Tendon Anterior Cruciate Ligament Reconstruction Research Articles

Suture tape reinforcement of hamstring tendon graft reduces postoperative knee laxity after primary ACL reconstruction

PurposeTo evaluate and compare subjective and objective knee outcomes following hamstring tendon (HT) and quadriceps tendon (QT) anterior cruciate ligament reconstruction (ACLR) with or without suture tape (ST) reinforcement. It was hypothesized that the addition of an intra-articular synthetic augmentation with a ST would reduce postoperative knee laxity and graft ruptures after ACLR.MethodsA 1:1 matched-cohort comparison of patients who underwent HT and QT autograft ACLR with or without ST reinforcement was performed. Patients with ST reinforcement were consecutively assigned to the study groups until a number of 20 in each group was achieved. Medical records were reviewed for demographic characteristics and additional injuries. Laxity measurements with KT-1000, strength measurements and physical examination findings were collected both preoperatively and at 6 months and patient reported outcome (PRO) scores were collected both preoperatively and at 12 months, and comparison was made HT vs HT + ST and QT vs QT + ST. Reoperations and re-ruptures were recorded during the 24-month follow-up period.ResultsOverall, 80 patients who underwent ACLR were included. Patients with HT + ST had significant less laxity postoperatively compared to HT at 6 months, 1.9 vs 0.8 mm, p < 0.05. No differences were found between the QT and QT + ST group. At 6 weeks patients treated with ST, both QT and HT, had a significant deficit in flexion compared to those without ST. However, this resolved at 6 months. There were no significant differences between HT + ST vs HT, or QT + ST vs QT, regarding postoperative PROs or strength measurements. Furthermore, the incidence of subsequent surgery and graft rupture was not significantly different between the groups.ConclusionACLR with HT + ST reduces laxity at 6 months compared to ACLR without ST, a difference not seen when ACLR was performed using QT with or without ST. No other differences were seen between the two techniques comparing subjective and objective findings.Level of evidenceLevel III.

Comparing the Stiffness of Peroneus Longus Tendon Versus Hamstrings in Anterior Cruciate Ligament Reconstruction: A Biomechanical Study

Background: The use of autografts originating from either hamstring tendons or peroneus longus tendons is a surgical option in anterior cruciate ligament (ACL) reconstruction. Objectives: This research aimed to compare the tensile strength between the hamstring tendon and the peroneus longus tendon in ACL reconstruction. The hypothesis of this study was: Peroneus longus grafts have tensile strength equal to hamstring grafts based on living donor patients. Methods: This cross-sectional study was a biomechanical study examining means and standard deviations (SD) by comparing the tensile strength of peroneus longus tendons and hamstring tendons when used as autograft donors in ACL reconstruction. Results: In this study, 51 patients with reconstructive ACL were enrolled. The mean diameter of the hamstring tendon was 7.86 with SD ± 0.69, while the mean diameter of peroneus longus tendon was 7.67 with SD ± 0.63. The mean diameter of the peroneus longus graft was not significantly different. The mean displacement on the hamstring tendon was 2.44 with SD ± 0.42, while the peroneus longus tendon was 2.06 with SD ± 0.14. The peroneus longus tendon had significantly more tensile strength compared to the hamstring tendon. Conclusions: Diameter of the peroneus longus graft was not significantly different from the hamstring graft. However, the peroneus longus graft had more tensile strength than the hamstring graft based on living donor patients.

Functional Outcome of Chronic Anterior Cruciate Ligament Rupture Reconstruction Using Peroneus Longus Tendon Graft According to AOFAS and IKDC Score: A Case Series

Introduction: The anterior cruciate ligament (ACL) is a crucial ligament structure of the knee that plays a significant role in knee joint stability and competitive sports performance. In order to reestablish knee stability, ACL reconstruction (ACLR) in the presence of rupture has been recognized as the most common surgical management procedure. Case: This study reported six cases of chronic ACL rupture reconstruction using peroneus longus tendon graft. All patients underwent an arthroscopic ACL repair procedure in Sanglah Hospital Bali. In terms of functional outcome, all patients were assessed using the scoring of AOFAS for the ankle and IKDC for the knee. Result: The functional outcomes of the IKDC and AOFAS score were good from all six patients who already underwent ACL reconstruction using peroneus longus graft with a minimum follow-up of one year. Discussion: Chronic ACL ruptures were successfully treated using the peroneus longus tendon graft. Intraoperatively, there were no significant problems from the harvested peroneus longus tendon graft and ACL reconstruction with the graft. All patients showed no complications, including the local infection following the operation. Rehabilitation procedure post-ACL reconstruction was performed at the Rehabilitation Unit in Sanglah General Hospital. Conclusion: Peroneus longus tendon graft is considered a suitable choice of graft for ACL reconstruction. It presented satisfactory results, effectiveness, and safety based on the AOFAS and IKDC scores.

ISOKINETIC STRENGTH IS COMPARABLE AMONG ADOLESCENT PATIENTS WHO HAD EITHER A SINGLE INJECTION FEMORAL NERVE BLOCK OR CONTINUOUS FEMORAL NERVE CATHETER DURING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

Background:Single injection femoral nerve blocks or continuous femoral nerve catheters are commonly used during anterior cruciate ligament reconstruction (ACLR). However, both single injection and continuous femoral nerve catheters have been associated with decreased quadriceps strength and function up to 6 months postoperative compared to no regional anesthesiaPurpose/Hypothesis:We compared isokinetic limb asymmetry 5-10 months post-surgery between patients who received either single injection or continuous femoral nerve block during ACLR. We also assessed patient characteristics potentially associated with strength deficits. We hypothesized that patients with continuous femoral nerve catheters would demonstrate decreased quadriceps function due to increased local anesthetic.Methods:We reviewed medical records of patients ages 10-19 years who completed isokinetic testing 5-10 months following quadricep tendon ACLR by a single surgeon. Patients were excluded for previous lower limb surgery. We grouped patients based on whether they received a single injection femoral nerve block (FNB group) or a continuous femoral nerve catheter (FNC group) intraoperatively. Using isokinetic data at 60, 180, and 300 degrees per second, we calculated maximum torque percent deficit of the involved compared to the uninvolved leg, as well as compared peak torque extensor and flexor deficits (% difference between operative/non-operative sides) between groups.Results:Sixty-two patients were included: 50 who received FNC and 12 who received FNB (Table 1). There were no significant differences between continuous femoral nerve block and single-shot femoral nerve block groups for extensor deficits at any speed (Figure 1) or for flexor deficits at any speed (Figure 2). At 60 degrees/s (p=0.006) and 180 degrees/s (p=0.017), longer time since surgery was associated with smaller extensor deficits (Table 2). At 180 degrees/s (p=0.008) older age was associated with greater extensor deficits (Table 2). At 60 degrees/s (p=0.017) skeletal maturity was associated with greater extensor deficits (Table 2). At all speeds, an injured dominant limb was associated with smaller flexor deficits (Table 3). Older age was associated with greater flexor deficits at 60 deg/s (Table 3).Conclusion:No apparent significant isokinetic strength differences were found between groups 5-10 months postoperatively. Longer time from surgery was significantly associated with decreased extensor deficits among both groups at slower isokinetic test speeds. Our data suggest increased isokinetic strength recovery over the 5-10-month timeframe. The surgeon, anesthesia team, and patient should choose the pain management protocol based on resource and patient factors.Tables and Figures:Figure 1.Mean values (error bars represent 95% confidence intervals) for Peak Torque (ft-lb) extensor % deficits (% change between surgically affected and unaffected sides) between continuous femoral nerve block and single-shot femoral nerve block groups at each of the isokinetic test speeds.Figure 2.Mean values (error bars represent 95% confidence intervals) for Peak Torque (ft-lb) flexor % deficits (% change between surgically affected and unaffected sides) between continuous femoral nerve block and single-shot femoral nerve block groups at each of the isokinetic test speeds.

Perioperative Complications and Early Clinical Outcomes Following ACL Reconstruction with Soft Tissue Quadriceps Tendon Autograft in Adolescent Athletes

Objectives:Quadriceps tendon (QT) autograft has emerged as an increasingly popular soft tissue graft alternative to the hamstring tendon (HS) autograph for ACL reconstruction (ACLR). However, utilization of the technique is not yet widespread, particularly in the population of adolescent athletes, for whom safety and effectiveness of the technique remains under-investigated, despite this being the most affected epidemiologic sub-population, with regard to primary ACL injury, post-ACLR re-tear, and overall complications. The study hypothesis was that QT-ACLR would have equivalent or lower rates of perioperative complications and early ACL re-tear than historically reported for HS ACLR.Methods:A retrospective review of all 12-19 year-old athletes who underwent primary QT-ACLR by a single surgeon at a tertiary care pediatric hospital were included, with prospective outreach performed at 1 and 2 years to collect PROs and confirm absence of ACL re-tear or revision surgery. Patients with <6 months follow-up were excluded to insure adequate reporting of early perioperative complications. Patients with between 6-12 month follow up were excluded from the ACL re-tear analysis. Concomitant procedures at the time of primary ACL surgery, perioperative and early post-operative complications, and subsequent surgeries were analyzed. A sub-analysis excluding the first 25 knees was performed to eliminate any potential effects of a surgical ‘learning curve’.Results:90 patients (93 knees, 70% female) were included, with a mean age of 16.0 years (±1.85) and mean follow up of 12.6 months (IQR 9.1-21.4). Concomitant meniscal pathology was detected in more than half of patients, with 30% undergoing meniscal repair and 27% partial meniscectomy. There were 51 complications overall in 36 knees (39%, Table 1). Secondary surgery for a complication was performed in 22 knees (24%), most commonly for a cyclops lesion/arthrofibrosis (15%), but also for revision ACLR (5%) and removal of implants (1%). Of note, 6 additional knees (6%) were diagnosed by MRI for a cyclops lesion/arthrofibrosis, but were successfully treated with non-operative measures, including physical therapy, dynamic splinting, and/or intra-articular cortisone injections. ACL graft tear was more common in the first 25 knees for whom QT-ACLR was performed (16% vs. 1%, p=0.02), indicating that initial re-tear could be a function of the surgical learning curve and technique adjustments. Early graft tear rate of 5% is similar to reported rates in HS autograft in adolescents. Arthrosibrosis/cyclops lesions were more frequently observed than historically reported for other graft types, and were not significantly different based on learning curve (20% vs. 22%, p=1.00). Pedi-IKDC (Table 2) showed significant improvement from baseline to 6-month (p<0.001) and 1-year time (p<0.001) period. Patients without complications had a significantly higher Pedi-IKDC score at 1 year follow up (mean, 93.9) compared to those with complications (mean, 85.5; p=0.04).Conclusions:Quad tendon ACLR shows a relatively high overall early post-operative complication and subsequent surgery rate in adolescents, most notably cyclops lesions/arthrofibrosis, most cases of which underwent arthroscopic debridement/LOA. This is consistent with previous adult QT-ACLR studies. Graft tear rates at 1-year post-operatively are similar to historically reported re-tear rates of the HS ACLR for adolescents, with a higher re-tear rate in the earlier sub-cohort, which may relate to surgical learning curve. Continued research into minimizing risks and quantifying longer term ACL re-tear risk will be critical for this young, active population, who are increasingly undergoing ACLR with the QT autograft, which remains relatively understudied, particularly in the adolescent sub-population.

Return to Play and Career Length After Anterior Cruciate Ligament Reconstruction Among Canadian Professional Football Players

Background: For many athletes, a tear of the anterior cruciate ligament (ACL) represents a significant injury that requires a prolonged period away from the sport with substantial rehabilitation. Hypothesis: There will be no difference in return to play (RTP) and career length after hamstring tendon (HT) ACL reconstruction in a group of Canadian Football League professional players as compared with what has been already been reported in the literature among professional football players. Study Design: Case-control study; Level of evidence, 3. Methods: Data on athletes who sustained an ACL injury were collected by team physicians and head athletic trainers from 2002 to 2017 from 2 Canadian Football League teams. Patient details included age at the time of injury, initial injury date, position, practice versus game injury, and primary versus rerupture with injury-specific data, such as affected limb, concomitant injuries, graft choice, and procedure performed. RTP rates and career length data were collected through publically available internet sources. Comparisons between the non-RTP and RTP groups were made with independent-sample t tests. Binomial logistic regression was performed to determine variables (ie, games preinjury, graft type, meniscal injury, collateral ligament injury) that contributed to players not being able to RTP. Results: A total of 44 ACL reconstructions were performed over the study period (HT, n = 32 [72.7%]; bone–patellar tendon–bone [BPTB], n = 8 [18.2%]; allograft, n = 4 [9.1%]). Overall, 69.8% (n = 30) were able to RTP in at least 1 game, while 30.2% (n = 13) did not return. Mean time to return was 316.1 days (range, 220-427 days), or 10.4 months. For those players who did RTP, mean career length after ACL reconstruction was 2.8 seasons, or 34.4 games. The majority (56.8%) of injuries occurred early in the season. Breakdown by graft type demonstrated RTP rates among HT, BPTB, and allograft of 64.5% (n = 20), 87.5% (n = 7), and 75% (n = 3), respectively. Career length among HT, BPTB, and allograft was 2.9, 2.4, and 3 seasons. Logistic regression analysis found only concomitant medial collateral ligament (MCL) injuries to be a negative predictor for RTP. Meniscal injuries were associated with a decreased RTP rate and career length, but this was not statistically significant. Conclusion: The RTP rates after ACL reconstruction in this study are similar to those reported in National Football League players. A concomitant injury to the MCL injury was a negative predictor of RTP. Meniscal injuries demonstrated a trend for decreased RTP rate and career length, but this was not a significant predictor. A large portion of injuries occur early in the season, and further study should be done to examine potential preventative strategies to reduce ACL injuries.

ISOKINETIC PERFORMANCE AND LIMB ASYMMETRY DIFFERENCES BETWEEN ADOLESCENT MALES AND FEMALES FOLLOWING QUADRICEPS TENDON – PATELLAR BONE AUTOGRAFT ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

Background:Accurate measurement of limb strength asymmetry differences between sexes may be important to consider when determining readiness to return to sport among adolescents following ACL reconstruction.Hypothesis/Purpose:The purpose was to compare isokinetic performance between females and males after ACL reconstruction but before return to sport clearance on isokinetic measures of limb strength asymmetry and flexor/extensor strength ratio. We hypothesized there would be no difference in limb strength asymmetry or flexor/extensor strength ratio between sexes measured by isokinetic testing.Methods:We retrospectively collected demographic, surgical, and injury information on patients aged 10 – 18 years at time of surgery. Patients completed isokinetic testing within 5-10 months after primary quadriceps tendon ACL reconstruction, and before return to sport clearance. Isokinetic testing assessed maximum torque at three speeds, 60, 180, and 300 degrees per second, through a limited range of knee extension and flexion. Maximum torque percent deficit of the involved leg compared to the uninvolved leg and flexor/extensor strength ratios were calculated. We compared peak torque extensor deficits and flexor deficits (the % difference between operative and non-operative sides) and flexor/extensor ratios at the three isokinetic test speeds within sexes and between sexes.Results:80 subjects were tested during the study period, of which 44 subjects met inclusion criteria (female: n=29, 66%). Injury characteristics and time since surgery were similar between sexes (Table 1). Greater extensor deficits among males and females were observed at 60 degrees/s compared to 180 degree/s (p=0.003) and 300 degree/s (p<0.001), and at 180 degrees/s compared to 300 degrees/s (p=0.001) (Figure 1). Females demonstrated significantly greater peak torque flexor deficits at 300 degrees/s, compared to males (p=0.04, Figure 2). Within males, greater flexor deficits were observed at 60 degrees/s compared to 180 degrees/s (p<0.001) and 300 degrees/s (p=0.001) (Figure 2). Within females, greater flexor deficits were observed at 60 degrees/s compared to 180 degrees/s (p=0.02, Figure 2). There were no significant interactions or main effects of sex or speed for either the operative or the non-operative limb peak torque flexor/extensor ratio.Conclusion:The results demonstrate greater peak torque flexor deficits among females compared to males at the fastest testing speed in our protocol. Currently, our results indicate variability both within and between sex isokinetic performance at different speeds and suggest that isokinetic testing at slower speeds may be most effective in determining strength deficits between limbs.Tables and Figures:Table 1.Participant characteristics, compared between sexes. Continuous variables are presented as means ± sd, categorical variables are presented as n (%) included in the group. Variable Females (n=29) Males (n=15) P value Age (years)15.7 (1.5)16.3 (1.4)0.20Height (cm)162.4 (9.3)172.1 (8.1)0.002Mass (kg)61.0 (2.1)75.3 (22.1)0.007BMI (kg/m2)23.1 (4.0)25.1 (5.8)0.19Right side injury16 (55%)8 (53%)1.00Concomitant meniscus injury15 (52%)10 (67%)0.52Skeletally mature (pre-op X-ray)19 (66%)10 (67%)1.00Right leg dominant28 (97%)14 (93%)1.00Time since surgery (months)7.3 (1.7)7.0 (1.2)0.51Figure 1.Sex by speed comparisons for peak torque extensor deficits. Error bars represent 95% confidence intervals. A main effect of speed indicated that among both groups, greater extensor deficits existed at 60 degrees/s compared to 180 degrees/s (p=0.003) and 300 degrees/s (p< 0.001), and at 180 degrees/s compared to 300 degree/s (p=0.001).Figure 2.Sex by speed comparisons for peak torque flexor deficits. Error bars represent 95% confidence intervals.A significant sex x speed interaction (p=0.048) indicated:*Females demonstrated greater peak torque flexor deficits than males at 300 degree/s (p=0.04).† Males had greater deficits at 60 degrees/s compared to 180 degrees/s (p<0.001) and 300 degrees/s (p=0.001).† Females had greater deficits at 60 degrees/s compared to 180 degrees/s (p=0.02).

All inside full thickness quadriceps tendon ACL reconstruction: Long term follow up results

PurposeThe aim of this study is to evaluate results of anterior cruciate ligament reconstruction (ACL) using an All-Inside Full Thickness Quadriceps Reconstruction technique at 5 years follow up.MethodsThis is a Retrospective cohort study of patients undergoing ACL reconstruction. Inclusion criteria for this report were isolated primary ACL reconstructions without chondral lesions (Grade III/IV Outerbridge), using autologous full-thickness quadriceps tendon (FQT) graft with bone block, with an “all-inside” technique. Functional scales of Lysholm, IKDC, Tegner and objective results of side to side difference (KT1000) were used for this evaluation. Additionally, complications and comorbidities were also analyzed.ResultsTwo hundred and ninety-one ACL reconstructions were retrospectively reviewed at 5 years postoperatively; 268 (92.1%) were men and 23 (7.90%) women. Lysholm Score improved from 64 (SD = 6.09) to 91 (SD = 6.05) points average. IKDC showed 59.79%, excellent and 3.4% good results. Arthrometric analysis showed that 259 knees (89%) had a difference of less than 3 mm. Median pre-injury Tegner score was 9 (Range 4–10), while final median Tegner activity level at 5 years was 8 (Range 4–10). Among comorbidities, 5.15% of the patients presented anterior knee pain. No visualization difficulties or significant hematomas were found.ConclusionUse of all inside FQT for ACL reconstruction in a young, high demand sports population, present at 5 years, good to excellent results, functionally and objectively, with low rates of complications and comorbidities.

ACL reconstruction combined with lateral monoloop tenodesis can restore intact knee laxity

PurposeAn anterior cruciate ligament (ACL) injury is often combined with injury to the lateral extra-articular structures, which may cause a combined anterior and rotational laxity. It was hypothesised that addition of a ‘monoloop’ lateral extra-articular tenodesis (mLET) to an ACL reconstruction would restore anteroposterior, internal rotation and pivot-shift laxities better than isolated ACL reconstruction in combined injuries.MethodTwelve cadaveric knees were tested, using an optical tracking system to record the kinematics through 0°–100° of knee flexion with no load, anterior and posterior translational forces (90 N), internal and external rotational torques (5 Nm), and a combination of an anterior translational (90 N) plus internal rotational load (5 Nm). They were tested intact, after sectioning the ACL, sectioning anterolateral ligament (ALL), iliotibial band (ITB) graft harvest, releasing deep ITB fibres, hamstrings tendon ACL reconstruction, mLET combined with ACL reconstruction, and isolated mLET. Two-way repeated-measures ANOVA compared laxity data across knee states and flexion angles. When differences were found, paired t tests with Bonferroni correction were performed.ResultsIn the ACL-deficient knee, cutting the ALL significantly increased anterior laxity only at 20°–30°, and only significantly increased internal rotation at 50°. Additional deep ITB release significantly increased anterior laxity at 40°–90° and caused a large increase of internal rotation at 20°–100°. Isolated ACL reconstruction restored anterior drawer, but significant differences remained in internal rotation at 30°–100°. After adding an mLET there were no remaining differences with anterior translation or internal rotation compared to the intact knee. With the combined injury, isolated mLET allowed abnormal anterior translation and rotation to persist.ConclusionsCutting the deep fibres of the ITB caused large increases in tibial internal rotation laxity across the range of knee flexion, while cutting the ALL alone did not. With ACL deficiency combined with anterolateral deficiency, ACL reconstruction alone was insufficient to restore native knee rotational laxity. However, combining a ‘monoloop’ lateral extra-articular tenodesis with ACL reconstruction did restore native knee laxity.

Comparison of Drop Jump Landing Biomechanics and Asymmetry among Adolescents with Recent Hamstring, Patellar Tendon, and Quadriceps Tendon Anterior Cruciate Ligament Reconstruction

INTRODUCTION Anterior cruciate ligament reconstruction (ACLR) in adolescents commonly utilizes hamstring (HT), patellar (PT) or quadriceps tendon (QT) autografts. Recent studies demonstrated improved outcomes with PT and QT grafts over HT, but consensus is lacking regarding optimal graft choice. This study compared landing biomechanics and symmetry during the rehabilitation period among adolescent ACLR patients reconstructed with HT, PT and QT grafts as well as uninjured controls. METHODS 61 adolescent patients with recent unilateral ACLR (27 HT, 20 PT, 14 QT; 4-12 months post-surgery, mean 6.4; age 15.4±1.4 years) and …

Comparison of Drop Jump Landing Biomechanics and Asymmetry among Adolescents with Recent Hamstring, Patellar Tendon, and Quadriceps Tendon Anterior Cruciate Ligament Reconstruction

Comparison of Drop Jump Landing Biomechanics and Asymmetry among Adolescents with Recent Hamstring, Patellar Tendon, and Quadriceps Tendon Anterior Cruciate Ligament Reconstruction

Lateral Extra-Articular Tenodesis Reduces Failure of Hamstring Tendon Autograft ACL Reconstruction -Two Year Outcomes from the STABILITY Study Randomized Clinical Trial

Objectives: Persistent anterolateral rotatory laxity following anterior cruciate ligament reconstruction (ACLR) has been correlated with poor outcome and graft failure. We hypothesized that anterolateral complex reconstruction by way of a Lateral Extra-articular Tenodesis (LET) in combination with single bundle ACLR would reduce the risk of persistent rotatory laxity in young individuals who are deemed as being at high risk of failure. Methods: This is a pragmatic, multicenter, randomized clinical trial comparing standard hamstring tendon ACLR with combined ACLR and LET, utilizing a strip of iliotibial band (Modified Lemaire). Patients aged 25 years or less with an ACL deficient knee were included. They also had to have two of the following three criteria: 1) Grade 2 pivot shift or greater; 2) Returning to high risk/pivoting sports; 3) Generalized ligamentous laxity. The primary outcome was graft failure defined as either the need for revision ACLR or symptomatic instability associated with a positive asymmetric pivot shift, indicating persistent rotational laxity. Secondary outcome measures included the P4 pain scale, KOOS, IKDC. Patients were followed for two years with visits at 3, 6, 12 and 24 months postoperatively. A sample size of 300 per group was calculated based on a relative reduction in graft failure by 40%, with type 1 error of 5%, 80% power and 15% loss to follow-up rate. Results: 624 patients were randomized with a mean age of 18.9 (range: 14-25), 293 male. 436 (87.9%) patients presented pre-operatively with high-grade rotatory laxity (grade 2 pivot or greater) and 215 (42.1%) were diagnosed as having generalized ligamentous laxity (Beighton Score of 4 or greater). 523 of the 624 patients are at least 2 years postoperative; 29 lost to follow-up (˜5%). In the ACLR group 104/252 (41%) of patients suffered the primary outcome compared to 61/242 (25%) of the ACLR+LET patients (RR=0.61, 95%CI 0.47 to 0.79), p&lt;0.0001. 39 patients suffered graft rupture, 28/252 (11%) in the ACLR group compared to 11/242 (4.5%) in the ACL+LET group (RR=0.41, 95%CI 0.21 to 0.80, p&lt;0.001). At 3 months postoperative, patients in the ACLR group had less pain (p=0.004); at 3 and 6 months all KOOS subdomains, the IKDC favored the ACLR alone group (p=0.03). At 12 and 24 months, no important between-group differences were observed in any patient reported outcome. Conclusion: The addition of LET to a hamstring autograft ACLR in young active patients significantly reduces graft failure and persistent anterolateral rotatory laxity at 2 years post operatively.

A Randomized Clinical Trial Comparing Patellar Tendon, Hamstring Tendon, and Double-Bundle ACL Reconstructions: Patient-Reported and Clinical Outcomes at 5-Year Follow-up.

This randomized clinical trial evaluated the 5-year, disease-specific quality-of-life outcomes of patients treated for anterior cruciate ligament (ACL) deficiency with use of a patellar tendon, single-bundle quadruple-stranded hamstring, or double-bundle hamstring reconstruction. Patients (n = 110 per group; 183 male; 14 to 50 years of age) were randomly allocated to anatomically positioned ACL reconstruction with use of a patellar tendon graft (patellar tendon group; mean age, 28.7 years), quadruple-stranded hamstring tendon construct (hamstring tendon group; mean age, 28.5 years), or double-bundle hamstring tendon construct (double-bundle group; mean age, 28.3 years). Computer-generated allocation with varied block randomization was performed intraoperatively. The 5-year primary outcome measure was the Anterior Cruciate Ligament-Quality of Life (ACL-QOL) score, and secondary outcome measures included the International Knee Documentation Committee (IKDC) subjective score and objective grades, pivot shift assessment, range of motion, kneeling pain, Tegner activity scale, Cincinnati Occupational Rating Scale, complete traumatic reruptures, partial traumatic tears, total traumatic reinjuries, and atraumatic graft failures. Three hundred and fifteen patients (95%) completed the 5-year follow-up (4 withdrawals, and 11 lost to follow-up). ACL-QOL scores increased significantly from baseline for all groups (p < 0.0001), but mean scores at 5 years did not differ among the groups (p = 0.548): mean (and standard deviation) of 82.5 ± 17.9 (95% confidence interval [CI], 79.0 to 86.0) for patellar tendon, 83.9 ± 18.2 (95% CI, 80.3 to 87.4) for hamstring tendon, and 81.1 ± 19.3 (95% CI, 77.4 to 84.8) for double-bundle. The proportions of patients at 5 years with a pivot shift grade of ≥2 (12% for patellar tendon, 16% for hamstring tendon, and 22% for double-bundle; p = 0.149) and with normal and nearly normal knees per IKDC grade (87%, 82%, and 75% for the 3 groups, respectively; p = 0.093) trended in favor of patellar tendon reconstruction. No differences were seen for the IKDC subjective scores, knee range of motion including passive extension deficits, the single leg hop test, Cincinnati Occupational Rating scores, and Tegner activity levels. Kneeling pain was more common with patellar tendon reconstruction (10% of patients compared with 4% for hamstring tendon and 2% for double-bundle; p = 0.029). For hamstring tendon and double-bundle reconstructions, there were trends toward more complete traumatic reruptures (4% for patellar tendon, 10% for hamstring tendon, and 10% for double-bundle; p = 0.145) and partial traumatic tears (0%, 5%, and 6%, respectively; p = 0.059), with significantly fewer combined traumatic reinjuries in the patellar tendon group (4 patients compared with 16 for hamstring tendon and 17 for double-bundle; p = 0.010). Atraumatic graft failure (pivot shift grade of ≥2) was found for 10% of the patients. At 5 years, we found no significant difference in the quality-of-life outcome among the patellar tendon, hamstring tendon, and double-bundle techniques for ACL reconstruction. Significantly more patients in the hamstring tendon and double-bundle groups experienced traumatic graft reinjury compared with the patellar tendon group. There was a trend toward a higher percentage with normal and nearly normal IKDC grades in the patellar tendon group compared with hamstring tendon and double-bundle groups. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Small Social Incentives Did Not Improve the Survey Response Rate of Patients Who Underwent Orthopaedic Surgery: A Randomized Trial.

The generalizability of data derived from patient-reported outcome measures (PROMs) depends largely on the proportion of the relevant population that completes PROM surveys. However, PROM survey responses remain low, despite efforts to increase participation. Social incentives, such as the offer to make a charitable donation on behalf of the survey respondent, have generally not been effective where online surveys are concerned, but this has not been extensively tested in medicine. (1) Do personalized social incentives increase response rates or response completeness for postoperative PROM surveys in an orthopaedic population? (2) Are there demographic factors associated with response and nonresponse to postoperative PROM surveys? (3) Are some demographic factors associated with increased response to social incentive offers? Participants were selected from an institutional orthopaedics database. Patients were older than 18 years, had an email address on file, and had undergone one of the following procedures 1 to 2 years ago: Achilles tendon repair, ACL reconstruction, meniscectomy, hip arthroscopy, TKA, or THA. Of 4685 eligible patients, 3000 (64%) were randomly selected for inclusion in the study. Participants were randomized to one of four groups: (1) control: no incentive (n = 750); (2) patient donation: offer of a USD 5 donation to provide medical supplies to a pediatric orthopaedic patient (n = 751); (3) research donation: offer of a USD 5 donation to a procedure-specific research program (n = 749); or (4) explanation: explanation that response supports quality improvement (n = 750). The four groups did not differ regarding patient age, gender, race, procedure type, or time since procedure. All patients were sent an email invitation with the same PROM survey link. The proportion of patients who responded (defined here as the response rate) was measured at 4 weeks and compared between intervention groups. We used a logistic regression analysis to identify demographic factors associated with response while controlling for confounding variables and performed subgroup analyses to determine any demographic factors associated with increased response to social incentives. There was no difference in the overall response rate (research donation: 49% [353 of 725], patient donation: 45% [333 of 734], control: 45% [322 of 723], explanation: 44% [314 of 719]; p = 0.239) or response completeness (research donation: 89% [315 of 353], patient donation: 90% [301 of 333], control: 89% [287 of 322], explanation: 87% [274 of 314]; p = 0.647) between the four groups. Women (odds ratio [OR], 1.175; p = 0.042), older patients (< 58 years: OR, 1.016 per 1-year increase; p = 0.001; 58-64 years: OR, 1.023 per 1-year increase; p < 0.001; > 64 years: OR, 1.021 per 1-year increase; p < 0.001), and white patients (OR 2.034 compared with black patients, p < 0.001) were slightly more likely to respond, after controlling for potential confounding variables such as gender, age, race, and procedure type. In subgroup analyses, men (research donation: 49% [155 of 316], patient donation: 45% [146 of 328], control: 40% [130 of 325], explanation: 39% [127 of 325]; p = 0.041) and patients younger than 58 years (research donation: 40% [140 of 351], control: 35% [130 of 371], patient donation: 32% [113 of 357], explanation: 27% [93 of 340]; p = 0.004) were slightly more likely to respond to the research donation than those with other interventions were. Despite small effects in specific subgroups, personalized social incentives did not increase the overall response to postoperative orthopaedic surveys. Novel and targeted strategies will be necessary to reach response thresholds that enable healthcare stakeholders to use PROMs effectively. Level I, therapeutic study.

Comparing porcine models and sawbones as a training tool for complex arthroscopic knee surgery

Background: Anterior cruciate ligament (ACL) reconstruction and meniscal repair are two commonly performed arthroscopic soft tissue surgeries. It can be challenging for training surgeons to become proficient in these techniques. The aim of our study is to investigate the viability of porcine stifles as training models for ACL reconstruction and meniscal repair.Method: A training session was held with various participants comparing the use of porcine stifles vs. sawbone replicas. Tendon harvesting, joint arthroscopy, meniscal repair and ACL reconstruction were performed on both groups of joints. The two training methods were compared by the completion of a questionnaire by four participants.Results: Porcine stifles were found to be a suitable alternative to human knee joints. Tactile sensation of performing these procedures with porcine stifles more closely resembled that of a human knee. Visualisation of the joint and its structures was considerably easier in the saw bone model, but the porcine stifle better resembled real life scenarios. The medial joint compartment was notably more difficult to visualise and access relative to the lateral compartment, increasing procedure time when repairing the medial meniscus. Conclusion: Porcine stifles provide a suitable model for education and surgical training for ACL reconstruction and meniscal repair for trainee surgeons. They are easy to procure, cost-effective, and better replicate the complexities of these procedures in human knees compared to sawbones. We believe that practically this provides an ideal platform for simulation scenarios which are similar to humans and fulfils the ethical mandates of beneficence and non-maleficence.

Greater magnitude tibiofemoral contact forces are associated with reduced prevalence of osteochondral pathologies 2-3years following anterior cruciate ligament reconstruction.

External loading of osteoarthritic and healthy knees correlates with current and future osteochondral tissue state. These relationships have not been examined following anterior cruciate ligament reconstruction. We hypothesised greater magnitude tibiofemoral contact forces were related to increased prevalence of osteochondral pathologies, and these relationships were exacerbated by concomitant meniscal injury. This was a cross-sectional study of 100 individuals (29.7 ± 6.5years, 78.1 ± 14.4kg) examined 2-3years following hamstring tendon anterior cruciate ligament reconstruction. Thirty-eight participantshad concurrent meniscal pathology (30.6 ± 6.6years, 83.3 ± 14.3kg), which included treated and untreated meniscal injury, and 62participants (29.8 ± 6.4years, 74.9 ± 13.3kg) were free of meniscal pathology. Magnetic resonance imaging of reconstructed knees wasused to assess prevalence of tibiofemoral osteochondral pathologies (i.e., cartilage defects and bone marrow lesions). A calibrated electromyogram-driven neuromusculoskeletal model was used to predict medial and lateral tibiofemoral compartment contact forces from gait analysisdata. Relationships between contact forces and osteochondral pathology prevalence were assessed using logistic regression models. In patients with reconstructed knees free from meniscal pathology, greater medial contact forces were related to reduced prevalence of medial cartilage defects (odds ratio (OR) = 0.7, Wald χ2(2) = 7.9, 95% confidence interval (CI) = 0.50-95, p = 0.02) and medialbone marrow lesions (OR = 0.8, Wald χ2(2) = 4.2, 95% CI = 0.7-0.99, p = 0.04). No significant relationships were found in lateral compartments. In reconstructed knees with concurrent meniscal pathology, no relationships were found between contact forces and osteochondral pathologies. In patients with reconstructed knees free from meniscal pathology, increased contact forces were associated with fewer cartilage defects and bone marrow lesions in medial, but not, lateral tibiofemoral compartments. No significant relationships were found between contact forces and osteochondral pathologies in reconstructed knees with meniscal pathology for any tibiofemoral compartment. Future studies should focus on determining longitudinal effects of contact forces and changes in osteochondral pathologies. IV.

No difference in the graft shift between a round and a rounded rectangular femoral tunnel for anterior cruciate ligament reconstruction: an experimental study.

We developed a novel technique of creating a rounded rectangular femoral bone tunnel for anatomical, single-bundle, autologous hamstring tendon anterior cruciate ligament (ACL) reconstruction. Although this tunnel has many advantages, its non-circular shape has raised concerns regarding excessive graft shift within the bone tunnel. This study aimed to compare the graft shift between round and rounded rectangular tunnels using a graft diameter tester for simulating the femoral bone tunnel. Seven semitendinosus tendon grafts harvested from fresh-frozen cadavers were prepared by removing all excess soft tissue. The two ends of a double-fold hamstring tendon were sutured using a baseball stitch and then looped over a TightRope (Arthrex Co., Ltd., Naples, Florida, USA) to make a fourfold graft. The diameter of the graft was standardized to 8mm using a round graft diameter tester. A round and an original rounded rectangular graft diameter tester were used for simulating the respective femoral bone tunnels. The graft was inserted into the tunnel, with the TightRope positioned on the outside of the tunnel. The distal end of the graft was tensioned to 40N at an angle of 75° to reproduce the most severe graft bending angle. Digital photographs of the tunnel aperture taken at each simulated tunnel and the range of graft shift in the simulated tunnel were analyzed by ImageJ software. Statistical analyses were performed using the Tukey test. P < 0.05 was considered to be significant. There were no significant differences between the round and the rounded rectangular tunnel groups (P > 0.05) in terms of graft shift, gap area, and graft shift ratio. In a simulated ACL reconstruction, there is no difference in the graft shift between a round and a rounded rectangular bone tunnel.

Medial Meniscus Resection Increases and Medial Meniscus Repair Preserves Anterior Knee Laxity: A Cohort Study of 4497 Patients With Primary Anterior Cruciate Ligament Reconstruction

Background: There are still controversies regarding the effects on knee laxity of additional meniscus resection or repair in the setting of anterior cruciate ligament reconstruction (ACLR). Hypothesis/Purpose: The purpose was to determine the effects on knee laxity of resection or repair of medial meniscus (MM) or lateral meniscus (LM) injuries in the ACLR knee. The hypothesis was that patients with an additional meniscus resection would have significantly increased postoperative knee laxity versus that of an isolated ACLR, whereas patients with meniscus repair would have laxity comparable to that of an isolated ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: The KT-1000 arthrometer, with an anterior tibial load of 134 N, was used to evaluate knee laxity preoperatively and at 6-month postoperative follow-up for a total of 4497 patients with primary hamstring tendon ACLR. Patients with isolated ACLR or ACLR with additional MM resection, MM repair, LM resection, LM repair, or MM plus LM resection were compared, with the isolated ACLR group as a control. Results: All patients showed a significant reduction of knee laxity preoperatively (3.6 ± 3.1 mm) to postoperatively (1.9 ± 2.2 mm) (P < 0.0001). Patients who had an ACLR with either an MM resection (2.2 ± 2.55 mm) or MM + LM resection (2.35 ± 2.30 mm) showed significant increased postoperative knee laxity versus isolated ACLR (1.74 mm ± 2.11 mm) (P < 0.05), whereas patients with MM repair (1.69 ± 2.37 mm) did not show significantly different knee laxity when compared with the control group (P > 0.05). LM resection or repair did not significantly affect knee laxity. Significantly more surgical failures, defined as side-to-side difference >5 mm, were found in the ACLR + MM resection group and the ACLR + MM + LM resection group. Conclusion: In ACLR, additional MM resection increased whereas MM repair preserved knee laxity in comparison with the ACLR knee with intact menisci. Neither LM resection or LM repair showed a significant effect on knee laxity. Surgeons should make every effort to repair the meniscus whenever possible to avoid the residual postoperative laxity present in the meniscus-deficient knee.

A Randomized Clinical Trial Comparing Patellar Tendon, Hamstring Tendon and Double-Bundle ACL Reconstructions: Patient-Reported and Clinical Outcomes at Five-Year Follow-Up

A Randomized Clinical Trial Comparing Patellar Tendon, Hamstring Tendon and Double-Bundle ACL Reconstructions: Patient-Reported and Clinical Outcomes at Five-Year Follow-Up

Prospective randomised comparison of femoral transfix versus endobutton with constant tibial fixation in hamstring tendon ACL reconstruction: a preliminary study

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The purpose of this study is to evaluate clinico radiological outcome of hamstring tendon ACL reconstruction using femoral Transfixation and Endobutton with identical Tibial fixation.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A Prospective randomized clinical outcome study was done from January 2002 to June 2008, a total of 132 patients with quadruple hamstring ACL reconstruction using a femoral fixation group A Endobutton (n=68; median age=27.4) and group B with Transfix (n=64; median age=26.1) and identical Tibial fixation with Biointerference screw and bone staple were studied. Patients in each group had a clinical and radiological assessment at &amp;lt;3, 3-12, 12-24 and &amp;gt;24 months after surgery.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; The mean Lysholm Knee score has improved significantly with time within these groups but no difference on comparison between groups. Ninety percent of all patients had functionally normal or near normal International Knee Documentation Committee (IKDC) knee ligament ratings. IKDC Subjective Knee evaluation mean score has progressively increased significantly from pre op values of 37.58 and 36.55 to about 74.51 and 75.85 in group A and group B respectively. The tibial and femoral tunnels also showed widening of about 9.64% and 7.79% in group A as compared to 7.71% and 7.27% in group B at &amp;gt;24 months follow-up, which was statistically insignificant. MRI done in limited patients showed good graft incorporation in both groups.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; So keeping the tibial graft fixation constant, the two different femoral fixation methods, Endobutton and transfixation have not influenced in the clinical outcome in this short term preliminary study. But long term follow up of these is necessary to evaluate the significance of tunnel widening and its final outcome.&lt;/p&gt;