Higher rates of anatomical insertion of medial hamstring tendon regeneration post-anterior cruciate ligament reconstruction with stump preservation graft harvesting technique: A prospective, randomised, double-blinded clinical trial with magnetic resonance imaging evaluation

OBJECTIVE(S)

The purpose of this study was to compare the regeneration of semitendinosus and gracilis tendons from two different graft harvesting techniques, which are the stump preservation and conventional graft harvesting techniques. We hypothesised that the stump preservation graft harvesting technique, which preserved the distal attachment of tendons at their insertion, would facilitate anatomical regeneration to the pes anserinus.

METHODS

This is a prospective, randomised, double-blinded study whereby thirty consecutive patients who underwent single bundle anterior cruciate ligament reconstruction with ipsilateral semitendinosus and gracilis autografts were recruited. The patients were randomly assigned to the stump preservation group (14 patients) or conventional group (16 patients). Magnetic resonance imaging (MRI) evaluation was performed preoperatively and at six months post-operatively.

RESULTS

At 6-month follow-up, MRI evaluations showed a higher percentage of insertion of regenerated semitendinosus and gracilis at the pes anserinus in the stump preservation group (75.0%) than that in the conventional group (68.8%). There was a significantly higher proximal shift of the musculotendinous junction of semitendinosus (5.70 ​cm versus 3.36 ​cm, p ​= ​0.029) and gracilis (5.28 ​cm versus 3.16 ​cm, p ​= ​0.045) in the conventional group post-operatively.

CONCLUSION

The stump preservation technique yields a higher percentage of anatomical insertion of regenerated tendons and a lesser amount of proximal shift of the musculotendinous junction.

LEVEL OF EVIDENCE

III - Prospective study with up to two negative criteria.

Obesity-associated outcomes after ACL reconstruction: a propensity-score-matched analysis of the US Nationwide Inpatient Sample 2005-2018

BACKGROUND

Anterior cruciate ligament (ACL) injuries are common among physically active individuals, and obesity may increase the risk of such injuries due to factors like biomechanical stress on the knee. We aimed to determine if obesity affects postoperative outcomes after ACL reconstruction.

METHODS

Data from adults aged 20 years and older with ACL injuries who underwent inpatient reconstruction from 2005 to 2018 were extracted from the United States (US) Nationwide Inpatient Sample (NIS) database. Patients were divided into two groups based on the presence of co-existing obesity, defined as a body mass index (BMI) ≥ 30 kg/m2. Propensity-score matching (PSM) was employed to balance between-group differences. Associations between obesity and concomitant meniscus injury, length of stay (LOS), post-procedural complications, and non-routine discharge were examined using univariate and multivariable logistic and linear regressions.

RESULTS

After PSM, data from 1323 patients (representing 6396 individuals in the US) were analyzed. Of these, 441 (33%) were classified as obese, while 882 (67%) were not obese. After adjustment, obesity was significantly associated with a longer LOS (adjusted beta (aBeta) = 0.32, 95% confidence interval (CI) 0.31-0.321) and an increased likelihood of non-routine discharge (adjusted OR (aOR) = 2.18, 95% CI 1.47-3.22). There were no significant associations between obesity and concomitant meniscus injury (aOR = 1.04, 95% CI 0.81-1.32) or post-procedural complications (aOR = 0.97, 95% CI 0.74-1.27).

CONCLUSIONS

In patients undergoing ACL reconstruction in the US, obesity is independently associated with a longer LOS and a higher risk of non-routine discharge. Nevertheless, obesity does not appear to be associated with concomitant meniscus injury or post-procedural complications.

Anterior Cruciate Ligament (ACL) Reconstruction Augmentation With Bone Marrow Aspirate, Demineralized Bone Matrix, and Suture Tape Demonstrates No Difference In Outcomes, But Faster Functional Recovery, Versus Non-augmented ACL Reconstruction

PURPOSE

To compare outcomes after anterior cruciate ligament reconstruction (ACLR) with bone marrow aspirate concentrate (BMAC), demineralized bone matrix (DBM), and suture tape augmentation (STA) vs. ACLR without biologic augmentation or STA.

METHODS

A prospective randomized controlled trial at a single institution was performed to compare ACLR with BMAC, DBM, and STA (Group A) vs. ACLR without biologic or STA (Group NA). One hundred patients were required. Skeletally mature patients <25 years old received quadriceps tendon autografts, while patients ≥25 years old received allograft ACLR with an all-inside technique. Concomitant meniscal pathologies were included. Primary outcomes compared were range-of-motion (ROM), limb symmetry, and patient-reported outcomes (PROs). Secondary outcomes included radiographic outcomes and surgical complications. Univariate and mixed-model regression analysis were used to compare outcomes.

RESULTS

Fifty-nine patients were included (Group A: 29 patients, 11 females, 38%; Group NA: 30 patients, 15 females, 50%). Early range-of-motion at 6 weeks (125° vs 109° flexion, p<0.0001) and limb symmetry testing at 12 weeks (80.6 % vs. 36.7% [Delta 43.9%], p<0.001) were significantly improved in Group A. At two years, International Knee Documentation (IKDC) scores were similar (91.1 ± 12.7 vs. 85.3 ± 10.8, p=0.109). Knee Injury and Osteoarthritis and Outcome Score (KOOS) Quality of Life (QOL) scores were significantly enhanced in Group A (85.2 ± 20.9 vs. 72.1 ± 20.4, p=0.042). Twenty-two patients (12 Group A, 10 Group NA) underwent CT scans at 6-months to compare bone tunnel healing. Overall, the mean increase in bone tunnel diameter was significantly smaller in Group A vs. NA. No difference in graft re-ruptures or re-operations was observed. Seven of 59 patients (11.9%) underwent re-operation for stiffness (A: 3 (10%) vs. NA: 4 (13%), p=1.0).

CONCLUSION

There were no differences in IKDC scores between groups at 2-year follow-up. Functional outcomes including early range-of-motion and limb symmetry were significantly improved in patients who received ACLR with BMAC, DBM, and STA. ACLRACLR.ACLR.

Lateral Extra-Articular Tenodesis and Anterolateral Procedures

The treatment of rotational instability has been an intriguing challenge since the era of modern anterior cruciate ligament (ACL) surgery. Lateral extra-articular procedures (LEAPs) have emerged as a solution to this problem, particularly in high-risk populations. Several studies have shown significant benefits of combining LEAPs with ACL reconstruction, including reduced graft failure rates, improved knee stability, improved rotational stability, and higher return-to-play rates. These findings have led to an in-depth evaluation of LEAPs as lateral extra-articular tenodesis and anterolateral ligament reconstruction and their potential role in improving outcomes after ACL reconstruction.

Characteristics of early complications in isolated primary anterior cruciate ligament reconstruction surgery

PURPOSE

The early complications of isolated anterior cruciate ligament reconstruction surgery (ACLR) have not been well characterized using large databases. This study aims to characterize incidence, impact, and risk factors for short-term operative complications following elective, isolated ACLR surgery. We hypothesize that demographic and perioperative factors may predict 30-day complications after isolated ACLR.

METHODS

This case-control analysis of the American College of Surgeons National Surgical Quality Improvement Program Database (2005-2017) used Current Procedural Terminology codes to identify elective, isolated ACLR patients. Patients undergoing concomitant procedures were excluded. Complications were analyzed using bivariate analysis against demographic variables. Multiple stepwise logistic regression was used to identify independent risk factors for morbidity after ACLR.

RESULTS

A total 12,790 patients (37.0% female, p = 0.674) were included with a mean age of 32.2 years old (SD 10.7 years, p < 0.001). Mean BMI was 27.8 kg/m2 (6.5) where 28.9% of patients had a BMI > 30 (p = 0.064). The most common complications were wound-related (0.57%). In cases with complications, there were higher rates of (1.3% vs 0.8%, p = 0.004) prolonged operation (> 1.5 h), higher rate (2.9% vs 1.8%, p = 0.004) of extended length of stay (≥ 1 day), unplanned reoperation (15.8% vs 0.3%, p < 0.001), and unplanned readmission (17.5% vs 0.3%, p < 0.001). Multivariate analysis showed prolonged operative time (p = 0.001), dyspnea (p = 0.008), and non-ambulatory surgery (p = 0.034) to be predictive of any complication. Dependent functional status (p = 0.091), mFI-5 > 0.2 (= 0.173), female sex (p = 0.191), obesity (p = 0.101), and smoking (p = 0.113) were not risk factors for complications.

CONCLUSION

ACLR is associated with low rates of morbidity and readmissions. The most common comorbidities, complications, and predictors of morbidities were identified to aid surgeons in further reducing adverse outcomes of ACLR. Operative time > 1.5 h, dyspnea, and non-ambulatory surgery are predictive of complications.

Postoperative healing and complications based on anterior cruciate ligament reconstruction graft type

Injury to the anterior cruciate ligament (ACL) is a devastating injury to athletes of all ages. The current gold standard treatment following complete rupture of the ACL is reconstruction of the torn ligament with autograft or allograft tendon. Commonly used tendon grafts include patellar tendon, hamstring tendon, and quadriceps tendon. Although ligaments and tendons have similar collagen and proteoglycan compositions, they maintain a unique composition and arrangement of cells to serve their unique biomechanical needs. Therefore, following ACL reconstruction (ACLR), the implanted tendon tissue undergoes a process of remodeling which is termed "ligamentization". The process of ligamentization is divided into three main phases, which include the early healing phase, the proliferative phase, and the maturation phase. Following the process of ligamentization, the graft tissue closely mimics the appearance of ligament tissue on an ultrastructural level. Successful outcome following ACLR is contingent upon adequate remodeling of the tissue as well as healing of the graft within the bone tunnels in the femur and tibia. Choice of graft has individual implications regarding their associated risk of complications, failure, and infection. The purpose of this review is to summarize the process of ligamentization and graft healing and to discuss how graft type influences the rate and types of complications, failures, and infections.

Larger hip external rotation motion is associated with larger knee abduction and internal rotation motions during a drop vertical jump

Associations among hip motions, knee abduction and internal rotation motion during a drop vertical jump (DVJ), which increases the risk of anterior cruciate ligament injury, remain unclear. The purpose of this study was to examine associations among knee abduction, internal rotation and hip joint motions during a DVJ. Fifty-seven young female participants performed a DVJ from a 30-cm height. Hip and knee kinematics and kinetics were analysed using a three-dimensional motion analysis system and force plates. Multiple regression analysis showed that peak knee abduction angle was negatively associated with knee internal rotation and hip internal rotation excursions from initial contact (IC) to peak knee flexion, and positively associated with peak knee abduction moment (R2 = 0.465, P< 0.001). Peak knee internal rotation angle was negatively associated with the hip flexion excursion from IC to peak knee flexion and peak hip adduction moment (R2 = 0.194, P= 0.001). In addition, hip internal rotation excursion was negatively associated with knee abduction and internal rotation excursion from IC to 50 ms after IC. To avoid a large knee abduction and internal rotation motion during jump-landing training, it might be beneficial to provide landing instructions to avoid a large hip external rotation motion.

Vitamin D as an intervention for improving quadriceps muscle strength in patients after anterior cruciate ligament reconstruction: study protocol for a randomized double-blinded, placebo-controlled clinical trial

BACKGROUND

The goal of anterior cruciate ligament reconstruction (ACLR) is to restore the preinjury level of knee function to return to play (RTP). However, even after completing the rehabilitation programme, some patients may have persistent quadriceps muscle weakness affecting knee function which ultimately leads to a failure in returning to play. Vitamin D has been long recognized for its musculoskeletal effects. Vitamin D deficiency may impair muscle strength recovery after ACLR. Correcting vitamin D levels may improve muscle strength.

METHODS

This is a double-blinded, randomized controlled trial to investigate the effects of vitamin D supplementation during the post-operative period on quadriceps muscle strength in anterior cruciate ligament (ACL)-injured patients. Patients aged 18-50 with serum vitamin D < 20 ng/ml, unilateral ACL injury, > 90% deficit in total quadriceps muscle volume on the involved leg compared with uninvolved leg, Tegner score 7 + , and no previous knee injury/surgery will be recruited. To assess patient improvement, we will perform isokinetic and isometric muscle assessments, ultrasound imaging for quadriceps thickness, self-reported outcomes, KT-1000 for knee laxity, biomechanical analysis, and Xtreme CT for bone mineral density. To investigate the effect of vitamin D status on quadriceps strength, blood serum samples will be taken before and after intervention.

DISCUSSION

Patients with low vitamin D levels had greater quadriceps fibre cross-sectional area loss and impaired muscle strength recovery after ACL. The proposed study will provide scientific support for using vitamin D supplementation to improve quadriceps strength recovery after ACLR.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05174611. Registered on 28 November 2021.

Principles for optimizing anterior cruciate ligament reconstruction outcomes in elite athletes: a review of current techniques

Anterior cruciate ligament (ACL) tears are one of the most common sport-related injuries and occur in greater than 3% of athletes in a four-year window of sports participation. Non-contact injuries are the most common mechanism for ACL injury in elite-level athletes, especially with increased valgus and external rotation of the knee when loading eccentrically in flexion. Because of the immense toll these injuries and their recovery take on athletes especially, optimal treatment has been a subject of great interest for some time. Many ACL reconstruction (ACLR) and repair techniques have been implemented and improved in the last two decades, leading to many surgical options for this type of injury. The surgical approach to high-level athletes in particular requires additional attention that may not be necessary in the general population. Important considerations for optimizing ACL treatment in high-level athletes include choosing repair vs. reconstruction, surgical techniques, choice of auto- or allograft, and associated concomitant procedures including other injuries or reinforcing techniques as well as attention to rehabilitation. Here, we discuss a range of surgical techniques from repair to reconstruction, and compare and contrast various reconstructive and reinforcing techniques as well as associated surgical pearls and pitfalls. Good outcomes for athletes suffering from ACL injury are attainable with proper treatment including the principles discussed herein.

Bone morphology features associated with knee kinematics may not be predictive of ACL elongation during high-demand activities

PURPOSE

Bony morphology has been proposed as a potential risk factor for anterior cruciate ligament (ACL) injury. The relationship between bony morphology, knee kinematics, and ACL elongation during high-demand activities remains unclear. The purpose of this study was to determine if bone morphology features that have been associated with ACL injury risk and knee kinematics are also predictive of ACL elongation during fast running and double-legged drop jump.

METHODS

Nineteen healthy athletes performed fast running and double-legged drop jump within a biplane radiography imaging system. Knee kinematics and ACL elongation were measured bilaterally after using a validated registration process to track bone motion in the radiographs and after identifying ACL attachment sites on magnetic resonance imaging (MRI). Bony morphological features of lateral posterior tibial slope (LPTS), medial tibial plateau (MTP) depth, and lateral femoral condyle anteroposterior width (LCAP)/lateral tibial plateau anteroposterior width (TPAP) were measured on MRI. Relationships between bony morphology and knee kinematics or ACL elongation were identified using multiple linear regression analysis.

RESULTS

No associations between bony morphology and knee kinematics or ACL elongation were observed during fast running. During double-legged drop jump, a greater range of tibiofemoral rotation was associated with a steeper LPTS (β = 0.382, p = 0.012) and a deeper MTP depth (β = 0.331, p = 0.028), and a greater range of anterior tibial translation was associated with a shallower MTP depth (β = - 0.352, p = 0.018) and a larger LCAP/ TPAP (β = 0.441, p = 0.005); however, greater ACL elongation was only associated with a deeper MTP depth (β = 0.456, p = 0.006) at toe-off.

CONCLUSION

These findings indicate that observed relationships between bony morphology and kinematics should not be extrapolated to imply a relationship also exists between those bone morphology features and ACL elongation during high-demand activities. These new findings deepen our understanding of the relationship between bony morphology and ACL elongation during high-demand activities. This knowledge can help identify high-risk patients for whom additional procedures during ACL reconstruction are most appropriate.

Prediction of Hamstring Autograft sizes for Anterior Cruciate Ligament Reconstruction using Preoperative Magnetic Resonance Imaging

BACKGROUND

The purpose of this study is to determine whether preoperative magnetic resonance image measurements can predict the hamstring tendon autograft diameter during anterior cruciate ligament reconstruction.

METHODS

We prospectively evaluated Forty-two patients with anterior cruciate ligament injury who underwent reconstruction using hamstring tendon autograft. Preoperative diameters and cross-sectional areas of the hamstring tendons were estimated using magnetic resonance imaging of the knee. Intraoperative diameters of the hamstring tendon graft were measured using a cylindrical graft sizer. We used Pearson's correlation test to compare the Preoperative and intraoperative graft size measurements. A possible cutoff value for the hamstring graft size was determined using Receiver operating characteristic analysis.

RESULTS

The mean age of the patient in the study was 27.5 ± 8.5 years. There were statistically significant correlations between preoperative and intraoperative hamstring tendon graft measurements (P < 0.001). Our study found 13.3 mm² cross-sectional area as the cutoff for predicting 7mm of quadrupled hamstring graft size with both sensitivity and specificity of 85.7 %, respectively.

CONCLUSIONS

We can conclude that preoperative magnetic resonance imaging measurements can predict the intraoperative graft size. This study can help in preoperatively planning for the graft choice.

Current development in surgical techniques, graft selection and additional procedures for anterior cruciate ligament injury: a path towards anatomic restoration and improved clinical outcomes-a narrative review

Background and Objective

Anterior cruciate ligament (ACL) reconstruction has been widely used for ACL injury for a long time. However, residual rotational instability and osteoarthritic changes after ACL reconstruction have been identified as problems. Thus, anatomic reconstruction techniques, various types of grafts and additional procedures have been desired to improve the clinical outcomes and knee instability. Although clinical outcomes and knee stability are better than in the past, ipsilateral graft failures still occur in 4-17% and osteoarthritic changes are seen in about 20% of patients after ACL reconstruction. To remedy these problems, it is necessary to improve the understanding of various surgical techniques and grafts and to pursue further improvement of surgical techniques. Therefore, the objective of this review is to summarize the advantages and disadvantages of various surgical techniques and graft selection, and additional procedures for ACL injury.

Methods

A literature review was conducted on the surgical procedures for ACL injury. Recent trends in surgical techniques, graft selection, and additional procedures for ACL injury were described. We performed a literature search in PubMed for studies published from origin to May 8, 2023. Studies were required to be English-language articles.

Key Content and Findings

Although many reports indicate that double-bundle ACL reconstruction is comparable to anatomic single-bundle (SB) reconstruction, intraoperative complications such as tunnel coalition exist in double-bundle reconstruction, and the technique needs to be improved. ACL repair has shown good short-term results, but long-term results need to be examined in the future. Quadriceps tendon autograft is being used more frequently, but hamstrings tendon autograft and bone-patellar tendon-bone autograft also have good results. In addition, in higher-risk cases, lateral extra-articular tenodesis (LET) and anterolateral ligament (ALL) reconstruction can be performed with good results.

Conclusions

To further improve clinical outcomes, more anatomical reconstructions should be pursued. Autografts are better than allografts and synthetic grafts, but further study is needed to determine which graft is better. Additional procedures should be performed in highly unstable cases and in revision cases.

Reconstruction of the anterior cruciate ligament: a historical view

Management of anterior cruciate ligament (ACL) tears has continuously evolved since its first description in approximately 170 A.D. by Claudius Galenus of Pergamum and Rome. The initial immobilization using casts was replaced by a variety of surgical and conservative approaches over the past centuries. The first successful case of ACL repair was conducted by Mayo Robson in 1885, suturing cruciate at the femoral site. In the nineteenth century, surgical techniques were focused on restoring knee kinematics and published the first ACL repair. The use of grafts for ACL reconstruction was introduced in 1917 but gained popularity in the late 1900s. The introduction of arthroscopy in the 1980s represented the greatest milestones in the development of ACL surgery, along with the refinements of indications, development of modern strategies, and improvement in rehabilitation methods. Despite the rapid development and multitude of new treatment approaches for ACL injuries in the last 20 years, autografting has remained the treatment of choice. Compared to the initial methods, arthroscopic procedures are mainly performed, and more resistant and safer fixation devices are available. This results in significantly less trauma from the surgery and more satisfactory long-term results. The most commonly used procedures are still patellar tendon or hamstring autograft. Additionally, popular, but less common, is the use of quadriceps tendon (QT) grafts and allografts. In parallel with surgical developments, biological reconstruction focusing on the preservation of ACL remnants through the use of cell culture techniques, partial reconstruction, tissue engineering, and gene therapy has gained popularity. In 2013, Claes reported the discovery of a new ligament [anterolateral ligament (ALL)] in the knee that could completely change the treatment of knee injuries. The intent of these modifications is to significantly improve the primary restriction of rotational laxity of the knee after ACL injury. Kinematic studies have demonstrated that anatomic ACL reconstruction and anterolateral reconstruction are synergistic in controlling pivot displacement. Recently, there has been an increased focus on the application of artificial intelligence and machine learning to improve predictive capability within numerous sectors of medicine, including orthopedic surgery.

A clinical practice review of therapeutic movement-based anterior cruciate ligament reconstruction return to sports bridge program: the biological, biomechanical and behavioral rationale

This clinical practice review describes the biological, biomechanical and behavioral rationale behind a return to sport bridge program used predominantly with non-elite, youth and adolescent high school and college athletes following anterior cruciate ligament (ACL) reconstruction. Post-physiotherapy, this program has produced outcomes that meet or exceed previous reports. With consideration for athletic identity and the Specific Adaptations to Imposed Demands (SAID) principle, the early program focus was on restoring non-impaired bilateral lower extremity joint mobility and bi-articular musculotendinous extensibility. Building on this foundation, movement training education, fundamental bilateral lower extremity strength and power, and motor learning was emphasized with use of external focus cues and ecological dynamics-social cognition considerations. Plyometric and agility tasks were integrated to enhance fast twitch muscle fiber recruitment, anaerobic metabolic energy system function, and fatigue resistance. The ultimate goal was to achieve the lower extremity neuromuscular control and activation responsiveness needed for bilateral dynamic knee joint stability. The rationale and conceptual basis of selected movement tasks and general philosophy of care concepts are described and discussed in detail. Based on the previously reported efficacy of this movement-based therapeutic exercise program we recommend that supplemental programs such as this become standard practice following release from post-surgical physiotherapy and before return to sports decision-making.

More anterior placement of femoral tunnel position in ACL-R is associated with postoperative meniscus tears

PURPOSE

The purpose of this study was to investigate the relationship between tunnel position in ACL reconstruction (ACL-R) and postoperative meniscus tears.

METHODS

This was a single institution, case-control study of 170 patients status-post ACL-R (2010-2019) separated into two matched groups (sex, age, BMI, graft type). Group 1-symptomatic, operative meniscus tears (both de novo and recurrent) after ACL-R. Group 2-no postoperative meniscus tears. Femoral and tibial tunnel positions were measured by 2 authors via lateral knee radiographs that were used to measure two ratios (a/t and b/h). Ratio a/t was defined as distance from the tunnel center to dorsal most subchondral contour of the lateral femoral condyle (a) divided by total sagittal diameter of the lateral condyle along Blumensaat's line (t). The ratio b/h was defined as distance between the tunnel and Blumensaat's line (b) divided by maximum intercondylar notch height (h). Wilcoxon sign-ranks paired test was used to compare measurements between groups (alpha set at p < 0.05).

RESULTS

Group 1 had average follow up of 45 months and Group 2 had average follow up of 22 months. There were no significant demographic differences between Groups 1 and 2. Group 1-a/t was 32.0% (± 10.2), which was significantly more anterior than group 2, 29.3% (± 7.3; p < 0.05). There was no difference in average femoral tunnel ratio b/h or tibial tunnel placement between groups.

CONCLUSIONS

A relationship exists between more anterior/less anatomic femoral tunnel position and the presence of recurrent or de novo, operative meniscus tears after ACL-R. Surgeons performing ACL-R should strive for recreation of native anatomy via proper tunnel placement to maximize postoperative outcomes.

LEVEL OF EVIDENCE

Level III.

GNRB® laximeter with magnetic resonance imaging in clinical practice for complete and partial anterior cruciate ligament tears detection: A prospective diagnostic study with arthroscopic validation on 214 patients

BACKGROUND

Accurate diagnosis of anterior cruciate ligament (ACL) injury is not always obtained with magnetic resonance imaging (MRI). Other tools, such as the GNRB® arthrometer, help to accurately identify the type of ACL tear. The aim of this study was to show that the GNRB® could be a relevant complementary solution to MRI in ACL injuries detection.

METHODS

A prospective study performed between 2016 and 2020 included 214 patients who had undergone knee surgery. The study compared sensitivity/specificity pairs of MRI and the GNRB® at 134 N to detect healthy ACL, partial and complete ACL tears. Arthroscopies were the 'gold standard'. Forty-six patients had a healthy ACL with associated knee lesions, 168 patients had ACL tears where 107 were complete tears and 61 were partial tears.

RESULTS

For healthy ACL, MRI scored 100% for sensitivity (SE) and 95% for specificity (SP), and the GNRB® scored SE 95.65% and SP 97.5% at 134 N. For complete ACL tears, MRI scored 80.81% for sensitivity (SE) and 64.49% for specificity (SP), and the GNRB® scored SE 77.78% and SP 85.98% at 134 N. For partial tears, MRI scored SE 29.51% and SP 88.97%, and the GNRB® scored SE 73.77% and SP 85.52% at 134 N.

CONCLUSION

GNRB® sensitivity and specificity were equivalent to those of MRI for healthy ACL and complete ACL tear detection. However, MRI had some difficulty in detecting partial ACL tears compared with the GNRB® which showed better sensitivity.

Augmentation with Fibertape Leads to Biomechanically Superior but Similar Clinical Outcomes in ACL Surgeries: Systematic Review and Meta-analysis

Purpose

The current generation has witnessed significant progress in the field of knee arthroscopy. Suture tapes have gained immense popularity due to perceived improved biomechanical support to the graft while it heals. The purpose of the present systematic review is to analyze the biomechanical construct of suture tapes in ACL repairs and reconstructions along with clinical outcomes.

Methods

Cochrane Library, PubMed, and Embase were searched until December 2021. All Biomechanical Studies on animal or cadaver knees that compared construct characteristics of suture tape in ACL repair or reconstruction and clinical studies in English focusing on outcomes following suture tape augmentation in ACL repair or reconstruction were included. The quality of clinical studies using the Modified Coleman Methodology Score (MCMS).

Results

A total of 16 studies biomechanical and 23 clinical studies were included in qualitative synthesis, leaving nine biomechanical studies for final quantitative analyses. Suture tape revealed biomechanical superiority in terms of ultimate strength, stiffness, cyclic displacement, and elongation of graft, while comparing ACLR with internal brace to standard ACLR. No significant difference in retear rates was seen in clinical studies. Clinical score(IKDC score) was found similar in both augmented and non-augmented construct. Similar results were obtained in biomechanical studies.

Conclusion

The use of suture tape as a ligament augmentation in both ACL reconstruction and ACL repair offers more strength, less elongation or displacement, and is biomechanically stable and sound. There is a lack of data to comprehensively comment upon the clinical superiority of the use of internal augmentation. However, a meta-analysis of the retear rates and clinical outcome score revealed similar outcomes between suture tape augmented and nonaugmented groups.

Biomechanical comparison of anterior cruciate ligament reconstruction fixation methods and implications on clinical outcomes

Anterior cruciate ligament reconstruction (ACLR) is one of the more common surgeries encountered by orthopaedic surgeons, which has its inherent challenges due to the complex anatomy and biomechanical properties required to reproduce the function and stability of the native ACL. Multiple biomechanical factors from graft choice and tunnel placement to graft tensioning and fixation methods are vital in achieving a successful clinical outcome. Common methods of ACLR graft fixation in both the primary and revision setting are classified into compression/interference, suspensory, or hybrid fixation strategies with multiple adjunct methods of fixation. The individual biomechanical properties of these implants are crucial in facilitating early post-operative rehabilitation, while also withstanding the shear and tensile forces to avoid displacement and early graft failure during graft osseointegration. Implants within these categories include the use of interference screws (IFSs), as well as suspensory fixation with a button, posts, surgical staples, or suture anchors. Outcomes of comparative studies across the various fixation types demonstrate that compression fixation can decrease graft-tunnel motion, tunnel widening, and graft creep, at the risk of damage to the graft by IFSs and graft slippage. Suspensory fixation allows for a minimally invasive approach while allowing similar cortical apposition and biomechanical strength when compared to compression fixation. However, suspensory fixation is criticized for the risk of tunnel widening and increased graft-tunnel motion. Several adjunct fixation methods, including the use of posts, suture-anchors, and staples, offer biomechanical advantages over compression or suspensory fixation methods alone, through a second form of fixation in a second plane of motion. Regardless of the method or implant chosen for fixation, technically secure fixation is paramount to avoid displacement of the graft and allow for appropriate integration of the graft into the bone tunnel. While no single fixation technique has been established as the gold standard, a thorough understanding of the biomechanical advantages and disadvantages of each fixation method can be used to determine the optimal ACLR fixation method through an individualized patient approach.

Biomechanical considerations for graft choice in anterior cruciate ligament reconstruction

Injury to the anterior cruciate ligament (ACL) of the knee is common and often requires surgical reconstruction. There are numerous graft options available to the operating surgeon, to each of which a growing body of dedicated literature exists. Each of these potential choices of ACL graft specimen has a distinctive set of biomechanical properties, clinical outcome profiles, and other special considerations (e.g., autograft versus allograft, harvest site factors, and operating time). The purpose of this review is to discuss the biomechanical characteristics of the native ACL alongside those of several of the most commonly used ACL graft specimens based on a current review of the biomechanical literature. In doing so, this review will also briefly discuss the biomechanical implications for allograft versus autograft usage and single-bundle versus double-bundle repair techniques. This review lists and discusses the stress, strain, stiffness, Young's modulus, and ultimate load to failure of the native ACL, several common autografts [patellar bone-tendon-bone (BTB), hamstring tendon (HT), and quadriceps tendon (QT)], and several common allografts. Given the important biomechanical role of the ACL in stabilizing the knee to translational and rotational forces, it is crucial that the operating surgeon make a decision on graft choice that is informed in the biomechanical implications of ACL graft selection.

Evolution of anterior cruciate ligament reconstruction & graft choice: a review

The surgical treatment of anterior cruciate ligament (ACL) injuries dates back over 100 years from the present day [2022]. While open repair of the torn ACL was popularized in the early 1900s, the first ACL reconstructions utilized the fascia lata as a graft and other extra-articular stabilizing techniques. The first free tendon graft reported for ACL reconstructions was the quadriceps tendon (QT) in the 1930s, followed by the hamstrings tendon (HT), and then the patellar tendon. With improved understanding of the ACL anatomy and biomechanics and the invention of the arthroscope, ACL reconstruction evolved from open procedures to arthroscopic. Similarly, with the help of many surgeon-scientists who reported patient outcomes following ACL reconstruction with various techniques, graft choice evolved with the hamstrings and patellar tendon grafts becoming the dominant and preferred choice of both surgeons and patients. In present day, we see a resurgence of one of the original grafts reported, the QT, as well as primary ACL repair. Future research will result in continued advancements of ACL surgical techniques and graft harvesting, which will allow the orthopedic community (including patients and surgeons) to benefit from such innovations and advanced technologies.

Boys demonstrate greater knee frontal moments than girls during the impact phase of cutting maneuvers, despite age-related increases in girls

PURPOSE

Anterior cruciate ligament (ACL) injury rate is low among children, but increases during adolescence, especially in girls. Increases in the knee valgus moment within 70 ms of contact with the ground (KFM_0-70) may explain the sex-specific increase in the risk of ACL injury. The purpose of the study was to investigate sex-dependent changes in the KFM_0-70 from pre-adolescence to adolescence during a cutting maneuver (CM).

METHODS

Kinematic and kinetic data during the CM task, performed before and after physical exertion, were recorded using a motion capture system and a force plate. A total of 293 team handball and soccer players, aged 9-12 years, were recruited. A number of those who continued sports participation (n = 103) returned five years later to repeat the test procedure. Three mixed-model analysis of variance (ANOVA) for repeated measures tests were used to determine the effects of sex and age period on the KFM_0-70 (1: with no adjustment, 2: adjusted for repeated measurements, and 3: additionally adjusted with hip and knee joint frontal plane kinematics).

RESULTS

Boys had significantly higher KFM_0-70 than girls at both age periods (p < 0.01 for all models). Girls, not boys, demonstrated significantly increased KFM_0-70 from pre-adolescence to adolescence. Importantly, this was fully explained by kinematic variables.

CONCLUSION

Although the marked increase in KFM_0-70 seen in girls may play a role in their risk of ACL rupture, the higher values demonstrated by boys during CM reflect the complexity of multifactorial biomechanical risk factor analysis. The role of kinematics in mediating the KFM_0-70 provides means for modification of this risk factor, but as boys had higher joint moments, continued investigation into sex-dependent biomechanical risk factors is warranted.

LEVEL OF EVIDENCE

II.

Anatomical double-bundle anterior cruciate ligament reconstruction moderately improved tegner scores over the long-term: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

To assess the effects of anatomical double-bundle (DB) versus single-bundle (SB) for anterior cruciate ligament (ACL) reconstruction in skeletally mature patients with ACL injuries.

METHODS

MEDLINE, EMBASE, and CENTRAL were searched from inception to February 7, 2022 were screened for randomized controlled trials. The Anatomic Anterior Cruciate Ligament Reconstruction Checklist was used to categorize studies as anatomic. A random-effects meta-analysis was conducted, with pooled results being summarized using mean difference (MD). Risk of Bias (RoB) was assessed using the RoB 2.0 tool. Certainty of evidence was rated using GRADE.

RESULTS

A search of 1371 unique articles yielded eight eligible trials, representing 735 patients (360 DB, 375 SB) with mean (SD) age of 28.5 (2.86) years and follow-up of 52.1 (36.2) months. Most trials had moderate to low RoB. Overall, DB was not significantly better than SB on Lysholm scores (MD = 0.52, 95% CI, - 1.80-2.85, p = 0.66; moderate certainty) or subjective International Knee Documentation Committee (IKDC) scores (MD = - 0.40, 95% CI, - 4.35-3.55, p = 0.84; moderate certainty). Tegner scores were significantly higher in SB than DB in the intermediate term (MD = - 0.72, 95% CI, - 1.10 to - 0.34, p = 0.0002; high certainty), while significantly higher in DB relative to SB in the long-term (MD = 0.52, 95% CI, 0.02-1.03, p = 0.04; high certainty).

CONCLUSION

DB ACL reconstruction significantly improves Tegner scores relative to SB ACL reconstruction over the long-term (t ≥ 5 years). Intermediate term Tegner scores favour SB reconstruction. In both durations, there was no clinically significant difference based on the pre-specified minimal clinically important difference of 1.0 point. There were also no significant differences in IKDC or Lysholm scores. Surgeons should consider anatomical DB ACL reconstruction as a result of long-term improvement in patient-reported outcomes.

LEVEL OF EVIDENCE

I.

Reconstruction of chronic anterior cruciate ligament rupture using the ligament advanced reinforcement system artificial ligament-comparisons between patients over 50 years and under 50 years

Background

With the increasing physical activity level in elderly population, anterior cruciate ligament (ACL) injuries are becoming more frequent. Due to the possible surgery complications, treatment for ACL rupture in patients with advanced age is still controversial. The purpose of this study was to compare the therapeutic effects of reconstruction using the ligament advanced reinforcement system (LARS) artificial ligament in patients older than 50 and patients younger than 50 with chronic ACL rupture.

Methods

Indications included: (I) concurrent history of subjective symptomatic anterior knee instability despite nonoperative rehabilitation for least 3 months, (II) positive preoperative Lachman and pivot shift tests, (III) ACL stump still connecting the femur with the tibia as demonstrated by Magnetic Resonance Imaging (MRI), and (IV) some residual ligament fibers still connecting the femur with the tibia as demonstrated by arthroscopy. Participants were divided into groups based on their age. Participants were divided into groups based on their age. A total of 37 patients who underwent reconstruction of chronic ACL rupture using the LARS artificial ligament were divided into group A (≥50 years, n=16) and group B (<50 years, n=21).

Results

The outcome measures were compared between the 2 groups. These included the baseline clinical data, the International Knee Documentation Committee (IKDC) scoring system, Pivot shift test, Lachman test, Kneelax arthrometer measurements, Tegner activity scale, Lysholm knee scoring scale, and Kellgren-Lawrence radiographic classification of arthritis and complications. Postoperative knee laxity and the functional examination were significantly improved compared to preoperative measurements for both groups (all P<0.01). No significant differences were found in postoperative knee laxity and functional examination between the 2 groups (all P>0.05). The level of osteoarthritis did not statistically increase in either group during follow-up (all P>0.05). No complications associated with the arthroscopic surgery were found in either group.

Conclusions

The reconstruction of chronic ACL rupture using the LARS artificial ligament showed similar therapeutic effects in patients over the age of 50 and those under the age of 50.

Coordination of the Lower Limbs of Soccer Players after Anterior Cruciate Ligament Reconstruction with Allograft and Autograft during Landing

Objectives

Quantitative biomechanical tests, along with physical assessment, may be useful to understand kinematics associated with graft types in anterior cruciate ligament surgery, particularly in individuals aiming for a safe return to sport.

Methods

Sixty male soccer players in three groups participated in this study. Three equal groups of healthy, auto transplanted and allotransplanted participants, matched for age, gender, activity level and functional status, landed with one foot on a force plate. Their kinematic information was recorded by the motion analyzer and used to describe coordination the variability by measuring coupling angles using vector coding.

Results

The coordination variability of the allograft group in the surgical limb was significantly greater than that of the healthy group at least 9 months after the reconstructive surgery of the ACL and at the stage of return to sports, (F (6, 35) = 2.79, p = 0.025; Wilk's Λ = 0.676, partial η2 = 0.32). The coordination pattern in the surgical and healthy limbs of the surgical groups also differed from that of the healthy people, which was more pronounced in the allograft group, (F (6, 35) = 2.61, p = 0.034; Wilk's Λ = 0.690, partial η2 = 0.31).

Conclusion

These results show that the allograft group has a different coordination variability at return to sport than the healthy group, so they may need more time for excessive training and competition.

The apex of the deep cartilage is a stable landmark to evaluate the femoral tunnel position in ACL reconstruction

PURPOSE

To develop a simple and effective method for evaluating the femoral tunnel position using the apex of the deep cartilage (ADC) as the landmark.

METHODS

A total of 52 patients who underwent arthroscopic ACL reconstruction were recruited between June and September 2021. The femoral tunnel was placed on the central point of the anteromedial footprint with an accessory anteromedial and a high anterolateral portal. Then, the length from the ADC to the shallow cartilage margin (L₁) and to the center of the femoral tunnel (l₁), as well as the center to the low cartilage margin (H₁, intraoperative height), was measured under arthroscopy and on postoperative CT scans (L₂, l₂ and H₂). Moreover, intraoperative and postoperative cartilage ratios were equivalent to l₁/L₁ and l₂/L₂, respectively. Linear regression, Pearson correlation and Bland-Altman analysis were performed to evaluate the consistency between these two measurements of cartilage ratio (l/L) and height (H).

RESULTS

The mean age at the time of surgery was 28.7 years; 42 patients were male, and 17 patients were hurt in the left knee among 52 patients. The intraoperative cartilage ratio was 0.37 ± 0.04, and the height was 8.1 ± 1.1 mm with almost perfect inter-observer reproducibility. After the surgery, the cartilage ratio and height were measured as 0.39 ± 0.04 and 8.2 ± 1.3 mm on 3D-CT, respectively, with almost perfect intra- and inter-observer reproducibility. Significant positive correlations and linear regression were detected in the cartilage ratio (r = 0.844, p < 0.001), and height (r = 0.926, p < 0.001) intraoperatively and postoperatively. The Bland-Altman plot also showed excellent consistency between arthroscopy and 3D-CT.

CONCLUSIONS

The ADC is a good landmark in the assessment of femoral tunnel position, with excellent consistency between intraoperative arthroscopic measurements and postoperative 3D-CT.

CLINICALTRIALS

gov Identifier: NCT04937517.

LEVEL OF EVIDENCE

Level III.