Tendon Anterior Cruciate Ligament Reconstruction Research Articles

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.

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.

Proprioceptive training after ACL reconstruction: Standard versus stump preservation technique

BACKGROUND: Anterior cruciate ligament (ACL) injuries are considered to be among the most disabling knee injuries. The proprioception function affected due to ACL injuries results in functional instability as neuromuscular control is altered in consequence. PURPOSE: To compare proprioceptive training outcomes following ACL reconstruction with and without stump removal. METHODS: Thirty male patients received a three months rehabilitation program, including an integral proprioceptive training component, after having autogenous hamstring tendon ACL reconstruction. Fifteen patients had done stump shaving technique (group A), and fifteen patients with stump preservation (group B). Mean age was (32.87±7.51 years) for group A and (31.53±6.46 years) for group B. Clinical evaluation included functional performance measured by Lysholm scale, dynamic balance measured by Biodex balance system test (overall stability index), and sense of position measured by active and passive repositioning tests (absolute angular error) on Biodex system 3 isokinetic dynamometer. RESULTS: No significant differences were detected for active and passive repositioning tests and overall stability index of affected and non-affected legs between groups. Moreover, Lyshlom scores between both groups revealed no significant difference. Pairwise comparisons of affected and non-affected legs within either groups were also non- significant ( p &lt; 0.05). CONCLUSION: Proprioceptive training after arthroscopic ACL reconstruction showed similar effects on function, dynamic balance, and sense of position in patients operated by stump shaving or preservation techniques.

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.