fixed-loop cortical button device (FLD) (n= 5). All specimens were prepared using a No. 2 whipstitch technique, and tape-reinforced specimens had an integrated braided tape implant. Graft preparation time was recorded for double-suspensory constructs. Samples were tested on an electromechanical testing machine using a previously published protocol simulating rehabilitative kinematics and loading. Tape-reinforced graft suturing resulted in greater graft load retention after cycling (11.9% difference, P= .021), less total elongation (mean [95% confidence interval (CI)], 5.57 mm [3.50-7.65 mm] vs 32.14 mm [25.38-38.90 mm]; P < .001), greater ultimate failure stiffness (mean [95% CI], 171.9 N/mm [158.8-185.0 N/mm] vs 119.4 N/mm [108.7-130.0 N/mm]; P < .001), and less graft preparation time (36.4% difference, P < .001) when compared with unreinforced specimens. Retensioned ALD constructs had less cyclic elongation compared with FLD constructs (mean total elongation [95% CI], 7.04 mm [5.47-8.61 mm] vs 12.96 mm [8.67-17.26 mm]; P= .004). Tape-reinforced graft suturing improves time-zero ASTQT ACLR construct biomechanics in a cadaveric model with 83% less total elongation, 44% greater stiffness, and reduced preparation time compared with a whipstitched graft without tape reinforcement. ALD fixation improves construct mechanics when compared with FLD fixation as evidenced by 46% less total elongation. Tape-reinforced implants and graft retensioning using ALDs improve time-zero ACLR graft construct biomechanics in a time-zero biomechanical model. Clinical studies will be necessary to determine whether these implants improve clinical outcomes including knee laxity and the incidence of graft rupture.

Suture Augmentation of a Four-Strand Semitendinosus Graft Improves Time-Zero Biomechanical Properties

To compare the time-zero biomechanical properties of hamstring graft preparations with or without suture augmentation for anterior cruciate ligament reconstruction (ACLR) in a full-construct cadaveric model. Hamstring grafts were harvested from 24 fresh frozen human cadavers and prepared in 1 of 3 ways: quadrupled SemiTendinosus (SemiT), and quadrupled SemiT with suture augmentation (SemiT+2.0-mm tape or SemiT+1.3-mm tape; n= 8 per group). Adjustable loop suspensory implants and cortical buttons were used for fixation on a porcine tibia and acrylic block. Testing included force-controlled cyclic loading at 250 N and 400 N followed by load to failure. The 2 suture augmentation groups had less total elongation and increased stiffness compared to the nonsuture-augmented group (P= .025). The SemiT+2.0-mm tape group had 36% less total elongation and 34% increased stiffness compared to SemiT+1.3mm tape (P < .001). Suture augmentation improves construct biomechanics at time zero following hamstring tendon ACLR. Augmentation with 2.0-mm tape suture improves construct biomechanics compared to 1.3-mm tape suture. Independent suture augmentation of a quadrupled SemiT graft improves ACLR construct biomechanics. Outcomes were improved with augmentation using 2.0-mm tape suture compared to 1.3-mm tape suture.

Evaluation of Autografts Used in Anterior Cruciate Ligament Reconstruction in Terms of Tensile Strength.

Introduction Anterior cruciate ligament (ACL) injuries increase the likelihood of chronic knee problems in later years, including early onset osteoarthritis. Therefore, ACL treatment is important in preventing knee problems from developing. The treatment of choice for ACL tears is surgery (ACL reconstruction), and the most popular tendons for ACL reconstruction are the patellar tendon, hamstring tendon (semitendinosus and gracilis tendons), and bone-patellar tendon-bone. The present study compares the tensile strength of autografts used in ACL reconstruction to identify the optimum autograft for ACL in terms of mechanical properties. Methods Cadavers were dissected, and the Achilles tendons, quadriceps tendons, hamstring tendons (semitendinosus and gracilis tendons), patellar tendon grafts, and ACLs were harvested. Tensile tests of each tendon graft were performed using a Shimadzu Autograph AG-IS 100 kN tester (Shimadzu, Kyoto, Japan). Results The mean difference in tensile strength between ACL and other grafts was lowest for the quadriceps in both males and females (p ˂ 0.001), meaning that ACL and quadriceps grafts are more compatible than other tendon grafts in terms of tensile strength. Conclusion The present study found the lowest mean difference in tensile strength to be between the ACL and the quadriceps tendon, suggesting that the use of the quadriceps tendon in ACL reconstruction will yield more positive outcomes.

Complications Following Quadriceps Tendon Anterior Cruciate Ligament Reconstruction in Pediatric Patients: A Case Series

Complications Following Quadriceps Tendon Anterior Cruciate Ligament Reconstruction in Pediatric Patients: A Case Series

Anterior Cruciate Ligament Reconstruction Plus Lateral Extra-articular Tenodesis Has a Similar Return-to-Sport Rate to Anterior Cruciate Ligament Reconstruction Alone but a Lower Failure Rate

To determine whether the addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament reconstruction (ACLR) would improve return-to-sport (RTS) rates in young, active patients who play high-risk sports. This multicenter randomized controlled trial compared standard hamstring tendon ACLR with combined ACLR and LET using a strip of the iliotibial band (modified Lemaire technique). Patients aged 25 years or younger with an anterior cruciate ligament-deficient knee were included. Patients also had to meet 2 of the following criteria: (1) pivot-shift grade 2 or greater, (2) participation in a high-risk or pivoting sport, and (3) generalized ligamentous laxity. Time to return and level of RTS were determined via administration of a questionnaire at 24 months postoperatively. We randomized 618 patients in this study, 553 of whom played high-risk sports preoperatively. The proportion of patients who did not RTS was similar between the ACLR (11%) and ACLR-LET (14%) groups; however, the graft rupture rate was significantly different (11.2% in ACLR group vs 4.1% in ACLR-LET group, P= .004). The most cited reason for no RTS was lack of confidence and/or fear of reinjury. A stable knee was associated with nearly 2 times greater odds of returning to a high-level high-risk sport postoperatively (odds ratio, 1.92; 95% confidence interval, 1.11-3.35; P= .02). There were no significant differences in patient-reported functional outcomes or hop test results between groups (P > .05). Patients who returned to high-risk sports had better hamstring symmetry than those who did not RTS (P= .001). At 24 months postoperatively, patients who underwent ACLR plus LET had a similar RTS rate to those who underwent ACLR alone. Although the subgroup analysis did not show a statistically significant increase in RTS with the addition of LET, on returning, the addition of LET kept subjects playing longer by reducing graft failure rates. Level I, randomized controlled trial.

Osteoconductive Scaffold Placed at the Femoral Tunnel Aperture in Hamstring Tendon ACL Reconstruction: A Randomized Controlled Trial.

Bone tunnel enlargement after single-bundle anterior cruciate ligament reconstruction remains an unsolved problem that complicates revision surgery. Positioning of an osteoconductive scaffold at the femoral tunnel aperture improves graft-to-bone incorporation and thereby decreases bone tunnel widening. Randomized controlled trial; Level of evidence, 1. In a 1:1 ratio, 56 patients undergoing primary anterior cruciate ligament reconstruction were randomized to receive femoral fixation with cortical suspension fixation and secondary press-fit fixation at the tunnel aperture of the tendon graft only (control) or with augmentation by an osteoconductive scaffold (intervention). Adverse events, patient-reported outcomes, and passive knee stability were recorded over 2 years after the index surgery. Three-dimensional bone tunnel widening was assessed using computed tomography at the time of surgery and 4.5 months and 1 year postoperatively. The intervention group exhibited a similar number of adverse events as the control group (8 vs 10; P = .775) including 2 partial reruptures in both groups. The approach was feasible, although 1 case was encountered where the osteoconductive scaffold was malpositioned without adversely affecting the patient's recovery. There was no difference between the intervention and control groups in femoral bone tunnel enlargement, as expressed by the relative change in tunnel volume from surgery to 4.5 months (mean ± SD, 36% ± 25% vs 40% ± 25%; P = .644) and 1 year (19% ± 20% vs 17% ± 25%; P =.698). Press-fit graft fixation with an osteoconductive scaffold positioned at the femoral tunnel aperture is safe but does not decrease femoral bone tunnel enlargement at postoperative 1 year. NCT03462823 (ClinicalTrials.gov identifier).

Combined press-fit and extracortical fixation in patellar tendon anterior cruciate ligament reconstruction results in reliable graft fixation and early bone block incorporation

BackgroundAnterior cruciate ligament (ACL) reconstruction with bone–patellar-tendon–bone (BPTB) autograft has the potential biological advantage of direct bone-to-bone healing over soft tissue grafts. The primary aim of this study was to investigate possible graft slippage and therefore fixation strength in a modified BPTB autograft technique with suspensory fixation on both sides for primary ACL reconstruction until bony integration takes place. MethodsTwenty-one patients undergoing primary ACL reconstruction with a modified BPTB autograft (bone-on-bone (BOB) technique) between August 2017 and August 2019 were included in this prospective study. A computed tomography (CT) scan of the affected knee was performed directly postoperatively, as well as 3 months postoperatively. Examiner-blinded parameters for graft slippage, early tunnel widening, bony incorporation, as well as remodeling of the autologous refilled patellar harvest site were investigated. ResultsA series of 21 patients treated with a BPTB autograft with this technique underwent two CT investigations. Comparison of CT scans showed no bone block displacement and therefore no graft slippage in the patient cohort. Only one patient showed signs of early tunnel enlargement. Radiological bone block incorporation took place showing bony bridging of the graft to the tunnel wall in 90% of all patients. Furthermore, 90% showed less than 1 mm bone resorption of the refilled harvest site at the patella. ConclusionsOur findings suggest graft fixation stability and reliability of anatomic BPTB ACL reconstruction with a combined press-fit and suspensory fixation technique by absence of graft slippage within the first 3 months postoperatively.

COMPARATIVE STUDY OF FUNCTIONAL OUTCOME OF ACL RECONSTRUCTION BY HAMSTRING VS PERONEUS LONGUS AUTOGRAFT

Introduction: Anterior cruciate ligament (ACL) reconstruction improves knee stability and function with many graft types, either autografts or allografts, which have already been studied extensively. Among these grafts, bone–patellar tendon–bone (BPTB) and four-strand hamstring autografts are the two most common autografts used for ACL reconstruction and each has its advantages and disadvantages. Orthopaedic surgeons are attempting to use peroneus longus tendon as a graft. Peroneus longus tendon autografts are commonly used in some orthopaedic procedures, including spring ligament reconstruction, deltoid ligament reconstruction and medial patellofemoral ligament reconstruction. The purpose of this study is to compare the functional outcome between the peroneus longus tendon and hamstring tendon in ACL Reconstruction. Material And Methods: In our study we took 40 cases of ACL tear fulfilling inclusion and exclusion criteria. Patient selection was randomised, half of the patients were operated by Diagnostic Arthroscopy with ACL reconstruction using hamstring autograft and the other half by using peroneus longus autograft. Patients were in the age group of 19 to 54 years. The male/female ratio is 32 males and 8 females. Results: Patient was followed at 6 weeks, 3 and 6-months post operatively for clinical and radiological evaluation and results at end of 6 months were calculated by using IKDC and Lysholm knee score. The functional and radiological outcome is similar in both groups Conclusion: Anterior cruciate ligament reconstruction with peroneus longus autografts produces a functional score (IKDC, Lysholm) comparable to that of hamstring autografts at a 6-month follow-up.

No increase in adverse events with lateral extra-articular tenodesis augmentation of anterior cruciate ligament reconstruction – Results from the stability randomized trial

ObjectivesResults from the Stability Study suggest that adding a lateral extra-articular tenodesis (LET) to a hamstring tendon autograft reduces the rate of anterior cruciate ligament reconstruction (ACLR) failure in high-risk patients. The purpose of this study is to report adverse events over the 2-year follow-up period and compare groups (ACLR alone vs. ACLR + LET). MethodsStability is a randomized clinical trial comparing hamstring tendon ACLR with and without LET. Patients aged 14–25 years with an ACL deficient knee were included. Patients were followed and adverse events documented (type, actions taken, resolution) with visits at 3, 6, 12, and 24 months postoperatively. Adverse events were categorized as none, minor medical, minor surgical, contralateral ACL rupture, or graft rupture. Patient reported outcome measures (PROMs) collected at each visit included the Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee Score (IKDC), and ACL Quality of Life Questionnaire (ACL-QOL). ResultsIn total, 618 patients were randomized (mean age 18.9 years, 302 (49%) male). Forty-five patients (7%) suffered graft rupture; 34 (11%) in the ACLR group compared to 11 (4%) in the ACLR + LET group (RRR = 0.67, 95% CI 0.36 to 0.83, p < 0.001). There were no differences in effusion or infection rates between groups. The ACLR + LET group experienced an increased number of hardware removals (10 vs. 4). Overall, the rate of minor medical events (11%), minor surgical events (7%), and ipsilateral or contralateral ACL tears (10%) were low considering the high-risk patient profile. Increasing severity of adverse events was associated with lower PROMs at 24 months post-operative. Patients in the ACLR + LET group reported greater degree of pain at 3 months only. There were no clinically significant differences in range of motion between groups. ConclusionsThe addition of LET to hamstring tendon autograft ACLR in young patients at high risk of re-injury resulted in a statistically significant reduction in graft rupture. While the addition of LET may increase rates of hardware irritation, there was no significant increase in overall rates of minor medical adverse events, minor surgical events, or overall re-operation rates. The concerns regarding complications associated with a LET did not materialize in this study. Level of evidenceLevel I

Patient Reported Outcome Measures in Pediatric Anterior Cruciate Ligament Reconstruction: Does Promis Correlate with Pedi-Ikdc?

Background:The Pedi-IKDC is a well-established patient reported outcome (PRO) measure used in knee and sports surgery. Recently, the computer adaptive PROMIS test has emerged as an alternative measure of patient function in this realm, but it is unclear if it captures information similar to the Pedi-IKDC and other PROs.Hypothesis/Purpose:The purpose of this study was to evaluate the strength of correlation between PROMIS and Pedi-IKDC scores for pediatric anterior cruciate ligament reconstruction (ACLR) patients during the postoperative period.Methods:Pediatric (<18yo) patients undergoing primary ACLR at a single urban tertiary care children’s hospital were identified. Patients completing both PROMIS and Pedi-IKDC within 2 weeks of each other were included. PROMIS domains including Physical Function, Anxiety, Depressive Symptoms, Fatigue, Peer Relationships, and Pain Interference were compared with the Pedi-IKDC using Pearson or Spearman correlations. Correlations were performed between Pedi-IKDC and PROMIS domains within subgroups based on timing of survey completion post-operatively (<6 weeks, 6-12 weeks, 3-6 months, 6-9 months, and >9 months). Multivariable robust regression modeling was performed to generate an equation of best fit to calculate a patient’s projected Pedi-IKDC result from PROMIS subdomains.Results:Study criteria were met by 150 patients. The cohort averaged 15.0 ± 2.2 years of age, was 50.7% male and underwent predominantly quadriceps (55.3%) or hamstring (36.7%) tendon ACLR. Score correlations appeared stronger with increased follow-up (Table 1.1). Both PROMIS Physical Function and Pain scores demonstrated moderate correlation to IKDC scores at 6-9 months (R=0.689, p<0.001; R=-0.556, p<0.001) and >9 month (R=0.487, p=0.001; R=-0.429, p=0.003) post-operatively. Across all timepoints, Pedi-IKDC and PROMIS Physical function demonstrated a strong correlation (R=0.844, p<0.001) while PROMIS Pain interference showed a moderate correlation (R=-0.541, p<0.001). A conversion equation for predicting Pedi-IKDC score was generated from PROMIS Physical Function and Pain Interference subdomains based on forward stepwise variable selection for robust regression model. This model demonstrates strong predictive ability for Pedi-IKDC (R⁁2=0.752, p<0.001) (Figure 1.2). Conclusion:The results from this study suggest that Pedi-IKDC demonstrates moderate to strong correlation with PROMIS physical function and pain interference domains following pediatric ACLR. Together, these two PROMIS domains also provide a reasonably strong prediction of a patient’s Pedi-IKDC score at a similar postoperative timepoint. These findings serve to facilitate cross-study outcome comparisons and can aid in the reduction of patient survey burden. Further work will be necessary to confirm these results across a broader patient cohort with longer periods of postoperative follow-up.Table 1.1.

Tibial tunnel enlargement is affected by the tunnel diameter-screw ratio in tibial hybrid fixation for hamstring ACL reconstruction

IntroductionThere is no evidence on screw diameter with regards to tunnel size in anterior cruciate ligament reconstruction (ACLR) using hybrid fixation devices. The hypothesis was that an undersized tunnel coverage by the tibial screw leads to subsequent tunnel enlargement in ACLR in hybrid fixation technique.MethodsIn a retrospective case series, radiographs and clinical scores of 103 patients who underwent primary hamstring tendon ACLR with a hybrid fixation technique at the tibial site (interference screw and suspensory fixation) were obtained. Tunnel diameters in the frontal and sagittal planes were measured on radiographs 6 weeks and 12 months postoperatively. Tunnel enlargement of more than 10% between the two periods was defined as tunnel widening. Tunnel coverage ratio was calculated as the tunnel diameter covered by the screw in percentage.ResultsOverall, tunnel widening 12 months postoperatively was 23.1 ± 17.1% and 24.2 ± 18.2% in the frontal and sagittal plane, respectively. Linear regression analysis revealed the tunnel coverage ratio to be a negative predicting risk factor for tunnel widening (p = 0.001). The ROC curve analysis provided an ideal cut-off for tunnel enlargement of > 10% at a tunnel coverage ratio of 70% (sensitivity 60%, specificity 81%, AUC 75%, p < 0.001). Patients (n = 53/103) with a tunnel coverage ratio of < 70% showed significantly higher tibial tunnel enlargement of 15% in the frontal and sagittal planes. The binary logistic regression showed a significant OR of 6.9 (p = 0.02) for tunnel widening > 10% in the frontal plane if the tunnel coverage ratio was < 70% (sagittal plane: OR 14.7, p = 0.001). Clinical scores did not correlate to tunnel widening.ConclusionTibial tunnel widening was affected by the tunnel diameter coverage ratio. To minimize the likelihood of disadvantageous tunnel expansion—which is of importance in case of revision surgery—an interference screw should not undercut the tunnel diameter by more than 1 mm.