Synovialization on second-look arthroscopy after anterior cruciate ligament reconstruction using Achilles allograft in active young men

Anterior Cruciate Ligament Reconstruction Using Autologous Hamstrings Augmented with Ligament Augmentation and Reconstruction Systems (LARS) or Synthetic Meshwork of LARS Compared with Four-Strand Hamstring Tendon Grafts Alone, a Prospective, Randomized Clinical Study with 2- to 8-Year Follow-Up

Purpose

To compare the long-term outcomes of anterior cruciate ligament (ACL) reconstruction using a four-strand hamstring tendon graft alone (hamstring group) or with synthetics (Ligament Augmentation and Reconstruction System, LARS group) or synthetic meshwork of LARS (meshwork group).

Methods

Patients who underwent ACL reconstruction using four-strand hamstring tendon grafts (hamstring group), autologous hamstrings augmented with the LARS (LARS group), or synthetic meshwork of LARS (meshwork group) were selected in this prospective randomized clinical study. Patient-reported outcome measures (PROMs) were obtained preoperatively; at 6, 12, and 18 months postoperatively; and at final follow-up between 3 and 8 years. Second-look arthroscopic findings were used to evaluate graft morphology based on graft tension, graft tear, and synovial coverage.

Results

A total of 141 consecutive patients underwent ACL reconstruction, 47 patients in each group, and 21 patients were lost to follow-up during the study period. At the 6-month follow-up, the IKDC scores and Lysholm scores were significantly better in the LARS group (P < 0.05). At the 6- and 12-month follow-ups, the KOS-ADLS, KOOS-activities of daily living and quality of life, NSARS scores, GRC scores, Tegner scores, and ACL-RSI scores were significantly better in the LARS group (P < 0.05). For the LARS group, hamstring group, and meshwork group, the cumulative failure rates were 8.5%, 12.8%, and 4.3%, respectively. Malposition of the femoral tunnel was significantly associated with cumulative failure (P < 0.05). There was no difference between the groups in other outcomes at any other time, including radiographic and arthroscopic outcomes.

Conclusions

ACL reconstruction using autologous hamstring augmented with LARS resulted in significantly better clinical scores with a faster return to sports and comparative side-to-side differences in graft laxity by 6 and 12 months follow-up. Despite these findings, no statistically significant differences were seen among the three patient groups in terms of objective outcomes and clinical scores at the 18-month, 3-year and 8-year follow-ups. Additionally, a malpositioned femoral tunnel was associated with graft failure.

Comparison of ACL and Anterolateral Ligament Reconstruction With Isolated ACL Reconstruction Using Hamstring Autograft: Outcomes in Young Female Patients With High-Grade Pivot Shift

Background

Inferior return to sports (RTS) and functional outcomes have been reported in women after anterior cruciate ligament reconstruction (ACLR).

Purpose/Hypothesis

The purpose was to evaluate the results of combined ACLR and anterolateral ligament reconstruction (ALLR) in young women with a high-grade pivot shift (grade ≥2). It was hypothesized that combined ACLR and ALLR would result in better RTS and rotational stability than isolated ACLR.

Study Design

Cohort study; Level of evidence, 3.

Methods

Two groups were retrospectively evaluated and compared. Group I (n = 39; mean age, 31.1 ± 5.7 years) underwent isolated ACLR using hamstring autografts; group C (n = 39; mean age, 30.4 ± 6.1 years) underwent combined ACLR and ALLR. Subjective outcome measures included the International Knee Documentation Committee subjective form, Lysholm, Tegner, and ACL-Return to Sport after Injury (ACL-RSI). Objective tests included a KT-2000 arthrometer stress test, a pivot-shift test, an isokinetic strength test, a Y-balance test, and a single-leg hop test. A postoperative questionnaire was administered to determine the rates and types of RTS, quality of sports performance, and reinjury and satisfaction rates. Subjective scores and clinical tests were performed at 2 years. Magnetic resonance imaging and second-look arthroscopy were conducted during the 1- and 2-year follow-ups, respectively.

Results

The mean follow-up for groups I and C were 30.4 ± 3.9 and 29.3 ± 3.5 months, respectively (P = .194). Patients in group C had better anteroposterior (P = .001) and rotational (P = .005) stability and higher ACL-RSI scores (P = .025) than those in group I. Group C had higher composite and posteromedial reach scores on the Y-balance test than group I (P = .014 and P = .010, respectively). A total of 26 (66.7%) patients in group C and 17 (43.6%) in group I returned to their prior level of sports (P = .040). Rerupture of the ACL graft and contralateral ACL rupture occurred in 2 (5.1%) and 2 (5.1%) patients in group I, respectively, compared with no rerupture or contralateral ACL rupture in group C.

Conclusion

Combined ACLR and ALLR in young women with a high-grade pivot shift was associated with better knee stability parameters, dynamic postural stability, and psychological readiness to RTS than isolated ACLR.

Clinical and arthroscopic outcomes of single-bundle anterior cruciate ligament reconstruction using autologous hamstrings augmented with ligament augmentation and reconstruction systems compared with four-strand hamstring tendon grafts alone

PURPOSE

To compare the clinical, radiological, and second-look arthroscopic outcomes in patients who underwent anterior cruciate ligament (ACL) reconstruction using a four-strand hamstring tendon graft (hamstring group) either without augmentation or with ligament augmentation and reconstruction system (LARS) augmentation (LARS augmentation group).

METHODS

From January 2018 to December 2019, patients who underwent ACL reconstruction were included. Patient-reported outcome measures (PROMs) were undertaken pre-operatively and at three, six, 12, and 24 months post-operatively. Arthroscopic evaluation was performed focusing on the morphology of the graft based on graft tension, graft tear, and synovial coverage.

RESULTS

A total of 178 consecutive patients received single-bundle ACL reconstruction, 89 patients in each group, and 20 patients were lost to follow-up in the first two years. At the three month follow-up, the LARS augmentation group had significantly higher Lysholm scores, IKDC scores, and KOS-ADLS scores than the hamstring group (P < 0.001). At the three, six and 12-month follow-ups, there were significantly higher Tegner scores and ACL-RSI scores in the LARS augmentation group than in the hamstring group (P < 0.05). At the three and six month follow-ups, the LARS augmentation group had significantly higher rates of return to sports and return to sports at their preinjury level (P < 0.05). There were no between-group differences in other outcomes, including arthroscopic outcomes, graft signal intensity, post-operative complications or rerupture rates.

CONCLUSIONS

Autologous hamstring augmented with the LARS augmentation technique provides good and realistic clinical and functional results during the early post-operative period with high levels of satisfaction of patients, including participation in sports and physical activity, and high rates of return to sports at the preinjury level, without any apparent complications compared with hamstring ACL reconstruction alone. No increases in complication, reinjury rates, or increased lateral laxity were observed at the 12-month or 24-month follow-up.

Adolescents show a lower healing rate of anterolateral ligament injury and a higher rotational laxity than adults after anterior cruciate ligament reconstruction

BACKGROUND

This study aimed to compare anterolateral ligament (ALL) injuries in anterior cruciate ligament (ACL) ruptures, as well as ALL healing and clinical outcomes following ACL reconstruction between adolescents and adults.

METHODS

This retrospective study involved 98 patients who underwent ACL reconstruction. They were divided into two groups according to age: group A (adolescents, 16-20 years of age; n = 49) and group B (adults, 21-45 years of age; n = 49). Subjective scores including ACL-Return to Sport after Injury (ACL-RSI) scale and objective tests were assessed. Follow up magnetic resonance imaging (MRI) and second-look arthroscopy was conducted at 1-year and 2-year follow up, respectively.

RESULTS

Good healing rate of ALL was higher in adults than in adolescents (P = 0.048). Graft tension and synovial coverage showed no significant differences between two groups. Group A showed a higher rate of high-grade pivot shift and a lower ACL-RSI at last follow up than group B (P = 0.126 and P = 0.016). Poor healing of ALL was significantly associated with lower ACL-RSI and failure to return to sports (P < 0.001 and P = 0.001). Re-rupture of the ACL graft was found in four (8.2%) and one (2.0%) of group A and B, respectively.

CONCLUSIONS

Adolescents showed a lower healing rate of ALL, a lower ACL-RSI, a higher rate of high-grade pivot shift than adults. Moreover, poor healing of ALL was significantly associated with a lower ACL-RSI and failure to return to sports. We suggest that adolescents need to pay more attention to the presence of ALL injury.

Synovialization and Revascularization Enhancement in Repaired and Reconstructed ACL: PCL Fat Pad Transfer Technique

The rapid development of anterior cruciate ligament (ACL) reconstruction and repair techniques has significantly improved the outcomes of these procedures. However, there is still some place for how to improve surgical techniques to limit the amount of revision surgeries. Over the past decade, biological solutions and methods of ligament remodeling enhancement have been proposed. The use of the native ACL remnants has been the most thoroughly analyzed technique. However, despite its benefits, this technique may not to be sufficient to improve outcomes and may cause some technical difficulties. On the other hand, the posterior cruciate ligament (PCL) fat pad contains an abundant synovial vascular network and is located in close proximity to the ACL, which makes it a potential biological donor place of cells and tissue that could enhance the ligamentization of the repaired or reconstructed ACL. To optimize the use of this donor site, we propose the technique of ACL synovialization and revascularization enhancement with a PCL fat pad transfer.

Influence of posteromedial corner injuries on clinical outcome and second-look arthroscopic findings after allograft transtibial anterior cruciate ligament reconstruction

BACKGROUND

The purpose of this study was to evaluate the influence of posterior medial corner (PMC) injuries on clinical outcome and second-look arthroscopic findings after anterior cruciate ligament (ACL) reconstruction.

METHODS

Seventy-eight consecutive patients underwent a second-look arthroscopic surgery after ACL reconstruction and magnetic resonance imaging (MRI) examination of the PMC. The patients were divided into a PMC intact group (n = 42) and a PMC injured group (n = 36). The stability and clinical outcomes were evaluated using the Lachman test, pivot-shift test, a KT-2000 arthrometer, and the Lysholm knee scoring scale. Graft tension and synovial coverage were evaluated in second-look arthroscopy.

RESULTS

The clinical function showed no significant differences regarding PMC injury. Although the graft tendon tension revealed no significant differences (p = 0.141), the second-look arthroscopic findings indicated that the PMC intact group showed better synovial coverage compared to the PMC injured group (p = 0.012).

CONCLUSION

Patients who injured the PMC had poor synovial coverage as assessed by second-look arthroscopic findings after transtibial ACL reconstruction, even though clinical outcomes and stability showed no significant differences.

The relationship between the clinical results and the remnant type following anterior cruciate ligament reconstruction using a hamstring tendon

PURPOSE

The aim of the present study was to investigate the correlations among the preoperative and postoperative knee laxity, the clinical results, and the type of remnant tissue following the anterior cruciate ligament (ACL) reconstruction.

METHODS

One hundred ninety-two patients (male, n = 101; female, n = 91; mean age, 27.1 years) with ACL-deficient knees who had undergone double-bundle reconstruction were included. The time between injury and surgery (TBIS) was 34.7 weeks (range, 1-504 weeks). The subjects were divided into four groups according to the Crain's classifications and factors such as the age at surgery, gender, TBIS, side-to-side difference (SSD), Tegner activity score (TAS), and Lysholm score were compared.

RESULTS

The percentage of patients with ACL remnant pattern types 1, 2, 3, 4 was 19% (37 knees), 52% (101 knees), 9% (19 knees), and 18% (35 knees), respectively. The TBIS of the patients with Crain type 4 was significantly longer in comparison to the other groups ( p < 0.01). A significant difference was observed in the preoperative SSD of the Crain type 3 and Crain type 4 (6.2 ± 3.4 mm, 9.3 ± 3.6, respectively) groups. The TBIS in patients with Crain type 4 was significantly longer in comparison to the other groups ( p < 0.01). There were no significant differences between the groups in terms of the postoperative SSD, TAS, or Lysholm score.

CONCLUSION

This study suggests that a Crain type 3 remnant was associated with a significantly lower preoperative SSD. In addition, the TBIS in patients with Crain type 4 was found to be significantly longer in comparison to the other groups.

LEVEL OF EVIDENCE

Level III, case-control study.

Clinical outcomes and second-look arthroscopic findings of anterior cruciate ligament reconstruction with autograft, hybrid graft, and allograft

Background

There is no consensus as to the choice of grafts for primary anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to compare the clinical and second-look arthroscopic outcomes after ACL reconstruction by use of autograft, hybrid graft, and γ-irradiated allograft.

Methods

Ninety-seven patients who underwent second-look arthroscopy after ACL reconstruction with autografts (28 patients, hamstring autograft), hybrid grafts (32 patients, hamstring autograft augmented with γ-irradiated tibialis anterior tendon allograft), or γ-irradiated allografts (37 patients, tibialis anterior tendons) were included in this study. The clinical outcomes were compared by using Lysholm score, International Knee Documentation Committee (IKDC) score, and Tegner activity score, and the side-to-side differences of KT-1000 measurement. Second-look arthroscopic findings were compared in terms of synovial coverage and graft tension.

Results

There were no statistical significances among the three groups in Lysholm score, IKDC score, or Tegner activity score (P > 0.05). The KT-1000 examination showed more anterior laxity in the γ-irradiated allograft group than in the autograft or hybrid graft groups (P = 0.006, and P = 0.013, respectively). Two patients in the autograft group, 2 patients in the hybrid graft group and 4 patients in the allograft group were evaluated as graft failure on second-look arthroscopy. The synovial coverage was superior in the autograft group than that in the hybrid graft group or the allograft group (P = 0.013 and P = 0.010, respectively), and was comparable between the hybrid graft group and allograft group (P = 0.876). With regard to graft tension, the autograft group and hybrid group were comparable (P = 0.883) but showed better results than the allograft group (P = 0.011 and P = 0.007, respectively).

Conclusion

The hamstring autografts and hybrid grafts used for ACL reconstruction produced equal efficacy but provided better knee stability than allografts. In addition, the hamstring autografts showed better synovial coverage than the other two graft types.

Functional Effects of Single Semitendinosus Tendon Harvesting in Anatomic Anterior Cruciate Ligament Reconstruction: Comparison of Single versus Dual Hamstring Harvesting

Background

This study aimed to determine the effects of single semitendinosus tendon (ST) harvesting for anterior cruciate ligament (ACL) reconstruction by comparing outcomes of single ST and semitendinosus-gracilis tendon (ST-G) harvesting.

Methods

ACL reconstruction with ST-G harvesting (D group, n = 60) or single ST harvesting (S group, n = 60) were included according to inclusion criteria. Subjective assessments included subjective International Knee Documentation Committee score, Lysholm score, and Tegner activity scale score. Objective assessments included isokinetic strength and functional tests. These tests were completed at 36 months of follow-up. Magnetic resonance imaging (MRI) and second-look arthroscopy findings were evaluated. In the S group, regeneration properties were assessed by serial ultrasonography (US).

Results

The S group showed significantly less deep flexor strength deficit than the D group (p < 0.001). Deep flexor power deficits showed significant correlation with the shift of musculotendinous junction of the ST. There was significant difference in the cocontraction test between the groups (p = 0.012), and the S group tended to show better results in other functional tests at the last follow-up. There were no significant differences in graft tension and synovial coverage on second-look arthroscopy between the groups. In the S group, the regeneration rates assessed by US at the joint line and distal insertion were 81.7% and 80%, respectively at 6 months of follow-up.

Conclusions

The S group showed significantly less deficit in deep flexor strength and tended to show better clinical results at the last follow-up than the D group. In the S group, more than 80% showed good regeneration at the 6-month follow-up. Hence, single ST harvesting is effective in minimizing flexor weakness and functional deficits and shows great potential for regeneration.

Comparison of Modified Transtibial and Outside-In Techniques in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction

PURPOSE

To compare the bending angle of anterior cruciate ligament (ACL) graft at femoral tunnel, graft maturation, and tunnel positions and the clinical outcomes of the modified transtibial (mTT) and outside-in (OI) techniques.

METHODS

Patients who met the inclusion criteria were divided into the mTT group (n = 50) and the OI group (n = 50). Using 3-dimensional computed tomography (3-D CT), tunnel placement and femoral tunnel bending angle were analyzed. The 3.0-T magnetic resonance imaging (MRI) was used to assess the graft signal intensity (indicative of maturation) with signal/noise quotient (SNQ). Graft tension and synovialization were evaluated with second-look arthroscopy in all cases. Clinical and functional tests were completed at 36 months of follow-up.

RESULTS

When tunnel placements were analyzed using the quadrant method, no significant differences were found between the mTT group and the OI group. The femoral graft bending angle was reduced in the mTT group, and the total mean of SNQ values and mean SNQ values at the femoral intraosseous and proximal graft of the mTT group were significantly lower than in the OI group (P < .001), respectively. The femoral graft bending angle on the coronal and axial planes showed moderate-to-strong correlation with the SNQ values at the femoral intraosseous and proximal graft. Second-look arthroscopy revealed better synovialization in the mTT group than in the OI group (P = .040), with no significant difference in graft tension between the 2 groups (P = .328).

CONCLUSIONS

Anatomic tunnel placements did not vary between the mTT group and the OI group. However, the mTT group had more benefits in femoral graft bending angle and showed higher graft maturity and better synovial coverage than the OI group, although there were no significant differences in clinical outcomes. The acute femoral graft bending angle might negatively affect the maturation of proximal graft. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Relationship Between Intracapsular Fracture Patterns and Arthroscopic Findings

PURPOSE

To observe the superior joint compartment (SJC) using ultrathin arthroscopy in intracapsular condylar fracture (ICF) of the temporomandibular joint, describe the changes, and evaluate the relations among fracture pattern, arthroscopic findings, and clinical outcome.

PATIENTS AND METHODS

Twenty patients with 27 ICFs were the subject group. Thirteen patients had unilateral ICFs and 7 had bilateral ICF. The fracture patterns were classified into 9 categories, and all patients had arthroscopic examination of the traumatized joint at the time of definitive treatment. At 4 months after treatment of the injury, all patients had a secondary arthroscopy of the ICF joint. In all patients, range of motion (ROM) was measured as the interincisal distance (millimeters) at the first visit to 12 months after the first treatment, and the data were statistically evaluated.

RESULTS

Intra-articular hyperemia, hypervascularity, and temporal bone damage were found, and 4 patients had disc perforations at the first examination. At the second arthroscopy 4 months later, normal healing occurred in 11 joints, all of which had minimally displaced fractures. Fifteen joints showed complete filling of the SJC, all of which had a displaced minor fragment from the fossa. Comparison of the effect of the presence versus absence of SJC fibrosis on ROM showed marked differences from 1 to 12 months. The effect of early versus delayed definitive treatment showed marked differences at 4 and 12 months.

CONCLUSION

The intra-articular condition at 4 months after ICF as observed arthroscopically was related to the minor fragment position. If the minor fragment is nondisplaced, then it will heal to a normal state; however, if the minor fragment is displaced from the fossa, then the SJC shows disc damage and fibrosis. This could lead to fibrous ankylosis.

Comparison of Clinical Results, Second-Look Arthroscopic Findings, and MRI Findings Between the Transportal and Outside-In Techniques for Double-Bundle Anatomic Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Controlled Trial With a Minimum 2-Year Follow-up

BACKGROUND

Although image analysis has shown that the outside-in (OI) technique is associated with different femoral tunnel geometry than the transportal (TP) technique in anatomic anterior cruciate ligament (ACL) reconstruction, it is not known whether clinical results differ between the 2 techniques.

PURPOSE

To compare clinical results, second-look arthroscopic findings, and magnetic resonance imaging (MRI) findings between the TP and OI techniques in anatomic double-bundle (DB) ACL reconstruction.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

From November 2010 to March 2013, 128 patients were enrolled in this study and were randomly assigned to either the TP group (64 patients) or the OI group (64 patients), and DB ACL reconstructions were performed. At the minimum 2-year follow-up (34.9 ± 10.9 months), 111 patients (86.7%) were evaluated with multiple clinical scores and stability tests (KT-2000 arthrometer, Lachman test, and pivot-shift test). Ninety-three knees were evaluated for graft continuity, graft tension, and synovialization by use of second-look arthroscopy. Seventy-eight knees were evaluated on MRI for graft continuity, femoral graft tunnel healing, and graft signal/noise quotient (SNQ). The primary outcome was KT-2000 arthrometer results. Results were compared between the TP and OI groups.

RESULTS

No significant differences were found between the 2 groups in terms of KT-2000 arthrometer results, which was the primary outcome, and other clinical results, with the exception of the postoperative functional test of International Knee Documentation Committee (IKDC) objective score. The ratio of grade A and B on the postoperative functional test of IKDC objective score was significantly larger for the OI group (51/58) than the TP group (36/53) ( P = .005). The second-look arthroscopic findings were not significantly different between the 2 groups in either bundle ( P > .05). In addition, MRI findings did not differ significantly between the 2 groups ( P > .05).

CONCLUSION

With the exception of the functional test of IKDC objective score, we found that clinical results, second-look arthroscopic findings, and MRI findings did not differ significantly between the OI and TP techniques for anatomic ACL reconstruction, although femoral tunnel geometries differed significantly between the 2 techniques.

The remnant preservation technique reduces the amount of bone tunnel enlargement following anterior cruciate ligament reconstruction

PURPOSE

The aim of the present study was to investigate the correlation between postoperative tunnel enlargement after ACLR and remnant tissue preservation using the hamstring tendon.

METHODS

One hundred and ninety-two subjects (male, n = 101; female, n = 91; mean age 27.1) who had undergone double-bundle ACL reconstruction were included in the present study. The patients were divided into two groups: the remnant tissue preservation group (Group R) and the non-remnant tissue preservation group (Group N). Computed tomographic scans of the operated knee were obtained at 2 weeks and 6 months after surgery. The area of the tunnel aperture for the anteromedial femoral tunnel (FAMT), posterolateral femoral tunnel (FPLT), anteromedial tibial tunnel (TAMT), and posterolateral tibial tunnel (TPLT) was measured. The area at 2 weeks after ACLR was subtracted from the area at 6 months after ACLR and then divided by the area at 2 weeks after ACLR. The differences in the outcomes and characteristics of the two groups were evaluated.

RESULTS

Seventy-seven knees were classified into Group R, and 115 knees were classified into Group N. The age, gender, and body mass index did not differ to a statistically significant extent. The percentages of FAMT and TAMT enlargement in Group R were significantly smaller in comparison with Group N (P = 0.003 and P = 0.03, respectively). The percentage of FPLT and TPLT enlargement in the two groups did not differ to a statistically significant extent.

CONCLUSION

The remnant-preserving technique reduces the amount of bone tunnel enlargement. The present findings indicate the advantages of the remnant-preserving ACLR technique, and therefore the remnant-preserving technique should be recommended.

LEVEL OF EVIDENCE

II.

Second-Look Arthroscopic Evaluation and Clinical Outcomes of Anatomic Anterior Cruciate Ligament Reconstruction with Autograft and Hybrid Graft: A Retrospective Study

BACKGROUND Graft choice is very controversial. This study compared the second-look evaluation and clinical outcomes of anatomic ACL-R using a thin autograft versus a thick hybrid graft. MATERIAL AND METHODS Sixty-eight patients who had received ACL-R with hamstring autograft or autograft-allograft hybrid graft accepted second-look arthroscopy were grouped (autograft: n=31, age: 32.8±8.9, Male/Female: 16/15, and hybrid graft: n=37, age: 33.9±8.4, Male/Female: 27/10). Patients were evaluated with the functional score and KT-1000 test before reconstruction. The re-examination and second-look evaluation were performed at 2-year follow-up. Results were compared and further comparisons were made for grafts size >8.5 mm. RESULTS The hybrid group showed thicker graft size and bigger graft occupancy (9.0±0.5 mm vs. 8.5±0.7 mm, P=.003; 80.1±7.0% vs. 69.9±6.9%, P8.5 mm were selected and compared (autograft, n=16; hybrid, n=29). Graft tension and Synovial coverage showed a significant difference (P=.036 and P=.029). The Lysholm, IKDC, and KT-1000 test were significantly superior for the autograft than the hybrid graft (P=.036, P=.004, and P=.003, respectively). CONCLUSIONS A pure autograft is superior to a hybrid graft with same diameter in ACL-R because the augmenting allografts may be null and void. Therefore, a homogenous graft is recommended.

Clinical and arthroscopic outcome of single bundle anterior cruciate ligament reconstruction: Comparison of remnant preservation versus conventional technique

BACKGROUND

The purpose of this study was to compare the clinical outcomes and second-look arthroscopic findings of remnant preservation technique with those of conventional anterior cruciate ligament (ACL) reconstruction in single bundle ACL reconstructions.

METHODS

One hundred sixty two consecutive patients underwent ACL reconstruction by one surgeon, with 93 patients receiving remnant preservation technique (Group A) and 69 patients receiving conventional ACL reconstruction (Group B). The mean follow-up was 15months. Clinical outcomes were assessed using Lysholm scores and the International Knee Documentation Committee form (IKDC form) evaluation. Post-operative knee stability was evaluated through manual knee laxity evaluation, pivot-shift test, and a Telos device.

RESULTS

Differences in post-operative stability (manual knee laxity, pivot shift test and Telos device) were not significant between the groups (p=0.681, p=0.610, p=0.696). And also no significant differences were noted with respect to the IKDC form and the latest Lysholm scores. But in the second-look arthroscopic findings, synovial coverage was confirmed to be excellent in 36% (22/61) of Group A patients and 23% (7/30) of Group B patients.

CONCLUSIONS

ACL reconstruction with both techniques was found to result in acceptable stability, clinical outcomes and second-look arthroscopic findings. With regard to synovial coverage, the remnant reservation techniques were found to be superior to conventional ACL reconstruction.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Remnant-preserving and re-tensioning technique to cover the graft in anterior cruciate ligament reconstruction

PURPOSE

This study set out to assess the clinical and radiographic outcomes and the extent of synovial coverage on second-look arthroscopy of anterior cruciate ligament (ACL) reconstruction using a remnant-preserving and re-tensioning technique to easily cover the graft with a remnant.

METHODS

Forty-three subjects with ACL rupture underwent remnant-preserving and re-tensioning ACL reconstruction using a free tendon Achilles allograft between 2011 and 2013. The clinical outcomes were assessed by Lysholm knee score, Lachman stress test, pivot shift test, International Knee Documentation Committee (IKDC) classification, and Tegner Activity Scale score. Side-to-side difference (SSD) was assessed on stress radiographs. The extent of synovialization was evaluated on second-look arthroscopy.

RESULTS

The mean Lysholm score was 54 ± 11 before surgery and 94 ± 5 at the last follow-up (p < 0.001). On Lachman stress test, 42 subjects had grade 0 or 1 on the Lachman stress test, and 42 had grade 0 or 1 on the pivot shift test. Forty-one subjects had IKDC classification A or B; two were classified as C or D. The median Tegner Activity Scale score was 6.5 (range 5-9) before injury and 6 (range 4-8) at the last follow-up (p = 0.048). Mean SSD on stress radiographs was 9.9 ± 2.6 mm preoperatively and 1.0 ± 1.7 mm at the last follow-up (p < 0.001). In the assessment of the extent of synovial coverage of the graft, 39 subjects were in group 1 (>75 %) for synovial coverage of the graft, three were in group 2 (50-75 %), and one was in group 4 (≤25 %).

CONCLUSIONS

The remnant-preserving and re-tensioning technique resulted in satisfying short-term results clinically and radiologically and good synovial coverage on second-look arthroscopy.

LEVEL OF EVIDENCE

Case series, Level IV.

An Arthroscopic Second-Look Study on the Effect of Remnant Preservation on Synovialization of Bone-Patellar Tendon-Bone Allograft in Anterior Cruciate Ligament Reconstruction

PURPOSE

To assess the effects of preserved more anterior cruciate ligament (ACL) remnant on synovial coverage, knee stability, and function after bone patellar-tendon-bone (BPTB) allograft reconstruction through second-look arthroscopy and follow-up study.

METHODS

From June 2007 to February 2009, 51 patients received single bundle BPTB allograft ACL reconstruction and second arthroscopic examination. The patients were divided into 4 types according to the types of ACL remnant: type 1, 18 had bridging between the posterior cruciate ligament and the tibia; type 2, 21 had bridging between the intercondylar notch roof and the tibia; type 3, 4 had bridging between the lateral condyle and the tibia; and type 4, 8 subjects had no ACL remnants. Clinical results were evaluated with the KT-1000 maximum displacement test and Lysholm scale at mean 12.3- and 53.5-month follow-up. Second-look synovium coverage was recorded as follows: covering 25% or less, 25% to 50%, 50% to 75%, and more than 75%.

RESULTS

Mean percentage of synovium coverage, Lysholm scale, and KT-1000 side-to-side difference were poorer in types 3 and 4 than the other 2 types at mean 12.3-month follow-up without statistical differences. The result of the final follow-up was comparable with the first one. Four patients had ruptured grafts and accepted revision surgery. Three of them belonged to types 3 and 4, and 1 patient with sport trauma belonged to type 2. There were other 11 patients with different types of impingement and partial absorption of grafts.

CONCLUSIONS

Although lack of statistical power, follow-up study and second-look arthroscopy showed that preserved type 3 and 4 ACL remnant caused poorer synovium coverage and might lead to earlier failure when using BPTB allograft. Early minor laxity at 12.3-month follow-up seemed to be not progressive at the final follow-up.

LEVEL OF EVIDENCE

Level III, case-control study.

Anatomic Placement of the Femoral Tunnels in Double-Bundle Anterior Cruciate Ligament Reconstruction Correlates With Improved Graft Maturation and Clinical Outcomes

PURPOSE

To compare maturation of reconstructed graft on second-look arthroscopy and clinical outcomes between 2 groups: the provisional anatomic (PA) group, with both the anteromedial (AM) and posterolateral (PL) femoral tunnels in their anatomic location, and the nonanatomic (NA) group, with either 1 of the 2 femoral tunnels beyond its anatomic location after double-bundle anterior cruciate ligament reconstruction.

METHODS

We enrolled 154 patients who underwent 3-dimensional computed tomography scanning and second-look arthroscopy after double-bundle anterior cruciate ligament reconstruction. All of the patients were divided into the PA and NA groups according to the femoral tunnel position determined by the quadrant method. Graft maturation was evaluated with 3 subsections, including integrity, tension, and synovial coverage with revascularization, on second-look arthroscopy. We also compared Lachman test, pivot-shift test, KT-2000 (MEDmetric, San Diego, CA), and International Knee Documentation Committee grades at the last follow-up.

RESULTS

Of the 154 patients, 88 were classified as the PA group and 66 as the NA group by the quadrant method. A difference existed between groups for the AM tunnel position but not for the PL tunnel position. The PA group showed a higher graft maturation score (P < .001 for all comparisons) and better results according to the International Knee Documentation Committee knee rating, Lachman test, pivot-shift test, and KT-2000 assessment (P < .001 for all comparisons).

CONCLUSIONS

The PA group with anatomic femoral tunnel placement showed a higher graft maturation score on second-look arthroscopy, along with better clinical outcomes, than the NA group. There was a significant difference in the AM femoral tunnel position but not in the PL tunnel position between the 2 groups.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Comparison of second-look arthroscopic findings and clinical results according to the amount of preserved remnant in anterior cruciate ligament reconstruction

BACKGROUND

Although ACL reconstruction is prevalent, the most effective method for ACL reconstruction still remains controversial. The purpose of this study was to evaluate the effect of the preserved remnant in ACL reconstruction on graft morphology at second-look arthroscopy and clinical outcomes.

METHODS

66 consecutive patients who underwent a second-look arthroscopy after a remnant-preserving ACL reconstruction were enrolled. The patients were divided into two groups according to whether the remnant ACL fibers could be preserved by over 50% (Group I) or not (Group II). The Lysholm score, IKDC subjective score, Tegner activity score, pivot-shift test, and KT-2000 arthrometric findings were evaluated preoperatively and just prior to the second-look arthroscopy to assess clinical outcomes. At second-look arthroscopy, graft morphology was evaluated using hypertrophy rate and synovialization.

RESULTS

At second-look arthroscopy, the hypertrophy rate of Group I (42.1%) was higher than Group II (25.1%), which was statistically significant (p=0.002). In graft synovialization, there was a statistically significant difference between the two groups (p<0.001). The IKDC subjective score improved from 42.9, 43.1 to 77.8, 75.0 for Group I and Group II, respectively (p=0.025). For the Lysholm score, Group I and Group II improved from 55.4 and 55.7 to 87.8 and 84.9 (p=0.031). There was also a significant difference between the pivot shift tests between the groups (p=0.039). Other clinical tests showed no statistically significant differences.

CONCLUSION

Preserving the remnant ACL tissue during ACL reconstruction could have a positive effect on graft hypertrophy, synovialization and clinical outcomes.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Comparison of Achilles and tibialis anterior tendon allografts after anterior cruciate ligament reconstruction

PURPOSE

The purpose of this study was to compare the outcomes after anterior cruciate ligament (ACL) reconstruction using Achilles tendon allografts and tibialis anterior (TA) tendon allografts with respect to objective knee testing measures, second-look arthroscopy and femoral tunnel enlargement.

METHODS

A total of 131 patients who underwent ACL reconstruction between 2000 and 2006 were retrospectively reviewed. Achilles tendon allografts were used in 81 patients (group I). These patients were compared with 50 patients in whom TA tendon allografts were used (group II). The two groups were assessed using International Knee Documentation Committee (IKDC), Lysholm and Tegner activity scores, as well as KT-2000 testing. Second-look arthroscopic findings were evaluated. Cross-sectional area (CSA) perpendicular to the long axis of the femoral tunnel was also calculated digitally using magnetic resonance imaging.

RESULTS

No significant differences were observed between the two groups with respect to IKDC, Lysholm or Tegner activity scores or the results of laxity testing with arthrometry. Synovial coverage of more than 50 % was found in 71.1 % cases in group I and 75 % cases in group II. Mean CSA enlargement of 15 % (group I) and 38 % (group II) was detected (p = 0.017).

CONCLUSIONS

The clinical results associated with Achilles and TA tendons were not significantly different. The laxity evaluation and second-look arthroscopy demonstrated no significant differences between group I and group II. However, Achilles tendon-bone plugs for femoral tunnel fixation reduced femoral tunnel enlargement compared to the TA allograft. Achilles tendon allografts for ACL reconstruction could be a reasonable option in selected patients.

Single-bundle anterior cruciate ligament reconstruction in active young men using bone-tendon achilles allograft versus free tendon achilles allograft

PURPOSE

The purpose was to prospectively compare the outcomes of anterior cruciate ligament (ACL) reconstruction using bone-tendon Achilles allograft with those of free tendon Achilles allograft in 2 groups of active young men.

METHODS

We enrolled 72 subjects in the study. Of these, 33 subjects who had ACL reconstruction with Achilles allograft with calcaneal bone block on its end (group I) and 34 who had ACL reconstruction with free tendon Achilles allograft (group II) were followed up for a minimum of 2 years. The Lachman test, pivot-shift test, and 1-leg hop test were evaluated at the last follow-up. The International Knee Documentation Committee classification, Lysholm score, and side-to-side difference were assessed preoperatively and at the last follow-up. The Tegner activity scale was evaluated before injury and at the last follow-up.

RESULTS

The mean follow-up period was 30.9 months (range, 26 to 38 months). At the last follow-up, there were no statistically significant differences between the 2 groups for the Lachman test, pivot-shift test, 1-leg hop test, International Knee Documentation Committee classification, Lysholm score, and side-to-side difference (P > .05). Three subjects in group I and three in group II showed an activity level 2 steps below the preinjury activity level. The rest of the subjects returned to the preinjury activity level or showed a level 1 step below the preinjury activity level.

CONCLUSIONS

There were no significant differences in clinical outcomes of ACL reconstructions using Achilles allograft between the bone-tendon group and the free tendon group in active young men. Free tendon Achilles allograft may be considered an option for ACL reconstruction.

LEVEL OF EVIDENCE

Level II, therapeutic study, randomized controlled trial.