Tendon-bone Autograft Research Articles

All‐soft tissue quadriceps tendon autograft and bone–patellar tendon–bone autograft demonstrate no significant ACL tunnel widening: An MRI comparison

All‐soft tissue quadriceps tendon autograft and bone–patellar tendon–bone autograft demonstrate no significant ACL tunnel widening: An MRI comparison

Patient and Operative Risk Factors for Osteoarthritis After Primary Anterior Cruciate Ligament Reconstruction: A Cohort Study of 41,976 Patients

Background: The reported incidence of posttraumatic knee osteoarthritis (PTOA) after primary anterior cruciate ligament reconstruction (ACLR) varies considerably. Further, there are gaps in identifying which patients are at risk for PTOA after ACLR and whether there are modifiable factors. Purpose: To (1) determine the incidence of PTOA in a primary ACLR cohort and (2) identify patient and perioperative factors associated with the development of PTOA after primary ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: Data from the Kaiser Permanente ACLR Registry were used to conduct a cohort study. Patients who had undergone primary ACLR without a previous diagnosis of osteoarthritis were identified (2009-2020). The crude incidence of PTOA was calculated using the Aalen-Johansen estimator with a multistate model. The association of patient and operative factors with the development of PTOA after primary ACLR was modeled as a time to event using multistate Cox proportional hazards regression. Models stratified by age (<22 and ≥22 years) were also conducted because of the effect modification of age. Results: The study sample included 41,976 cases of primary ACLR. The incidence of PTOA was 1.7%, 5.1%, and 13.6% at 2, 5, and 10 year follow-ups, respectively. Risk factors for PTOA that were consistently identified in the overall cohort and age-stratified groups included a body mass index ≥30 versus <30 and an allograft or quadriceps tendon autograft versus a hamstring tendon autograft. Patients presenting with knee pain after ACLR were further identified when considering postoperative factors. Other risk factors for PTOA in the overall cohort included age ≥22 versus <22 years, bone–patellar tendon–bone autograft versus hamstring tendon autograft, hypertension, cartilage injury, meniscal injury, revision after primary ACLR with concomitant meniscal/cartilage surgery, multiligament injury, other activity at the time of injury compared with sport, and tibial tunnel drilling technique rather than the anteromedial portal. Conclusion: Knee pain after ACLR may be an early sign of PTOA. Surgeons should consider the adverse associations of a higher body mass index and an allograft or quadriceps tendon autograft with the development of PTOA, as these were factors identified with a higher risk, regardless of a patient’s age at the time of primary ACLR.

The Periosteum–Patellar Tendon–Bone Autograft for Anatomic, Single-Bundle Anterior Cruciate Ligament Reconstruction With Press-Fit Tibial Fixation

Optimal graft choice and fixation technique are still ongoing topics of debate for primary and revision anterior cruciate ligament reconstruction. Interference screws are frequently used as graft fixation devices but can sometimes lead to tunnel widening, cyst formation, chronic inflammation, screw breakage, and persistent pain. Tibial tunnel widening is of special concern because it is often associated with graft failure. This technical note introduces a graft technique with a periosteum–patellar tendon–bone autograft and a press-fit tibial fixation approach that could be a viable option for secure anterior cruciate ligament reconstruction while offering the possibility of a quicker postoperative recovery, less pain, and a quicker return to everyday activities.

Young men undergoing anterior cruciate ligament reconstruction with patellar tendon autograft and anteromedial drilling outperform at 5- to 10-year follow-up in terms of graft stability and activity levels compared to those undergoing reconstruction with hamstring autograft and transtibial drilling

ObjectiveTo compare 5- to 10-year outcomes of anterior cruciate ligament (ACL) reconstruction in young men performed with bone-patellar tendon bone (BPTB) autograft and anteromedial portal to reconstruction with hamstring autograft and transtibial technique. It was hypothesised that in young adult men, at 5- to 10-year follow-up, superior restoration of knee laxity and activity levels would be demonstrated using BPTB autograft and anteromedial portal technique. MethodsNinety-four men who had ACL reconstruction with BPTB autograft and anteromedial portal were eligible for comparison to 106 men who had reconstruction with hamstring autograft and transtibial technique. Inclusion criteria were: (1) age 18–35 years, (2) ACL tear caused by sports trauma only, (3) no concomitant ligament reconstruction and (4) 5- to 10-year follow-up. Outcome measures compared between the two groups included Lachman and pivot shift tests, KT side-to-side difference, Tegner and Marx scores, International Knee Documentation Committee (IKDC)-subjective score, Knee Osteoarthritis Outcome Scale (KOOS), Short Form (SF)-36, and single hop test for distance. P value ​< ​0.05 indicated statistical significance. ResultsForty-five patients with BPTB and 55 patients with hamstring ACL reconstruction were available for in-person assessment at 5–10 years after surgery. Outcomes in the BPTB group compared to the hamstring group showed KT difference 1.4 ​± ​1.9 mm vs. 2.8 ​± ​2.3 mm (p ​< ​0.01), pivot shift grade 2–3 in 4% vs. 34% (p ​< ​0.01), return to preinjury Tegner level in 51% vs. 36% (p ​= 0.1) and to preinjury Marx score in 29% vs. 11% (p ​= 0.02), and IKDC-subjective 88 ​± ​10 vs. 82 ​± ​13 vs (p ​< ​0.01), respectively. Statistically significant inter-relationships were found between KT side-to-side difference and the Tegner, Marx and IKDC-subjective scores at follow-up (r ​= ​−0.314, p ​< ​0.01; r ​= ​−0.263, p ​< ​0.01; r ​= ​−0.218, p ​= ​0.03, respectively). ConclusionYoung men undergoing ACL reconstruction with patellar tendon autograft and anteromedial drilling outperform at 5- to 10-year follow-up in terms of graft stability and activity levels compared to young men undergoing reconstruction with hamstring autograft and transtibial drilling. Level of EvidenceIII (Retrospective cross-sectional comparative study).

The Influence of Tunnel Parameters and Graft Inclination Angle on Clinical and Radiological Outcome at Long-term Follow-up after Arthroscopic Anterior Cruciate Ligament Reconstruction.

Objective To study the influence of various tunnel parameters and graft inclination angle (GIA) on the clinical and radiological outcome after anterior cruciate ligament reconstruction (ACLR) at long-term follow-up. Methods In this retrospective study, 80 patients with isolated anterior cruciate ligament (ACL) injury treated by single bundle ACLR using bone patellar tendon bone (BPTB) and hamstring (HT) autografts were evaluated clinically and radiologically at their long-term follow-up. The study population were divided into two groups based on ideal and nonideal tunnel parameters as well as ideal and nonideal GIA. The various tunnel parameters and GIA were interpreted with clinical and radiological outcome at long-term follow-up. Results Eighty patients, 36 (45%) using BPTB and 44 (55%) using HT autografts, were available to complete the study. Patients with ideal coronal tibial tunnel angle (CTTA) and coronal femoral tunnel angle (CFTA) show superior clinical outcome (pivot shift test) than nonideal CTTA and CFTA, which was found to be statistically significant ( p -value < 0.038 and 0.024, respectively). Similarly, patients with ideal coronal tibial tunnel position (CTTP) show superior clinical outcome (International Knee Documentation Committee - IKDC objective) over nonideal CTTP ( p -value < 0.017). All other tunnel parameters and GIA were not found to have influence on clinical outcome. None of the tunnel parameters have influenced osteoarthritis (OA) change. There was no progression of OA change in the study population at long-term follow-up after ACLR. Conclusion Ideal coronal tunnel parameters produced a better clinical outcome at long-term follow-up after ACLR. There was no progression of OA change at long-term follow-up after isolated ACLR.

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.

Hamstring Tendon Autograft Is Associated With Increased Knee Valgus Moment After Anterior Cruciate Ligament Reconstruction: A Biomechanical Analysis

Background: There is limited evidence related to the effects of autograft type on functional performance after anterior cruciate ligament reconstruction (ACLR). Purpose/Hypothesis: This study aimed to compare biomechanical outcomes during a drop vertical jump (DVJ) between patients with a hamstring tendon (HT) autograft, quadriceps tendon (QT) autograft with bone block, QT autograft without bone block, and bone–patellar tendon–bone autograft at 6 months postoperatively in an adolescent population. The authors’ hypothesized there would be differences in DVJ biomechanics between athletes depending on the type of autograft used. Study Design: Controlled laboratory study. Methods: Patients aged 8 to 18 years who underwent primary ACLR were included for analysis. Kinematic and kinetic data collected during a DVJ using a 3-dimensional computerized marker system were assessed at 6 months after ACLR and compared with the uninjured contralateral limb. Results: A total of 155 participants were included. There were no significant differences in terms of age, sex, or affected leg (P≥ .1973) between groups. The HT group was significantly associated with a larger knee valgus moment at initial contact compared with the QT group (28 × 10–2 vs −35 × 10–2 N·m/kg, respectively; P = .0254) and a significantly larger maximum hip adduction moment compared with the QT with bone block group (30 × 10–2 vs −4 × 10–2 N·m/kg, respectively; P = .0426). Both the QT with bone block (–12 × 10–2 vs −3 × 10–2 N·m/kg, respectively; P = .0265) and QT (–13 × 10–2 vs −3 × 10–2 N·m/kg, respectively; P = .0459) groups demonstrated significantly decreased mean knee extension moments compared with the HT group. Conclusion: The findings of this study suggest that utilizing an HT autograft resulted in a significantly increased knee valgus moment at initial contact compared with a QT autograft without bone block at 6 months after ACLR in adolescent patients performing a DVJ. A QT autograft was found to be associated with significantly decreased extensor mechanism function compared with an HT autograft. Clinical Relevance: This study adds unique kinematic and kinetic information regarding various ACLR autograft options and highlights the biomechanical deficits that should be taken into consideration in rehabilitation.

Anterior Cruciate Ligament Reconstruction Using Bone–Patellar Tendon–Bone Autograft With Lateral Compartment Meniscectomy or Chondroplasty Does Not Lead to Decreased Return to Sport and Activity Compared With No Lateral Pathology

PurposeTo investigate the influence of lateral meniscal and cartilage pathology on the outcome after ACL reconstruction in patients who participate in pivoting sports. MethodsUsing a single surgeon patient registry, patients undergoing an ACL reconstruction (ACLR) using BTB autograft were evaluated with minimum 2-year patient reported outcomes evaluated using Marx, Tegner, Lysholm, and International Knee Documentation Committee (IKDC) scales. Patients were divided into three groups: isolated ACL surgery, ACLR with a partial lateral meniscectomy, or a ACLR with partial lateral meniscectomy and lateral compartment chondroplasty. ResultsA total of 98 patients met inclusion criteria. Using the isolated ACL reconstruction group as a control, Marx scores were higher in patients who additionally underwent a partial lateral meniscectomy at 1-year (p=0.016). There were no significant differences between the ACL only group and the ACL with partial lateral meniscectomy and chondroplasty group. Within the partial meniscectomy cohort comparing the red-white zone tears to the white-white zone tear patients, there were no significant differences when compared with the ACL only control. There were no significant differences appreciated between groups using the IKDC, Lysholm, andTegner scales. ConclusionACL reconstruction using BTB autograft with anteromedial portal drilling technique does not have any significant short-term (2-year outcome) differences in return to activity and patient reported outcomes compared to if patients additionally have a partial lateral meniscectomy and/or lateral compartment chondroplasty. Additional partial lateral meniscectomy showed significantly higher Marx scores at 1 and 2 years post-operatively. Level of Evidence3, Retrospective Cohort Study

Outcome of Primary Anterior Cruciate Ligament Reconstruction with Peroneus Longus and Bone–Patellar Tendon–Bone Autografts: A Clinical Comparative Study

Background: The aim of this study is to compare the mid-term outcomes of primary tear of the anterior cruciate ligament (ACL) reconstruction via the use of peroneus longus tendon (PLT) and bone–patellar tendon–bone (BPTB) autografts. Methods: 53 patients (group 1) received ACL reconstruction via BPTB, whereas 55 patients (group 2) received arthroscopic ACL reconstruction using PLT autograft. Results: In group 1, the mean preoperative and postoperative scores on the Lysholm Knee Questionnaire (LKQ) scale resulted in 69.2 ± 10.7 points and −92.2 ± 6.4 points, respectively. The average preoperative and postoperative value on the International Knee Documentation Committee (IKDC) scale was 68.2 ± 10.6% and −90.1 ± 9.5%, respectively. For KT-1000, according to the results of surgical treatment, it is −3.7 ± 1.4 mm, and for the American Orthopaedic Foot &amp; Ankle Society (AOSAF) it is −95.3 ± 4.5%. The autograft ruptured within 2 years after operation in 4 of 50 patients. In group 2, the mean score on the LKQ scale before the operation was 70.2 ± 11.6 points, after −94.3 ± 0.5 points. The average value on the IKDC scale before surgery was 68.6 ± 8.7%, after −91.5 ± 8.2%. KT-1000 −3.4 ± 1.2 mm. Conclusion: The results in both groups can be assessed as good; peroneus longus muscle tendon autograft is an alternative graft for the primary reconstruction of ACL, preserving the dynamic stabilizers of the knee and has no effect on the formation of flat feet and other disease in the postoperative period.

Increased Bone Plug Depth From the Joint Increases Tunnel Enlargement in Anterior Cruciate Ligament Reconstruction Using Bone–Patellar Tendon–Bone Autograft With Suspensory Femoral Fixation

To determine a safe bone plug depth fixation zone based on early tunnel enlargement rates in anterior cruciate ligament (ACL) reconstruction using bone-patellar tendon-bone (BPTB) autograft with suspensory femoral fixation. Patients who had undergone rectangular tunnel ACL reconstruction using BPTB autograft with suspensory femoral fixation were retrospectively identified. Femoral and tibial tunnel aperture areas were measured on computed tomography 2 weeks and 6 months after surgery to calculate rates of femoral and tibial tunnel enlargement (FTE and TTE), respectively. Femoral bone plug depth (FBPD) and tibial bone plug depth (TBPD) were defined as the distance of the tip of the plug from the respective joint lines. Optimal FBPD and TBPD cutoff values were calculated for the following rates of FTE and TTE, respectively: 0%, 15%, 30%, and 50%. Sixty-four patients (19 females, 45 males; mean age, 29.5 ± 12.3 years) were included in the study. The femoral and tibial tunnel apertures significantly enlarged over time. FBPD (P < .001; r= 0.607) and TBPD (P= .013; r= 0.308) were positively correlated with FTE and TTE, respectively. The optimal FBPD cutoff value was 2.8 mm for FTE rates of 0% and 15%, 3.6 mm for 30%, and 6.0 mm for 50%. The optimal TBPD cutoff value was 1.48 mm for a 0% TTE rate and 5.1 mm for those higher. The cutoff value specificities were lower for the tibial tunnel than the femoral tunnel for each tunnel enlargement rate. Early tunnel enlargement and bone plug depth were significantly correlated in bone the femoral and tibial tunnels. The degree of correlation was higher in the femoral tunnel. To minimize bone tunnel enlargement, the distal end of the femoral bone plug should be placed less than 2.8 mm from the tunnel aperture. Level IV, therapeutic case series.

Ultrasonic Technique for Femoral Tunnel Creation in Anterior Cruciate Ligament Reconstruction

Bone tunnel creation in the anatomical location is essential in anterior cruciate ligament (ACL) reconstruction with an autogenous graft and is commonly performed with a drill bit matched to graft diameter. Anatomic rectangular tunnel ACL reconstruction with a bone–patellar tendon–bone autograft has been developed to anatomically create bone tunnels inside the ACL footprints and has been reported to achieve excellent outcomes. To make the rectangular tunnel, the surgeon needs to dilate 2 adjacent bone tunnels after creation of 2 round tunnels with a drill bit, while the tunnel wall occasionally cracks during dilating. An ultrasonic (US) device was developed with improvement of output power and has been implemented with a rectangular shape blade in the field of arthroscopic surgery. This US device can provide a precise and effective bone cut compared to drills. We introduced this device to clinically create a rectangular tunnel during ACL reconstruction. The US device can be useful for rectangular femoral tunnel creation and can create a precise rectangular femoral tunnel in the ACL footprint.

Return to Sport After Primary Anterior Cruciate Ligament (ACL) Reconstruction: A Survey of The American Orthopaedic Society for Sports Medicine.

Anterior cruciate ligament (ACL) tears are a common sports injury, and typically require a prolonged post-operative rehabilitation. The purpose of this study was to survey members of the American Orthopaedic Society for Sports Medicine (AOSSM) to determine their return to sport (RTS) criteria after primary ACL reconstruction (ACLR). A 23-question, anonymous survey hosted through Google® Docs was distributed electronically to AOSSM members. This survey included questions regarding the timing, as well as any functional tests or other metrics used to determine when an athlete is ready to RTS. A total of 863 surgeons responded over four months. The most popular graft choice was bone patellar tendon bone autograft (63%). For non-pivoting sports, 43% of respondents allowed RTS at five to six months, while 31% allowed RTS at seven to eight months. For pivoting sports, 34% of respondents allowed RTS at seven to eight months, while 36% allowed RTS at nine to ten months. The most common criteria for return to non-pivoting sports include full knee motion (89%) and time after ACLR (76%). The most common criteria for return to pivoting sports include full knee motion (87%) and passing a hop test (80%). Only 21% of respondents assessed for psychological readiness to RTS. RTS occurred sooner in non-pivoting than pivoting sports, with similar RTS criteria in both groups. Most respondents did not assess for psychological readiness to RTS.

Rates of Septic Arthritis After ACL Reconstruction: A Single-Center Analysis Highlighting Quadriceps Tendon Grafts

Background: Although the infection rates for bone–patellar tendon–bone autograft (BTB), hamstring tendon autograft (HT), and allograft have been reported previously, there are limited data available for a large cohort of individuals undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) using quadriceps tendon autograft (QT). Purpose: The aims of this study are (1) to compare rates of septic arthritis after primary and revision ACLR with QT, BTB, HT, and allograft and (2) to evaluate the association between an infection after ACLR and potential risk factors in a large single-system analysis. Study Design: Cohort study; Level of evidence, 3. Methods: All ACLR cases performed by 10 high-volume sports medicine fellowship–trained ACL surgeons between January 2000 and January 2022 were retrospectively analyzed. Minimum follow-up was 90 days after ACLR, and all multiligament reconstructions were excluded. Demographic information, surgical variables, infection characteristics, and rate of ACL graft retention were collected for all included patients. Independent samples t test, chi-square test, or Fisher exact tests with adjusted Benjamini-Hochberg post hoc procedure were used for group comparisons. Results: In total, 6652 patients were included in this study. The most commonly used graft was allograft (n = 2491; 37.4%), followed by HT (n = 1743; 26.2%), BTB (n = 1478; 22.2%), and QT (n = 940; 14.1%). The overall postoperative rate of septic arthritis was 0.34% (n = 23). Septic arthritis rates based on graft type were 0.74% (n = 13) for HT, 0.24% (n = 6) for allograft, 0.20% (n = 3) for BTB, and 0.10% (n = 1) for QT. While a statistically significant difference with regard to graft type (P = .01) was observed, no significant relationships were found between postoperative septic arthritis and age, sex, revision ACLR, ACLR surgical technique, and accompanying intra-articular procedures for all septic arthritis patients (P > .05). The average time from the onset of the symptoms of infection to surgical irrigation and debridement (I&D) was 2 days (minimum, 0; maximum, 6). ACL grafts were retained during I&D procedures in all patients with postoperative septic arthritis. Conclusion: The postoperative rate of septic arthritis was 0.1% after use of the QT autograft. While graft choice may affect rates of septic arthritis after ACLR, patient characteristics, ACLR technique, revision ACLR, and accompanying intra-articular procedures during ACLR were not associated with postoperative septic arthritis with the numbers available for analysis.

Ipsilateral Quadriceps Tendon-Bone ACL Revision Reconstruction to Address Failed Primary Bone-Patellar Tendon-Bone ACL Reconstruction with Persistent Patellar Bone Defect

Bone–patellar tendon–bone (BPTB) autograft is a popular graft choice for anterior cruciate ligament reconstruction (ACLR) in active young adults. In case of BPTB ACLR failure, the 3 most popular autograft choices for a revision surgery include contralateral BPTB, contralateral or ipsilateral hamstrings autograft, and contralateral or ipsilateral quadriceps tendon autograft. Quadriceps tendon autograft has been gaining increasing popularity in recent years in this respect, but using quadriceps tendon–bone autograft in the setup of a previous use of ipsilateral BPTB autograft deserves special technical considerations, with emphasis on preserving patellar bone integrity. We describe a technique for performing revision ACLR after failed primary BPTB ACLR by using ipsilateral quadriceps tendon–bone autograft in the setup of persistent distal patellar bone defect. Using this autograft benefits the advantages of highly resilient graft tissue in addition to fast bone-to-bone healing on the femoral side, and it can be an excellent choice in revision reconstruction for surgeons who prefer tendon-bone autograft for highly active young adults and specifically when the patients underwent bilateral primary autologous BPTB ACLRs.

Return to Play and Pattern of Injury After ACL Rupture in a Consecutive Series of Elite UEFA Soccer Players.

Anterior cruciate ligament rupture represents a career-threatening injury for professional soccer players. To analyze the pattern of injury, return to play (RTP), and performance of a consecutive series of elite professional soccer players after anterior cruciate ligament reconstruction (ACLR). Case series; Level of evidence, 4. We evaluated the medical records of 40 consecutive elite soccer players who underwent ACLR by a single surgeon between September 2018 and May 2022. Patient age, height, weight, body mass index, position, injury history, affected side, RTP time, minutes played per season (MPS), and MPS as a percentage of playable minutes before and after ACLR were retrieved from medical records and from publicly available media-based platforms. Included were 27 male patients (mean ± SD age at surgery, 23.2 ± 4.3 years; range, 18-34 years). The injury occurred during matches in 24 players (88.9%), with a noncontact mechanism in 22 (91.7%). Meniscal pathology was found in 21 patients (77.8%). Lateral meniscectomy and meniscal repair were performed in 2 (7.4%) and 14 (51.9%) patients, respectively, and medial meniscectomy and meniscal repair were performed in 3 (11.1%) and 13 (48.1%) patients, respectively. A total of 17 players (63.0%) underwent ACLR with bone-patellar tendon-bone autograft and 10 (37.0%) with soft tissue quadriceps tendon. Lateral extra-articular tenodesis was added in 5 patients (18.5%). The overall RTP rate was 92.6% (25 of 27). Two athletes moved to a lower league after surgery. The mean MPS% during the last preinjury season was 56.69% ± 21.71%; this decreased significantly to 29.18% ± 20.6% (P < .001) in the first postoperative season and then increased to 57.76% ± 22.89% and 55.89% ± 25.8% in the second and third postoperative seasons. Two (7.4%) reruptures and 2 (7.4%) failed meniscal repairs were reported. ACLR in elite UEFA soccer players was associated with a 92.6% rate of RTP and 7.4% rate of reinjury within 6 months after primary surgery. Moreover, 7.4% of soccer players moved to a lower league during the first season after surgery. Age, graft selection, concomitant treatments, and lateral extra-articular tenodesis were not significantly associated with prolonged RTP.

Quadriceps Strength and Knee Function After Anterior Cruciate Ligament Reconstruction with Quadriceps Tendon Bone Autograft: A Preliminary Report.

The purpose of this study was to evaluate quadriceps strength and knee function after anterior cruciate ligament (ACL) reconstruction using a quadriceps tendon bone (QTB) autograft. Preliminary data were extracted from an ongoing prospective cohort study in which the operative extremity was compared to non-operative extremity. Patients from 14 to 40 years of age who had an ACL reconstruction with QTB autograft volunteered to have knee assessment including quadriceps isokinetic strength measures and functional knee testing at 6 and 12 months post-operatively. Paired t-tests were conducted to compare post-operative strength and function scores on participants who had minimum one-year post-surgical follow-up. Patients had a significant recovery of quadriceps strength as determined by isokinetic testing and single leg hop test. For 31 participants, quadriceps strength of the operative leg measured at 60 deg/sec was 63% of the non-operative leg at six months, increasing to 79% at one year (p < 0.001); when measured at 180 deg/sec, these values were 68% at six months, increasing to 82% at one year (p < 0.001). For 30 participants, single leg hop functional scores of the operative leg were 80% of the non-operative leg at six months, increasing to 91% at one year (p < 0.001). After QTB autograft for ACL reconstruction, there were significant gains in quadriceps strength and knee function from six months to one year post-operative. These findings indicated the QTB is an acceptable ACL reconstruction option.

Technique of ACL Reconstruction With Autologous Quadriceps Tendon Bone Graft and Femoral Press Fit Fixation

Background: Recently, there has been an increase in interest in the quadriceps tendon (QT) as an alternative autologous graft option for primary anterior cruciate ligament (ACL) reconstruction. Indication: Anterior cruciate ligament reconstruction in skeletally mature patients (high-risk patients for re-rupture and patients with medial instability). Technique Description: The QT graft is harvested with a 4-cm skin incision over the superior pole of the patella. A double knife and an oscillating saw are used to obtain the QT graft with a bone block from the patella (65 mm x 10 mm graft and 15 mm bone block). Then an arthroscopy is carried out with assessment of the ACL tear and treatment of further intraarticular injuries. ACL reconstruction begins with debridement of the femoral insertion to expose the land marks. The medial portal is used for femoral tunnel drilling with the knee in more than 110° of flexion. A special portal aiming device is introduced via the anteromedial portal and a guide wire is placed in the area of the femoral anteromedial insertion. This guide wire is gradually overdrilled with various drills and dilators of increasing size. The final diameter should be 0.5 mm smaller than the diameter of the bone block of the graft to allow for press-fit fixation. Then, the tibial tunnel is drilled using a tibial drill guide leaving the tibial stump of the original ACL intact. The graft is pulled into the joint through the tibial tunnel until the bone block stops at the femoral tunnel entrance. The bone block is then pushed through the medial portal into the femoral tunnel (press-fit fixation). The tibial fixation is performed with an interference screw and optionally with an extracortical button. Results: Prior studies with 2 years follow-up have shown that the clinical outcomes in primary and revision ACL reconstruction were not significantly different between the use of QT grafts with femoral press-fit fixation and the use of hamstring grafts with femoral suspension fixation. Discussion/Conclusion: Quadriceps tendon bone autograft and femoral press-fit fixation provides an excellent alternative as a graft choice in ACL reconstruction. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Current trends in anterior cruciate ligament surgery. A worldwide benchmark study

ObjectivesTo benchmark current trends on anterior cruciate ligament reconstruction (ACLR) surgery. MethodsThe largest worldwide ACLR survey to date was performed during May 2020, targeted to reach representation of all continents. It was submitted electronically to all International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports surgeons (n = 3,026), asking those who perform ACLR to respond. ResultsWith a final sample size of 2,107, the overall response rate was 69.6%. Median years of practice as orthopaedic surgeon was 15 (range 1–52) and 49.6% of all respondents were defined as high-volume surgeons (>50 ACLR annually). Hamstrings tendon autograft was the preferred graft for primary ACLR (80.3%) and the medial portal femoral drilling was the most frequently used technique (78.5%). Cortical buttons (82.7%) and bioabsorbable screws (62.7%) were the preferred fixation methods for hamstring tendon autograft ACLR in femur and tibia, respectively. Metallic screws (45.2%) were the preferred fixation methods for bone patellar tendon bone autograft in femur and tibia. Most of the respondents routinely used pre-tensioning techniques for their graft preparation (63.8%), but less than half of surgeons preferred antibiotic soaking of the grafts (45.3%). The preferred knee position for graft fixation was 10–30° of knee flexion and neutral rotation (57.0%). The addition of anterolateral augmentation (or extra-articular tenodesis) was infrequent in primary and isolated ACLR (10.0%), but a statistically significant raise was seen for revision surgeries (20.0%). Most used brace in the initial postoperative rehabilitation (54.9%) and the time to allow patients to fully resume sports was at an average of 8.9 ± 2.0 months. Treatment algorithm of paediatric ACL injuries exhibited a low consensus among the respondents. ConclusionThis worldwide survey benchmarks the current trends in ACL reconstruction, achieving the largest participation of surgeons to date. Among the great variety of options available for ACL reconstructions, surgeons’ preferences showed some differences according to their location and expertise. Reporting trends in practice, and not only the evidence, is important to medical education and providing patients the safest care possible.This is a Level V, expert opinion study.

Return to play in paediatric & adolescent patients following anterior cruciate ligament reconstruction

BackgroundThere is an increased risk of anterior cruciate ligament (ACL) rupture and subsequent ACL reconstruction in patients <18 years old due to their high levels of sporting participation. PurposeThe purpose of this study was to assess the rate and timing of return to play (RTP) in paediatric and adolescent patients following ACL reconstruction, and to compare the outcomes between those undergoing ACL reconstruction with bone patella tendon bone autograft (BTB) and hamstring tendon (HT) autograft. Study DesignLevel of Evidence: Level III; Retrospective Comparative Cohort Study. MethodsThe institutional ACL registry was screened for patients <18 that had undergone a primary ACL reconstruction. Outcomes were analysed for patients undergoing either a BTB or HT autograft for rate and timing of return to play, functional outcomes and subsequent knee injuries. Statistical analysis was performed using SPSS. Results358 (BTB; 253, HT; 105) patients were followed up for 24-months (95% follow up). 86 athletes (27 BTB; 59 HT) were aged 13–15 years old with no significant difference in RTP rate or timing between graft types, however, there was a difference in ipsilateral re-ruptures (10.2% HT vs 0% BTB p = 0.03). 272 athletes (226 BTB; 46 HT) were aged 16–18 years old with no significant difference in RTP rate or timing between graft types, or ipsilateral re-ruptures (8.7% HT vs 2.7% BTB p = 0.07). Concurrent ligament, meniscal or chondral injuries found at the time was treated as necessary. ConclusionPaediatric and adolescent patients undergoing ACL reconstruction with either BTB or HT had high rates of return to play. This was seen in both subgroups with 13–15-year-olds mostly receiving a HT graft repair and 16–18-year-olds mainly receiving a BTB repair. A moderate re-rupture rate was seen at 24-months. However longer follow up is needed to truly see the long-term impact of such an injury at such a young age.

Comparison Between Functional Outcomes of Bone Patellar Tendon Bone Autografts versus Semitendinosus Autografts for Reconstruction of Anterior Cruciate Ligament

Purpose: Our study of comparison of functional outcomes and complications of bone patellar tendon bone autograft and semitendinosus autograft for Anterior Cruciate Ligament reconstruction. Material and Methods: 60 patients were operated for ACL reconstruction in a tertiary health care setup, out of them 30 were operated with semitendinosus graft and 30 were operated with bone-patellar tendon-bone graft and were reviewed at 3 months, 6 months, 9 months and 12 months. After the procedure, the patients were assessed for the functional outcome using Tegner-lysholm knee scoring scale and also with International Knee Documentation Committee (IKDC) Scoresat. Results: Mean lysholm score was comparable between STA and BPTB groups at baseline (41.50 vs 41.77; p-0.81). The mean scores significantly improved in both group at each follow up and was recorded as 93.43 and 90.6 by the end of one year in STA and BPTB group respectively. The improvement was slightly better in STA group at each follow up. Conclusion: Arthroscopic/open anterior cruciate ligament reconstruction by either semitendinosus autograft or bone patellar tendon graft gives satisfactory results in short term follow up in terms of knee functions. However, Rehabilitation with bone patellar tendon bone autografts group was accelerated in balance proprioception and running as compared to semitendinosus autografts also creep of graft is mostly seen in semitendinosus autografts which is less likely to be seen in bone patellar tendon bone autografts.