Autograft versus allograft: an economic cost comparison of anterior cruciate ligament reconstruction

Outcomes following open acetabular labrum reconstruction: Comparing fresh-frozen tendon with fresh meniscus allograft transplantation

Background

Symptomatic acetabular labral insufficiency in young, active patients is often treated with labral repair or reconstruction using fresh-frozen allografts. However, fresh-frozen tendon allografts do not have tissue or material properties that closely mimic acetabular labral fibrocartilage. Recent studies suggest meniscal allografts may be a better biomechanical, geometric, and material alternative for acetabular labrum reconstruction (ALR).

Hypothesis

Patients undergoing open ALR using fresh meniscus allograft transplants (MAT) will have better outcomes than those using fresh-frozen tendon allografts transplants (TAT) when comparing initial treatment success, diagnostic imaging assessments, and patient-reported pain and function scores.

Study design

Cohort Study.

Methods

With IRB approval, patients undergoing ALR with either TAT or MAT were included when initial (>1-year) outcomes data related to treatment success, pain, and function were available. In addition, a subcohort of patients underwent magnetic resonance imaging at least 6-months after surgery to evaluate allograft healing.

Results

Initial success rate, defined as no need for ALR revision or conversion to total hip arthroplasty (THA), was 88.9% for the entire group (n = 27, TAT = 5, MAT = 22) with 1 (20%) patient in the TAT cohort and 2 patients (9.9%) in the MAT cohort undergoing THA. In the MAT cohort, significant improvements were documented for physical function and pain scores at 1 year and final follow-up (FFU)(mean 26.8 months). Improvements in pain and function were noted at 1-year, but not at FFU (mean 59.6 months) in the TAT group. MRIs completed at least 6 months after labrum reconstruction showed improved allograft integrity and integration in the MAT cohort over the TAT cohort.

Conclusion

For acetabular labrum reconstructions, MAT was associated with a higher initial success rate, superior patient reported outcomes, and subjectively better MRI findings when compared to TAT.

Value-Based, Environmentally Sustainable Anterior Cruciate Ligament Surgery

Orthopedic surgeons are increasingly recognizing the broader societal impact of their clinical decisions, which includes value-based and environmentally sustainable care. Within anterior cruciate ligament reconstruction, value-based care-or most cost-effective care-includes an outpatient surgical setting with regional anesthesia, use of autograft, meniscus repair when indicated, and use of traditional metal implants such as interference screws and staples. Environmentally sustainable care includes slimming down surgical packs and trays to avoid opening unnecessary equipment, avoiding desflurane as an inhaled anesthetic agent, and minimizing waste in the operating room-a priority that addresses both cost and environmental impact.

Autograft Versus Allograft in Posterolateral Corner Reconstruction: A Systematic Review and Meta-analysis

Background

Several approaches to surgical techniques and graft types exist in posterolateral corner (PLC) reconstruction. The literature lacks knowledge regarding outcomes after autograft versus allograft reconstruction for PLC injuries.

Purpose

To comprehensively review the current literature on PLC reconstruction and compare outcomes between autograft and allograft tissues.

Study Design

Systematic review; Level of evidence, 4.

Methods

The PubMed and Scopus online databases were searched with the terms "PLC,""posterolateral knee,""posterolateral corner," and "reconstruction" in varying combinations. Patient characteristics, graft type, graft failure, surgical techniques, functional outcome scores, and varus laxity on stress radiographs were reviewed and compared between PLC reconstruction with autografts versus allografts.

Results

Included were 22 studies comprising 33 cohorts: 16 autografts (n = 280 knees) and 17 allografts (336 knees). There were 69 isolated PLC reconstructions (58 allografts and 11 autografts) and 493 multiligament reconstructions (269 autografts and 224 allografts). There was no difference in the mean patient age (30.5 vs 33.5 years, respectively; P = .11) or mean follow-up (39.5 vs 37.7 months, respectively; P = .68) between the autograft and allograft groups. There was no evidence to suggest a difference in graft failures between graft types (pooled mean autograft vs allograft: 0.44 vs 0.41 failures; P = .95). There was a significant difference in the mean postoperative Lysholm scores for autografts versus allografts (89.6 vs 85.5, respectively; P = .04). There was no difference between the cohorts in preoperative or postoperative International Knee Documentation Committee (IKDC) scores or postoperative varus laxity.

Conclusion

Our review and meta-analysis indicated no significant differences in graft failure rates or objective outcomes after PLC reconstruction based on graft type alone. There was a significant difference in postoperative Lysholm scores in favor of the autograft group and no significant difference in IKDC subjective scores.

Autograft patellar bone-tendon-bone use does not increase operative time in anterior cruciate ligament reconstruction

Background

Anterior cruciate ligament reconstruction (ACLR) is a common procedure that has been shown to have relatively good outcomes amongst various graft types. Operative time in ACLR has been found to influence outcomes and cost. The purpose of this study was to evaluate the association of operative time in primary arthroscopically performed anterior cruciate ligament reconstruction (ACLR) and graft type while controlling for confounders that influence time.

Methods

All patients who received ACLR between 2018 and 2022 were included in this retrospective cohort study. Exclusion criteria consisted of age (≤16 years), revisions, concomitant ligament reconstruction or tendon repairs, or other simultaneously performed procedures that could potentially add substantial variation in operative time. The primary outcome was operative time. Graft types included allograft, bone-tendon-bone (BTB) autograft, hamstring tendon (HS) autograft and quadriceps tendon (QT) autograft.

Results

A total of 1813 primary ACLRs were included. The average operative time was 98.9 ± 33.0 min. Graft utilization varies considerably among surgeons. The most used graft type was BTB autograft (42.6%) followed by HS autograft (32.3%) and allograft (21.4%). Only 68 cases (3.8%) used a QT autograft. Seven of the 15 included surgeons primarily used BTB autograft. One surgeon predominately used QT autograft. No difference in operative time was observed among the autograft types (p = 0.342). Allograft ACLR was significantly faster by 27-33 min compared to using BTB autograft, HS autograft, or QT autograft (p < 0.001).

Conclusion

Operative time did not vary by type of autograft selected. Allograft ACLR was performed approximately 30 min faster than autograft ACLR. Further studies examining the effect on patient outcomes of reduced operative time and minimizing graft harvest morbidity in ACLR is important to more accurately determine the cost-effectiveness of allograft ACLR.

Free tendon grafts for surgical management of chronic tears of the main body of the Achilles tendon: a systematic review

PURPOSE

After four weeks from injury, tears of the Achilles tendon are considered chronic. Their management is challenging, and the use of a graft is suggested when the gap between proximal and distal stumps is greater than 6 cm. The present study systematically reviews the outcome of free tendon grafts in chronic ruptures of the Achilles tendon, evaluating clinical outcomes, complications and return to sport.

METHODS

The present study was conducted according to the PRISMA 2020 guidelines. PubMed, Google Scholar, Embase, and Web of Science databases were accessed in February 2023. All the published clinical studies reporting clinical outcome, return to sport and complications of free tendon grafts used the treatment of chronic rupture of the midportion of the Achilles Tendon were accessed. The mean CMS (Coleman Methodology Score) of 65.7 suggested an overall good quality of the available published articles, attesting to the low risk of bias.

RESULTS

Data from 22 articles (368 patients with a mean age of 47 years) were retrieved. The average time from rupture to surgery was 25.1 week. At last follow-up, the AOFAS (American Orthopaedic Foot and Ankle Surgery) and ATRS (Achilles Tendon Total Rupture Score) scores improved of 33.8 (P = 0.0004), and 45.1 points (P = 0.0001) respectively. Return to activity was reported in 105 patients, and 82 (78.1%) had no activity limitations, while 19 (18.1%) had limited recreational but not daily activity limitations, and 4 (3.8%) reported limitations in daily activities. Return to sport data was reported in six studies, and 45 of 93 (48.4%) patients returned to sport at an average of 22.6 weeks.

CONCLUSION

In chronic tears of the Achilles tendon, with a gap of at least 6 cm, free tendon grafts allow predictable return to sport and acceptable recovery function.

LEVEL OF EVIDENCE

Level IV.

Cell-Instructive Mineralized Microenvironment Regulates Osteogenesis: A Growing SYMBIOSIS of Cell Biology and Biomaterials Engineering in Bone Tissue Regeneration

One of the objectives of bone tissue engineering is to produce scaffolds that are biocompatible, osteoinductive, and mechanically equivalent to the natural extracellular matrix of bone in terms of structure and function. Reconstructing the osteoconductive bone microenvironment into a scaffold can attract native mesenchymal stem cells and differentiate them into osteoblasts at the defect site. The symbiotic relationship between cell biology and biomaterial engineering could result in composite polymers containing the necessary signals to recreate tissue- and organ-specific differentiation. In the current work, drawing inspiration from the natural stem cell niche to govern stem cell fate, the cell-instructive hydrogel platforms were constructed by engineering the mineralized microenvironment. This work employed two different hydroxyapatite delivery strategies to create a mineralized microenvironment in an alginate-PEGDA interpenetrating network (IPN) hydrogel. The first approach involved coating of nano-hydroxyapatite (nHAp) on poly(lactide-co-glycolide) microspheres and then encapsulating the coated microspheres in an IPN hydrogel for a sustained release of nHAp, whereas the second approach involved directly loading nHAp into the IPN hydrogel. This study demonstrate that both direct encapsulation and a sustained release approach showed enhanced osteogenesis in target-encapsulated cells; however, direct loading of nHAp into the IPN hydrogel increased the mechanical strength and swelling ratio of the scaffold by 4.6-fold and 1.14-fold, respectively. In addition, the biochemical and molecular studies revealed improved osteoinductive and osteoconductive potential of encapsulated target cells. Being less expensive and simple to perform, this approach could be beneficial in clinical settings.

Contralateral grafts have comparable efficacy to ipsilateral grafts in anterior cruciate ligament reconstructions: a systematic review

PURPOSE

To perform a systematic review of the clinical outcomes of anterior cruciate ligament reconstruction using either contralateral or ipsilateral tendon autografts.

METHODS

A systematic review of literature published from inception to December 9, 2022, in multiple databases (PubMed, Embase, Scopus, and the Cochrane Library) was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews) guidelines. Two reviewers independently screened the literature, extracted the data, performed the risk of bias assessment and assessed the study quality. At least one of the following outcomes was evaluated for each study: muscle strength (isometric strength of the quadriceps or hamstring muscles, isokinetic peak flexion torque of the hamstring, or isokinetic peak extension torque of the hamstring), knee laxity examination, Lysholm score, pivot shift, International Knee Documentation Committee (IKDC) score, Knee Injury and Osteoarthritis Outcome Score (KOOS), Lachman test result, return to sports time, or incidence of complications. A random effects model was used for all analyses.

RESULTS

Four hundred scientific manuscripts were recovered in the initial search. After screening, 12 studies (2 randomized controlled trials, 9 cohort studies, and 1 case- control study) met the search criteria for the qualitative analysis. Among them, 9 cohort studies were used for the quantitative analysis. The results showed few statistically significant differences in terms of muscle strength (contralateral group versus ipsilateral group or donor site group versus ipsilateral group or donor site group versus nonoperative group), Lysholm score, and return to sports time. A comparison showed no significant differences in knee laxity, IKDC score, Tegner activity score, Lachman test score, or incidence of complication, or contralateral rupture.

CONCLUSIONS

In anterior cruciate ligament reconstruction, the contralateral autologous tendon has a similar effect as the ipsilateral autologous tendon.

Arthroscopic Hip Labral Reconstruction With Fresh Meniscal Allograft

The acetabular labrum is essential to maintaining the functional health of the hip joint through contributions to joint congruity, stability, and the negative pressure suction seal. Injury, overuse, long-standing developmental disorders, or failed primary labral repair can eventually lead to functional labral insufficiency requiring management via labral reconstruction. While numerous graft options exist for hip labral reconstruction, there is no current gold standard. The optimal graft should best mimic the native labrum with regard to geometry, structure, mechanical properties, and durability. This has led to the development of an arthroscopic technique for labral reconstruction with fresh meniscal allograft tissue.

Osteoregenerative Potential of 3D-Printed Poly ε-Caprolactone Tissue Scaffolds In Vitro Using Minimally Manipulative Expansion of Primary Human Bone Marrow Stem Cells

The repair of orthopedic and maxillofacial defects in modern medicine currently relies heavily on the use of autograft, allograft, void fillers, or other structural material composites. This study examines the in vitro osteo regenerative potential of polycaprolactone (PCL) tissue scaffolding, fabricated via a three-dimensional (3D) additive manufacturing technology, i.e., a pneumatic micro extrusion (PME) process. The objectives of this study were: (i) To examine the innate osteoinductive and osteoconductive potential of 3D-printed PCL tissue scaffolding and (ii) To perform a direct in vitro comparison of 3D-printed PCL scaffolding with allograft Allowash® cancellous bone cubes with regards to cell-scaffold interactions and biocompatibility with three primary human bone marrow (hBM) stem cell lines. This study specifically examined cell survival, cell integration, intra-scaffold cell proliferation, and differentiation of progenitor cells to investigate the potential of 3D-printed PCL scaffolds as an alternative to allograft bone material for the repair of orthopedic injuries. We found that mechanically robust PCL bone scaffolds can be fabricated via the PME process and the resulting material did not elicit detectable cytotoxicity. When the widely used osteogenic model SAOS-2 was cultured in PCL extract medium, no detectable effect was observed on cell viability or proliferation with multiple test groups showing viability ranges of 92.2% to 100% relative to a control group with a standard deviation of ±10%. In addition, we found that the honeycomb infill pattern of the 3D-printed PCL scaffold allowed for superior mesenchymal stem-cell integration, proliferation, and biomass increase. When healthy and active primary hBM cell lines, having documented in vitro growth rates with doubling times of 23.9, 24.67, and 30.94 h, were cultured directly into 3D-printed PCL scaffolds, impressive biomass increase values were observed. It was found that the PCL scaffolding material allowed for biomass increase values of 17.17%, 17.14%, and 18.18%, compared to values of 4.29% for allograph material cultured under identical parameters. It was also found that the honeycomb scaffold infill pattern was superior to the cubic and rectangular matrix structures, and provided a superior microenvironment for osteogenic and hematopoietic progenitor cell activity and auto-differentiation of primary hBM stem cells. Histological and immunohistochemical studies performed in this work confirmed the regenerative potential of PCL matrices in the orthopedic setting by displaying the integration, self-organization, and auto-differentiation of hBM progenitor cells within the matrix. Differentiation products including mineralization, self-organizing "proto-osteon" structures, and in vitro erythropoiesis were observed in conjunction with the documented expression of expected bone marrow differentiative markers including CD-99 (>70%), CD-71 (>60%), and CD-61 (>5%). All of the studies were conducted without the addition of any exogenous chemical or hormonal stimulation and exclusively utilized the abiotic and inert material polycaprolactone; setting this work apart from the vast majority of contemporary investigations into synthetic bone scaffold fabrication In summary, this study demonstrates the unique clinical potential of 3D-printed PCL scaffolds for stem cell expansion and incorporation into advanced microstructures created via PME manufacturing to generate a physiologically inert temporary bony defect graft with significant autograft features for enhanced end-stage healing.

Therapeutic Efficacy of Polymeric Biomaterials in Treating Diabetic Wounds-An Upcoming Wound Healing Technology

Diabetic wounds are one of the serious, non-healing, chronic health issues faced by individuals suffering from diabetic mellitus. The distinct phases of wound healing are either prolonged or obstructed, resulting in the improper healing of diabetic wounds. These injuries require persistent wound care and appropriate treatment to prevent deleterious effects such as lower limb amputation. Although there are several treatment strategies, diabetic wounds continue to be a major threat for healthcare professionals and patients. The different types of diabetic wound dressings that are currently used differ in their properties of absorbing wound exudates and may also cause maceration to surrounding tissues. Current research is focused on developing novel wound dressings incorporated with biological agents that aid in a faster rate of wound closure. An ideal wound dressing material must absorb wound exudates, aid in the appropriate exchange of gas, and protect from microbial infections. It must support the synthesis of biochemical mediators such as cytokines, and growth factors that are crucial for faster healing of wounds. This review highlights the recent advances in polymeric biomaterial-based wound dressings, novel therapeutic regimes, and their efficacy in treating diabetic wounds. The role of polymeric wound dressings loaded with bioactive compounds, and their in vitro and in vivo performance in diabetic wound treatment are also reviewed.

Meniscus Work and Implant Selection Are Major Cost Drivers of Anterior Cruciate Ligament Reconstruction

Background The current study examines the financial charges associated with primary anterior cruciate ligament reconstruction (ACLR), specifically the contribution of graft choice, graft type, and concomitant meniscus surgery, in the outpatient hospital setting. Methods A retrospective financial billing review was performed on patients who underwent ACLR at a single academic medical center from January to December 2019. Age, BMI, insurance, length of operation, regional block, implants, meniscus surgery, graft type, and graft choice were extracted from hospital electronic patient records. Charges attributed with graft, anesthesia services, supplies, implants, surgeon fees, radiology charges, and total charges were collected. Total amount that insurance and patient paid were also obtained. Descriptive and quantitative statistics were performed. Results A total of 28 patients were studied (18 males, 10 females). The average age was 23.8 years. There were 20 concomitant meniscus surgeries. Six allografts and 22 autografts were used [eight bone-patellar tendon-bone (BPTB), eight hamstrings, six quadriceps]. The average and median total charge was $61,004 and $60,390, respectively (range: $31,403 to $97,914). The average insurance paid was $26,045 while out-of-pocket costs were $402. The average paid by private insurance was higher compared to government insurance ($31,111 vs. $11,066, p<0.001). Graft choice such as allograft vs. autograft (p=0.035) and meniscus surgery (p=0.048) were significant factors to the overall cost. Conclusions Graft choice, specifically the quadrupled hamstring autograft, and concomitant meniscal surgery are major contributors to variations in ACLR charges. Decreasing implant and graft costs and limiting surgical time can decrease charges associated with ACLR. We hope these findings can help guide surgeon financial decisions, by demonstrating the need to take into account the increased total charges and amount paid associated with specific grafts, meniscus surgery, and prolonged OR time.

Allograft reconstruction of acetabular labrum has comparable outcomes to labral refixation

The acetabular labrum plays an important role in hip stability, intra-articular fluid pressurization and force distribution. For irreparable labral pathology, labral reconstruction is an increasingly adopted technique shown to decrease hip pain and improve function. We evaluated survivorship and clinical outcomes of allograft labral reconstruction using the mini-open anterior surgical approach. Twelve patients who underwent labral reconstruction using a semitendinosus tendon allograft (reconstruction group) were matched 1:3 based on age, gender, body mass index, year of surgery, preoperative Tönnis grade, previous hip surgery, residual hip pathology and extent of acetabular chondral lesion to a control group of 36 patients who underwent direct labral repair with anchors (refixation group). At a minimum follow-up of 2 years, patient-reported outcomes, radiological findings and failure rates were compared. The average age was 31.3 years (±13.6) for reconstruction and 34.7 (±10.2) for refixation. Both groups had similar preoperative symptomatic periods (P = 0.3), prevalence of residual hip pathology (P = 1.0) and prevalence of prior hip surgeries (P = 1.0). both groups had a significant improvement of modified Harris Hip scores and 36-Item Short-Form Health Survey physical scores. There was no statistically significant difference in conversion rates to total hip arthroplasty (25% versus 8.3%, P = 0.2); however, time to conversion was significantly longer in the reconstruction group (3.58 years ±1.04) compared to the refixation group (1.20 years± 0.93; P = 0.04). In conclusion, at a minimum of 2 years of follow-up, mini-open labrum reconstruction for severe insufficiency of acetabular labrum demonstrated comparable improvements in functional outcomes and significantly longer survivorship compared to labral refixation.

Graft Options for Hip Labral Reconstruction

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Arthroscopic hip labral reconstruction is a complex procedure which is growing in use as indications, techniques, and surgical expertise advance.

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Graft selection is an important component of labral reconstruction based on relative advantages and disadvantages of available types of autografts and allografts.

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The ideal graft should mimic the native acetabular labrum form and function while also being affordable, readily available, and associated with low morbidity.

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High rates of patient satisfaction and positive patient-reported outcomes have been reported after labral reconstruction using several graft types.

Quadriceps Tendon Versus Hamstring Tendon Autografts for Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

Autograft choice in anterior cruciate ligament reconstruction (ACLR) remains controversial, with increasing interest in the usage of quadriceps tendon (QT) autograft versus traditional hamstring tendon (HT) use. The current study undertakes an in-depth review and comparison of the clinical and functional outcomes of QT and HT autografts in ACLR.

HYPOTHESIS

The QT autograft is equivalent to the HT autograft and there will be little or no significant difference in the outcomes between these 2 autografts.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

The PUBMED, EMBASE, MEDLINE, and CENTRAL databases were systematically searched from their inception until November 2020. All observational studies comparing ACLR QT and HT autografts were assessed for their methodological quality. Patient outcomes were compared according to patient-reported outcome measures (International Knee Documentation Committee [IKDC], Cincinnati, Lysholm, Tegner, and visual analog scale [VAS] measures), knee extensor and flexor torque limb symmetry indices (LSIs), hamstring to quadriceps (H/Q) ratios, functional hop capacity, knee laxity, ipsilateral graft failure, and contralateral injury.

RESULTS

A total of 20 observational studies comprising 28,621 patients (QT = 2550; HT = 26,071) were included in the quantitative meta-analysis. In comparison with patients who received an HT autograft, those who received a QT autograft had similar postoperative Lysholm (mean difference [MD], 0.67; P = .630), IKDC (MD, 0.48; P = .480), VAS pain (MD, 0.04; P = .710), and Cincinnati (MD, -0.85; P = .660) scores; LSI for knee flexor strength (MD, 6.06; P = .120); H/Q ratio (MD, 3.22; P = .160); hop test LSI (MD, -1.62; P = .230); pivot-shift test grade 0 (odds ratio [OR], 0.80; P = .180); Lachman test grade 0 (OR, 2.38; P = .320), side-to-side laxity (MD, 0.09; P = .650); incidence of graft failure (OR, 1.07; P = .830) or contralateral knee injury (OR, 1.22; P = .610); and Tegner scores (MD, 0.11; P = .060). HT autografts were associated with a higher (better) side-to-side LSI for knee extensor strength (MD, -6.31; P = .0002).

CONCLUSION

In this meta-analysis, the use of the QT autograft was equivalent to the HT autograft in ACLR, with comparable graft failure and clinical and functional outcomes observed. However, HT autografts were associated with better LSI knee extensor strength.

Cost and Cost Driver Analysis of Anterior Cruciate Ligament Reconstruction Using Time-Driven Activity-Based Costing: Bone-Tendon-Bone Autograft Versus Hamstring Autograft

As health care transitions toward value-based care, orthopaedics has started to implement time-driven activity-based costing (TDABC) to understand costs and cost drivers. TDABC has not previously been used to study cost drivers in anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to use TDABC to (1) calculate bone-tendon-bone (BTB) and hamstring ACLR total costs of care and (2) evaluate the impact of graft choice and other factors on ACLR costs.

Methods

Data were collected from electronic medical records for primary ACLR from the institutional patient-reported outcome registry between 2009 and 2016 in 1 ambulatory surgery center. Patients receiving allograft, revision ACLR, or concomitant meniscal repair or ligament reconstruction were excluded. The total cost of care was determined using TDABC. Multivariate regression analysis was conducted between ACLR cost and group characteristics.

Results

A total of 328 patients were included; 211 (64.3%) received BTB autograft and 117 (35.7%) received hamstring autograft. The mean cost was $2,865.01 ± $263.45 (95% confidence interval: $2,829.26, $2,900.77) for BTB ACLR versus $3,377.44 ± $320.12 ($3,318.82, $3,436.05) for hamstring ACLR (p < 0.001). Operative time was 103.1 ± 25.1 (99.7, 106.5) minutes for BTB ACLR versus 113.1 ± 27.9 (108.0, 118.2) minutes for hamstring ACLR (p = 0.001). The total implant cost was $270.32 ± $97.08 ($257.15, $283.50) for BTB ACLR versus $587.36 ± $108.78 ($567.44, $607.28) for hamstring ACLR (p < 0.001). Hamstring graft (p = 0.006) and suspensory fixation on the femoral side (p = 0.011) were associated with increased costs.

Conclusions

The mean cost of care and operative time for BTB autograft ACLR are less than those for hamstring autograft ACLR. Operative time, implant choice, and graft choice were identified as modifiable cost drivers that can empower surgeons to manage primary ACLR costs while maximizing the value of the procedure.

Level of Evidence

Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

Polymer-Based Wound Dressing Materials Loaded with Bioactive Agents: Potential Materials for the Treatment of Diabetic Wounds

Diabetic wounds are severe injuries that are common in patients that suffer from diabetes. Most of the presently employed wound dressing scaffolds are inappropriate for treating diabetic wounds. Improper treatment of diabetic wounds usually results in amputations. The shortcomings that are related to the currently used wound dressings include poor antimicrobial properties, inability to provide moisture, weak mechanical features, poor biodegradability, and biocompatibility, etc. To overcome the poor mechanical properties, polymer-based wound dressings have been designed from the combination of biopolymers (natural polymers) (e.g., chitosan, alginate, cellulose, chitin, gelatin, etc.) and synthetic polymers (e.g., poly (vinyl alcohol), poly (lactic-co-glycolic acid), polylactide, poly-glycolic acid, polyurethanes, etc.) to produce effective hybrid scaffolds for wound management. The loading of bioactive agents or drugs into polymer-based wound dressings can result in improved therapeutic outcomes such as good antibacterial or antioxidant activity when used in the treatment of diabetic wounds. Based on the outstanding performance of polymer-based wound dressings on diabetic wounds in the pre-clinical experiments, the in vivo and in vitro therapeutic results of the wound dressing materials on the diabetic wound are hereby reviewed.

Aseptically Processed Allograft Implantation: A Safe Strategy for Knee Ligament Reconstructions

Postoperative infections after allograft implantation is a major concern in knee ligament reconstructions considering the theoretical risk of disease transmission and its potential severity. Here, we aimed to evaluate the postoperative infection rate after knee ligament reconstructions using aseptically processed allografts, and provide an overview of the allografts use in an academic tertiary hospital. A retrospective study was performed evaluating patients who underwent knee ligament reconstructions using aseptically processed allografts, including primary and revision surgeries, from 2005 to 2018. Demographic data, including the type of knee injury and trauma energy, and postoperative data were collected focusing on postoperative infections. Regarding these infected cases, further analyses were performed considering the presenting signs and symptoms, the isolated microorganism identified in culture, the time between graft implantation and diagnosis of infection (defined as acute, subacute, and late), and the need for graft removal. A total of 180 cases of ligament reconstructions were included. The mean follow-up was 8.2 (range: 2.1-15.6) years and the mean age at surgery was 34.1 (± 11.1) years. A total of 262 allografts were implanted in those 180 cases, 93 (35.5%) as bone plug allografts and 169 (64.5%) as soft tissue allografts. Common surgical indications included multiligament reconstruction (57.2%) and primary anterior cruciate ligament (ACL) reconstruction (15%). Seven cases (3.9%) presented postoperative infections. Knee pain (100%) and swelling (100%) were the most prevalent symptoms. Two cases (28.6%) presented sinus tract. Allografts were removed in two cases, the same cases that presented draining sinus (p = 0.04). High-energy trauma was the only statistically associated factor for infection (p = 0.04). No significant association between infection and the type of allograft (p > 0.99) or sex (p = 0.35) were observed. Four cases (57.1%) had monomicrobial staphylococcal infections. Based on that, the allograft-related infection rate was 1.7% (the remaining three infected cases). Nonirradiated, aseptically processed allografts have a low postoperative infection rate in knee ligament reconstructions, being a safe alternative for surgeries that require additional source, increased variety, and quantity of grafts.

Mechanistic Illustration: How Newly-Formed Blood Vessels Stopped by the Mineral Blocks of Bone Substitutes Can Be Avoided by Using Innovative Combined Therapeutics

One major limitation for the vascularization of bone substitutes used for filling is the presence of mineral blocks. The newly-formed blood vessels are stopped or have to circumvent the mineral blocks, resulting in inefficient delivery of oxygen and nutrients to the implant. This leads to necrosis within the implant and to poor engraftment of the bone substitute. The aim of the present study is to provide a bone substitute currently used in the clinic with suitably guided vascularization properties. This therapeutic hybrid bone filling, containing a mineral and a polymeric component, is fortified with pro-angiogenic smart nano-therapeutics that allow the release of angiogenic molecules. Our data showed that the improved vasculature within the implant promoted new bone formation and that the newly-formed bone swapped the mineral blocks of the bone substitutes much more efficiently than in non-functionalized bone substitutes. Therefore, we demonstrated that our therapeutic bone substitute is an advanced therapeutical medicinal product, with great potential to recuperate and guide vascularization that is stopped by mineral blocks, and can improve the regeneration of critical-sized bone defects. We have also elucidated the mechanism to understand how the newly-formed vessels can no longer encounter mineral blocks and pursue their course of vasculature, giving our advanced therapeutical bone filling great potential to be used in many applications, by combining filling and nano-regenerative medicine that currently fall short because of problems related to the lack of oxygen and nutrients.

Hyaluronic Acid-Based Scaffolds as Potential Bioactive Wound Dressings

The negative factors that result in delayed and prolonged wound healing process include microbial pathogens, excess wound exudates, underlying conditions, smoking, obesity, etc. Most of the currently used wound dressings demonstrate an inadequate capacity to treat wounds resulting from the factors mentioned above. The commonly used wound dressings include hydrogels, films, hydrocolloids, foams, fibers, sponges, dermal patches, bandages, etc. These wound dressings can be loaded with various types of bioactive agents (e.g., antibiotics, nanoparticles, anti-inflammatory drugs, etc.) to improve their therapeutic outcomes. Biopolymers offer interesting properties suitable for the design of wound dressings. This review article will be based on hyaluronic-acid-based scaffolds loaded with therapeutic agents for the treatment of wounds.

Predicting Autologous Hamstring Graft Diameter in the Pediatric Population Using Preoperative Magnetic Resonance Imaging and Demographic Data

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction before 18 years of age has been linked with an increased risk for failure when the graft diameter is <8 mm.

PURPOSE/HYPOTHESIS

The purpose of this study was to determine whether autologous hamstring graft size can be reliably predicted with the use of preoperative magnetic resonance imaging (MRI) measurements. We hypothesized that the average of multiple axial cross-sectional area MRI measurements for the semitendinosus tendon and gracilis tendon would alone accurately predict graft diameter. Additionally, factoring in specific demographic data to the MRI cross-sectional areas would provide a synergistic effect to the accuracy of graft diameter predictions.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

We retrospectively reviewed 51 pediatric patients undergoing ACL reconstructions (age <18 years) performed using either a quadruple-strand semitendinosus tendon or combined double-bundle semitendinosus tendon-gracilis tendon autograft. Preoperative axial MRI scans at multiple points along the craniocaudal axis-specifically, at the level of the joint line, 3 cm cephalad to the medial tibial plateau, and 5 cm cephalad to the medial tibial plateau-were used to determine the combined cross-sectional area of the semitendinosus and gracilis tendons. The MRI measurements were analyzed using Pearson correlation as well as regression analysis to evaluate strength of correlation between measurements. Binomial linear regression was used to analyze the same predictive variables assessed by multiple regression.

RESULTS

The predicted graft diameter was within 0.5 mm of the intraoperative graft size in 37 of 51 (72.5%) patients and within 1 mm of the intraoperative graft size in 49 of 51 (96.1%). With the addition of demographics, the accuracy of predictions increased to 78.4% within 0.5 mm and 98% within 1 mm of the actual graft size. Additionally, 38 of 42 patients whose true graft diameter was ≥8 mm were correctly classified, giving a sensitivity of 90.4%. For those whose true graft diameter was <8 mm, 8 of 9 patients were correctly classified; therefore, the specificity was 88.9%.

CONCLUSION

The results of our study suggest that taking the average of multiple preoperative MRI measurements can be used to accurately predict autologous hamstring graft size when approaching pediatric patients undergoing ACL reconstruction.

The management of acute knee dislocations: A global survey of orthopaedic surgeons' strategies

Purpose: Great variety and controversies surround the management strategies of acute multiligament knee injuries (aMKLIs) and no established guidelines exist for resource-limited practices. The aim of this study was to compare the management approach of acute knee dislocations (AKDs) by orthopedic surgeons from nations with different economic status. Methods: This descriptive cross-sectional scenario-based survey compares different management strategies for aMLKIs of surgeons in developed economic nations (DEN) and emerging markets and developing nations (EMDN). The main areas of focus were operative versus non-operative management, timing and staging of surgery, graft choice and vascular assessment strategies. The members of the Societe Internationale de Chirurgie Orthopedique et de Traumatologie (SICOT) were approached to participate and information was collected regarding their demographics, experience, hospital setting and management strategies of aMLKIs. These were analyzed after categorizing participants into DEN and EMDN based on the gross domestic product (GDP) per capita. Results: One-hundred and thirty-eight orthopedic surgeons from 47 countries participated in this study, 67 from DEN and 71 (51.4%) from EMDN. DEN surgeons had more years of experience and were older (p < 0.05). Surgeons from EMDN mostly worked in public sector hospitals, were general orthopedic surgeons and treated patients from a low-income background. They preferred conservative management and delayed reconstruction with autograft (p < 0.05) if surgery was necessary. Surgeons from DEN favored early, single stage arthroscopic ligament reconstruction. Selective Computerized Tomography Angiography (CTA) was the most preferred choice of arterial examination for both groups. Significantly more EMDN surgeons preferred clinical examination (p < 0.05) and duplex doppler scanning (p < 0.05) compared to DEN surgeons. More surgeons from EMDN did not have access to a physiotherapist for their patients. Conclusions: Treatment of aMLKIs vary significantly based on the economic status of the country. Surgeons from DEN prefer early, single stage arthroscopic ligament reconstruction, while conservative management is favored in EMDN. Ligament surgery in EMDN is often delayed and staged. EMDN respondents utilize duplex doppler scanning and clinical examination more readily in their vascular assessment of aMLKIs. These findings highlight very distinct approaches to MLKIs in low-resource settings which are often neglected when guidelines are generated.

Using a simplified version of a common surgical grading scale for acetabular labral tears improves the utility of preoperative hip MRI for femoroacetabular impingement

OBJECTIVE

To evaluate whether a commonly used surgical grading scale, when applied to acetabular labral findings on MRI, could improve preoperative planning and counseling for patients undergoing hip arthroscopy.

MATERIALS AND METHODS

We evaluated 76 clinical MRIs performed on patients with femoroacetabular impingement. Three musculoskeletal radiologists and one musculoskeletal fellow reviewed each scan in a blinded fashion, classifying the acetabular labrum from 12:00 to 4:00 using the Beck scale, a common surgical grading scale. Clinical correlation was provided via surgical examination and classification. Reliability was determined between readers and between reader and surgical data using Cohen's kappa and Krippendorff's alpha at each clock position and for the worst grading for each scan. In addition, a simplified version of the scale comprised of only two grades, potentially reparable and not potentially reparable, was evaluated.

RESULTS

When the scale was simplified into categories of potentially reparable and not potentially reparable, the sensitivity was excellent, ranging from 85.5 to 96%. Observer agreement when using individual Beck grades was found to range from poor to fair; Kappa ranged from 0.03 to 0.19, and Alpha ranged from - 0.27 to 0.22.

CONCLUSION

The simplified version of the Beck labral scale when applied to MRI is a highly sensitive predictor of potentially reparable labral pathology while excluding normal and grossly degenerative tissue. Use of this scale provides clinically relevant information that can drive preoperative planning and improve patient counseling. It does so in a standardized fashion that can be applied across practice sites and without additional cost.

Polymer-Based Materials Loaded with Curcumin for Wound Healing Applications

Some of the currently used wound dressings have interesting features such as excellent porosity, good water-absorbing capacity, moderate water vapor transmission rate, high drug loading efficiency, and good capability to provide a moist environment, but they are limited in terms of antimicrobial properties. Their inability to protect the wound from microbial invasion results in wound exposure to microbial infections, resulting in a delayed wound healing process. Furthermore, some wound dressings are loaded with synthetic antibiotics that can cause adverse side effects on the patients. Natural-based compounds exhibit unique features such as good biocompatibility, reduced toxicity, etc. Curcumin, one such natural-based compound, has demonstrated several biological activities such as anticancer, antibacterial and antioxidant properties. Its good antibacterial and antioxidant activity make it beneficial for the treatment of wounds. Several researchers have developed different types of polymer-based wound dressings which were loaded with curcumin. These wound dressings displayed excellent features such as good biocompatibility, induction of skin regeneration, accelerated wound healing processes and excellent antioxidant and antibacterial activity. This review will be focused on the in vitro and in vivo therapeutic outcomes of wound dressings loaded with curcumin.

Anterior cruciate ligament grafts display differential maturation patterns on magnetic resonance imaging following reconstruction: a systematic review

PURPOSE

The appearance of anterior cruciate ligament (ACL) grafts on magnetic resonance imaging (MRI) is related to graft maturity and mechanical strength after ACL reconstruction (ACLR). Accordingly, the purpose of this review was to quantitatively analyze reports of serial MRI of the ACL graft during the first year following ACLR; the hypothesis tested was that normalized MRI signal intensity would differ significantly by ACL graft type, graft source, and postoperative time.

METHODS

PubMed, Scopus, and CINAHL were searched for all studies published prior to June 2018 reporting MRI signal intensity of the ACL graft at multiple time points during the first postoperative year after ACLR. Signal intensity values at 6 and 12 months post-ACLR were normalized to initial measurements and analyzed using a least-squares regression model to study the independent variables of postoperative time, graft type, and graft source on the normalized MRI signal intensity.

RESULTS

An effect of graft type (P = 0.001) with interactions of graft type * time (P = 0.012) and graft source * time (P = 0.001) were observed. Post hoc analyses revealed greater predicted normalized MRI signal intensity of patellar tendon autografts than both hamstring (P = 0.008) and hamstring with remnant preservation (P = 0.001) autografts at postoperative month 12.

CONCLUSION

MRI signal varies with graft type, graft source, and time after ACLR. Enhanced graft maturity during the first postoperative year was associated with hamstring autografts, with and without remnant preservation. Serial MRI imaging during the first postoperative year may be clinically useful to identify biologically or mechanically deficient ACL grafts at risk for failure.

LEVEL OF EVIDENCE

IV.

Outcomes After Arthroscopic Hip Labral Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

The acetabular labrum is critical to maintenance of hip stability and has been found to play a key role in preservation of the hip fluid seal. For irreparable labral damage, arthroscopic labral reconstruction is an evolving technique that has been shown to decrease hip pain and restore function.

PURPOSE

To provide a comprehensive review of current literature for arthroscopic hip labral reconstruction, with a focus on determining if outcomes differ between autograft or allograft tissue.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

PubMed and Scopus online databases were searched with the key terms "hip,""labrum,""reconstruction," and "graft" in varying combinations. Procedures performed, complications, failures, and functional outcome measures were included in this analysis. The inverse variance method was used to calculate pooled estimates and 95% CIs.

RESULTS

Eight studies with 537 hips were included. Mean age was 37.4 years (95% CI, 34.5-40.4 years), and mean follow-up time was 29 months (95% CI, 26-33 months). Survivorship after autograft reconstruction ranged from 75.7% to 100%, as compared with 86.3% to 90.0% in the allograft cohort. In the autograft cohort, failures included 0% to 13.2% conversion to total hip arthroplasty and 0% to 11.0% revision hip arthroscopy. Failures in the allograft cohort included 0% to 12.9% total hip arthroplasty conversion, 0% to 10.0% revision arthroscopy, and 0% to 0.8% open revision surgery. Based on 6 studies, the modified Harris Hip Score improved by a mean 29.0 points after labral reconstruction (P < .0001).

CONCLUSION

Arthroscopic hip labral reconstruction results in clinically significant improvements in patient-reported outcomes. Our analysis indicates that there are no significant differences in outcomes based on graft type alone. A number of factors may determine graft choice, including patient preference, surgeon experience, operative time, morbidity, and cost. Proper patient selection based on age and severity of degenerative joint disease will also optimize outcomes after labral reconstruction.

Biomechanical Testing of a Calcium Phosphate-Phosphoserine-Based Mineral-Organic Adhesive for Non-invasive Fracture Repair of Mandibular Fractures in Dogs

Mandibular fracture repair is complicated by limited availability of bone as well as the presence of the neurovascular bundle and an abundance of tooth roots. Fractures at the location of the mandibular first molar teeth are common and it can be particularly challenging to apply stable fixation. Non-invasive fracture repair techniques utilize intraoral placement of fixation devices typically involving polymerized composites and/or interdental wiring. A novel calcium phosphate-phosphoserine–based mineral–organic adhesive was tested ex vivo to determine its effects on augmenting strength of different non-invasive fracture fixation techniques. This study both tested the use of mineral–organic adhesive for the purpose of stabilizing currently used non-invasive fracture repair constructs (intraoral composite splinting ± interdental wiring) and evaluated adhesive alone or with subperiosteally placed plates on buccal cortical bone surface. Aside from controls, not receiving an osteotomy along the mesial root of the mandibular first molar tooth, six treatment groups were tested to evaluate ultimate strength, stiffness, angular displacement, bending moment, and application time. All forms of fixation were found to be significantly weaker than control (p < 0.001). Only the control (p < 0.001) and mineral–organic adhesive and composite (P = 0.002) groups were found to be significantly stronger than wire and composite. No difference was noted in stiffness between any groups with control or wire and composite. Application times varied from the mineral–organic adhesive group (mean = 206 s) to mineral–organic adhesive and composite (mean = 1,281 s). Twenty-three fixation devices exhibited adhesive failure, 20 demonstrated cohesive failure, and 5 failed by cohesive and adhesive failure. When evaluating the ultimate strength of the fixation device groups, mineral–organic adhesive, and composite was shown to be the strongest construct. The use of resorbable bone adhesive and composite may provide a stronger fixation construct over interdental wire and composite for mandibular fracture repair in dogs.

Efficient decellularization of equine tendon with preserved biomechanical properties and cytocompatibility for human tendon surgery indications

Chronic and acute tendon injuries are frequent afflictions, for which treatment is often long and unsatisfactory. When facing extended injuries, matrices and scaffolds with sufficient biomechanical properties are required for surgical repair and could additionally serve as supports for cellular therapies to improve healing. In this study, protocols of either commonly used detergents only (SDS 1%, Triton 1%, TBP 1%, and Tween‐20 1%) or a combination of freeze/thaw (F/T) cycles with decellularization agents (NaCl 1M, ddH₂O) were evaluated for the decellularization of horse equine superficial digital flexor tendon (SDFT) for hand flexor or extensor tendon reconstruction. Decellularization efficiency was assessed microscopically by histological staining (HE, DAPI) and DNA quantification. Macroscopical structure and biomechanical integrity of the tendon matrices were further assessed by gross observation, histological staining (SR), and mechanical testing (ultimate strain and stress, Young’s modulus, energy to failure) for select protocols. Decellularization with hypertonic NaCl 1M in association with F/T cycles produced the most robust tendon matrices, which were nontoxic after 10 days for subsequent recellularization with human fetal progenitor tendon cells (hFPTs). This standardized protocol uses a less aggressive decellularization agent than current practice, which allows subsequent reseeding with allogenic cells, therefore making them very suitable and bioengineered tendon matrices for human tendon reconstruction in the clinic.

Medial patellofemoral ligament reconstruction using an autograft or allograft for patellar dislocation: a systematic review

Purposes

The purpose of this study is to review the use of an allograft or autograft in medial patellofemoral ligament (MPFL) reconstruction.

Materials and methods

Various electronic databases were searched for relevant articles published from January 2000 to September 2017 that evaluated clinical outcomes of MPFL reconstruction using an autograft or allograft. Data search, extraction, analysis, and quality assessments were performed based on Cochrane Collaboration guidelines.

Results

The study of 21 autografts and one allograft was included in this review. Although direct comparative studies were unavailable, the Kujala score and subjective results were reported in the majority of these studies. While the use of an autograft for MPFL reconstruction yielded satisfactory clinical outcomes with few perioperative complications, no new outcome has been drawn from the use of allografts.

Conclusions

Although many studies have shown favorable clinical results for MPFL reconstruction using an autograft, the clinical results of MPFL reconstruction using an allograft have not yet been sufficient to achieve meaningful clinical results due to low levels of evidence. Direct comparisons were not conducted because there were very few studies on allografts; thus, further research in this area should be performed in the future.

Electronic supplementary material

The online version of this article (10.1186/s43019-019-0008-0) contains supplementary material, which is available to authorized users.

Orthopedic versus Neurosurgery-Understanding 90-Day Complications and Costs in Patients Undergoing Elective 1-Level to 2-Level Posterior Lumbar Fusions by Different Specialties

BACKGROUND

Lumbar fusions are routinely performed by either orthopedic or neurologic spine surgeons. Controversy still exists as to whether a provider's specialty (orthopedic vs. neurosurgery) influences outcomes.

METHODS

The 2007-2015Q2 Humana Commercial Database was queried using Current Procedural Terminology codes (22612, 22614, 22630, 22632, 22633 and 22634) to identify patients undergoing elective 1-to-2 level posterior lumbar fusions (PLFs) with active enrollment up to 90 days after procedure. Ninety-day complication rates were calculated for the 2 specialties. The surgical and 90-day resource utilization costs for the 2 groups were compared, by studying average reimbursements for acute-care and post-acute-care categories. Ninety-day complications and costs were compared using multivariable logistic and linear regression analyses.

RESULTS

A total of 10,509 patients (5523 orthopedic and 4986 neurosurgery) underwent an elective 1-to-2 level PLF during the period. With the exception of a significantly lower odds of wound complications (odds ratio, 0.81) and a higher odds of dural tears (odds ratio, 1.29) in elective PLFs performed by orthopedic surgeons, no statistically strong differences were seen in 90-day complication rates between the 2 groups. Total 90-day costs were also similar between orthopedic surgeons and neurosurgeons, with the only exception being that surgeon reimbursement was lower for orthopedic surgery versus neurosurgery ($1202 vs. $1372; P < 0.001).

CONCLUSIONS

It seems that a provider's specialty does not largely influence 90-day surgical outcomes and costs after elective PLFs. The results of the study promote the formation and acceptance of dual training pathways for entry into spine surgery.

Synovitis following anterior cruciate ligament reconstruction using the LARS device

PURPOSE

The Ligament Augmentation and Reconstruction System (LARS^®) has been at the forefront of a recent revival in the use of synthetic ligaments for ACL reconstruction. However, despite promising short-to-mid-term results its role has been approached with caution due to a high number of major complications in previous synthetic graft designs including mechanical failures, synovitis and osteoarthritis. This study aims to report on the incidence of synovitis in a series of patients undergoing second-look surgery following LARS ACL reconstruction.

METHODS

A retrospective analysis was performed of a single surgeon's series of 12 patients that underwent second-look arthroscopic surgery following primary LARS ACL surgery for indications including mechanical symptoms (meniscal tears/cyclops lesions/chondral flaps) and/or symptomatic instability secondary to LARS failure. In all cases an examination under anaesthesia (EUA) was performed, and a qualitative assessment of the synovium was carried out and graded as normal, reactive or inflammatory. A synovial biopsy was performed in all knees with visible evidence of synovitis and in all cases of LARS failure.

RESULTS

The second-look arthroscopy was performed at a mean of 23 months (7-66) after the index surgery. In 6 (50%) knees the LARS device had failed necessitating removal and revision ACL reconstruction, while in the remaining 6 knees the LARS was still intact. Arthroscopic evaluation of the synovium revealed a normal appearance in 8 knees (67%) and reactive synovitis in 4 knees (23%); of these 4 knees, one had an intact LARS device and 3 had failed LARS. Histological examination from these 4 knees and the 3 knees with graft failures without visible synovitis revealed chronic hypertrophic synovitis (moderate 2, mild 5) in all cases with rare giant cells, consistent with a reaction to foreign body material.

CONCLUSIONS

Foreign body synovitis is a common finding in our series of patients undergoing a repeat arthroscopy following a LARS ACL reconstruction. The histological diagnosis of synovitis was more frequently encountered than an arthroscopic appearance of synovitis. Whilst the results of this case series cannot support a direct causative link between LARS failure and the development of synovitis, this study highlights the need to remain vigilant about the risk of reactive synovitis following LARS ACL reconstruction due to exposure of the knee to foreign body material.

LEVEL OF EVIDENCE

Level IV, case series.

Autograft or allograft for reconstruction of anterior cruciate ligament: a health economics perspective

PURPOSE

To assess the clinical and cost-effectiveness of allografts versus autografts in the reconstruction of anterior cruciate ligaments.

METHODS

Systematic review of comparative clinical effectiveness and cost-effectiveness analysis.

RESULTS

Both autograft and allograft reconstruction are highly effective. Recent studies show little difference in failure rates between autografts and allografts (about 6% and 7%, respectively). In cost-effectiveness analysis, the price differential is the main factor, making autografts the first choice. However, there will be situations, particularly in revision ACL reconstruction, where an allograft may be preferred, or may be the only reasonable option available.

CONCLUSION

In ACL reconstruction, clinical results with autografts are as good as or slightly better than with allografts. Allografts cost more, indicating that autografts are more cost-effective and should usually be first choice.

LEVEL OF EVIDENCE

II.

Modeling-Based Assessment of 3D Printing-Enabled Meniscus Transplantation

3D printing technology is able to produce personalized artificial substitutes for patients with damaged menisci. However, there is a lack of thorough understanding of 3D printing-enabled (3DP-enabled) meniscus transplantation and its long-term advantages over traditional transplantation. To help health care stakeholders and patients assess the value of 3DP-enabled meniscus transplantation, this study compares the long-term cost and risk of this new paradigm with traditional transplantation by simulation. Pathway models are developed to simulate patients' treatment process during a 20-year period, and a Markov process is used to model the state transitions of patients after transplantation. A sensitivity analysis is also conducted to show the effect of quality of 3D-printed meniscus on model outputs. The simulation results suggest that the performance of 3DP-enabled meniscus transplantation depends on quality of 3D-printed meniscus. The conclusion of this study is that 3DP-enabled meniscus transplantation has many advantages over traditional meniscus transplantation, including a minimal waiting time, perfect size and shape match, and potentially lower cost and risk in the long term.

What Are the Primary Cost Drivers of Anterior Cruciate Ligament Reconstruction in the United States? A Cost-Minimization Analysis of 14,713 Patients

PURPOSE

To analyze the individual costs associated with anterior crucial ligament reconstruction (ACLR), accounting for patient demographics, perioperative decision making, and location of the surgical procedure (hospital vs ambulatory surgery center), utilizing a cost-minimization analysis in a large national database.

METHODS

Univariate analysis and multiple linear regression were performed to determine which patient and surgical variables were the largest cost drivers for ACLR in the United States according to the State Ambulatory Surgery and Services Database.

RESULTS

The average cost for ACLR (n = 14,713) was $24,707 (standard deviation, $15,644). When patient variables were considered, younger age (P < .001), male sex (P < .001), Hispanic ethnicity (P < .001), number of chronic medical conditions (P < .001), Medicare insurance (P < .001), and quartile of household income (P < .001) were all associated with higher costs after ACLR. For operative variables, time spent in the operating room (P < .001), meniscal repair (P < .001), and use of general anesthesia alone (P < .001) were all associated with higher costs for ACLR. There was no significant difference between cost of surgery performed at a private surgery center and cost at a hospital-owned center. In the multivariate regression, the 3 variables with the greatest influence on cost of ACLR were use of isolated general anesthesia (associated with an increase of $2,049), Hispanic ethnicity ($1,828), and >1 chronic medical condition ($1,749). Male sex, time in operating room, and older age also significantly increased ACLR cost.

CONCLUSIONS

The greatest contributor to cost of ACLR was the use of general anesthesia alone. Time spent in the operating room increased ACLR cost by $108 per minute. Patient factors included greater age, male sex, Hispanic ethnicity, number of chronic medical conditions, Medicare insurance, and annual income. Meniscal repair and regional nerve block did not significantly affect cost as determined by multivariate regression.

Current practice: postoperative and return to play trends after ACL reconstruction by fellowship-trained sports surgeons

PURPOSE

Advances in anterior cruciate ligament (ACL) reconstruction have allowed for many progressions in postoperative management. However, there is no standardized protocol for immediate postoperative management or return to play. Our objective was to evaluate current trends in immediate postoperative and return to sport practices after ACL reconstruction.

LEVEL OF EVIDENCE

Cross sectional study, Level IV.

METHODS

Surveys were obtained from four large sports fellowship alumni networks. Demographics included years of practice and ACLs performed per year. Postoperative questions included weight bearing status, brace use and continuous passive motion (CPM) use. Return to play included time for return, brace use and metrics used for clearance to sport.

RESULTS

A total of 143 surveys were completed (32% response rate). Average years in practice were 15.1 years. Average ACL reconstructions performed per year was 20-50 in 44% and 50-100 in 29%. 26% used CPM in all patients, 8% if concomitant meniscal repair and 66% never. Bracing after surgery was used in 84% and 48% after return to play. Return to play was allowed at 6-9 months in 67% and overall 94% from 6 to 12 months. No consensus on return to play metrics was used, with the hop test being most important followed by specific time point after surgery.

CONCLUSION

Immediate weight bearing after surgery is commonplace with intermittent CPM use. Bracing is common postoperatively and half the time with return to play. Return to play is typically allowed after at least 6 months with no consensus on return to sport metrics. Years after fellowship and ACLs performed yearly had no correlation with postoperative practices.

Patient- and Procedure-Specific Variables Driving Total Direct Costs of Outpatient Anterior Cruciate Ligament Reconstruction

Background:

Few studies have investigated the influence of patient-specific variables or procedure-specific factors on the overall cost of anterior cruciate ligament reconstruction (ACLR) in an ambulatory surgery setting.

Purpose:

To determine patient- and procedure-specific factors influencing the overall direct cost of outpatient arthroscopic ACLR utilizing a unique value-driven outcomes (VDO) tool.

Study Design:

Cohort study (economic and decision analysis); Level of evidence, 3.

Methods:

All ACLRs performed by 4 surgeons over 2 years were retrospectively reviewed. Cost data were derived from the VDO tool. Patient-specific variables included age, body mass index, comorbidities, American Society of Anesthesiologists (ASA) classification, smoking status, preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Computerized Adaptive Testing (PF-CAT) score, and preoperative Single Assessment Numeric Evaluation (SANE) score. Procedure-specific variables included graft type, revision status, associated injuries and procedures, time from injury to ACLR, surgeon, and operating room (OR) time. Multivariate analysis determined patient- and procedure-related predictors of total direct costs.

Results:

There were 293 autograft reconstructions, 110 allograft reconstructions, and 31 hybrid reconstructions analyzed. Patient-specific factors did not significantly influence the ACLR cost. The mean OR time was shorter for allograft reconstruction (P < .001). Predictors of an increased direct cost included the use of an allograft or hybrid graft (44.5% and 33.1% increase, respectively; P < .001), increased OR time (0.3% increase per minute; P < .001), surgeon 3 or 4 (9.1% or 5.9% increase, respectively; P < .001 or P = .001, respectively), and concomitant meniscus repair (24.4% increase; P < .001). Within the meniscus repair cohort, all-inside, root, and combined repairs correlated with a 15.5%, 31.4%, and 53.2% increased mean direct cost, respectively, compared with inside-out repairs (P < .001).

Conclusion:

This study failed to identify modifiable patient-specific factors influencing direct costs of ACLR. Allografts and hybrid grafts were associated with an increased total direct cost. Meniscus repair independently predicted an increased direct cost, with all-inside, root, and combined repairs being costlier than inside-out repairs. The time-saving potential of all-inside meniscus repair was not realized in this study, making implant use a significant factor in the overall cost of ACLR with meniscus repair.

Editorial Commentary: National Football League Hopefuls Beware: Your Stock May Be Falling After Anterior Cruciate Ligament Reconstruction

Making a National Football League (NFL) team is tough; making one after undergoing an anterior cruciate ligament (ACL) reconstruction is tougher. NFL Combine participants who are post-ACL reconstruction, particularly with certain graft types such as allografts and to a lesser extent hamstring grafts, are frequently 'down-graded' despite the presence of a stable, well-placed graft without any associated meniscal or chondral damage. Whether NFL general managers are truly prescient in accurately predicting decreased performance by choosing a player later in the draft, or whether NFL coaching staffs knowingly or unknowingly restrict an athlete's playing time based on draft position or surgical history is unknown. Yet, any collegiate football player who is good enough to make it to the Combine possesses a rare combination of athleticism, strength, determination, and toughness. An ACL tear used to mark the beginning of the end of an athlete's playing career, but today's athletes are able to return at an elite level following ACL injury and surgery. Unfortunately, despite a successful surgery, prospective NFL players who undergo ACL reconstruction may still be at a disadvantage compared to their uninjured counterparts in terms of their ability to be drafted and play in the first two years of their careers.

A History of Anterior Cruciate Ligament Reconstruction at the National Football League Combine Results in Inferior Early National Football League Career Participation

PURPOSE

To evaluate whether players with a history of an anterior cruciate ligament reconstruction (ACLR) before the National Football League (NFL) Combine played or started fewer games and/or participated in fewer eligible snaps compared with NFL Combine participants without a history of knee injury or surgery.

METHODS

We performed a retrospective review of all players who participated in the NFL Combine between 2009 and 2015 and who had a history of an ACLR. NFL Combine participants were included if they had a previous ACLR or combined anterior cruciate ligament (ACL) injury and nonoperatively managed medial collateral ligament injury. The number of games started, number of games played, draft number, overall draft pick, and snap percentage for each position were determined. The mean value of each outcome metric was compared between case and control players.

RESULTS

We identified 110 players who had an ACL injury (n = 76) or a combined ACL and medial collateral ligament injury (n = 34). Players in the ACLR group had a significantly worse mean draft pick number (difference of 30.2, P = .002) and mean draft round (difference of 0.8, P = .019) versus controls. Compared with control players, players in the ACLR group started and played significantly fewer games in both season 1 (difference of 2.7 games started, P < .001; difference of 2.7 games played, P < .001) and season 2 (difference of 7.4 games started, P < .001; difference of 3.0 games played, P = .003) and had a significantly lower snap percentage in both season 1 (difference of 23.1%, P < .001) and season 2 (difference of 24.0%, P < .001).

CONCLUSIONS

Athletes at the NFL Combine who previously underwent an ACLR had significantly lower early-career NFL player metrics, including fewer games started, fewer games played, and a lower snap percentage, than uninjured controls. Defensive linemen, defensive backs, and linebackers were the 3 most affected positions. Players with a prior ACLR and combined meniscal-chondral pathology had significantly lower numbers of games started and games played in seasons 1 and 2 and a significantly lower season 2 snap percentage.

LEVEL OF EVIDENCE

Level III, case-control study.

Alginate in Wound Dressings

Alginate is a biopolymer used in a variety of biomedical applications due to its favourable properties, such as biocompatibility and non-toxicity. It has been particularly attractive in wound healing applications to date. It can be tailored to materials with properties suitable for wound healing. Alginate has been used to prepare different forms of materials for wound dressings, such as hydrogels, films, wafers, foams, nanofibres, and in topical formulations. The wound dressings prepared from alginate are able to absorb excess wound fluid, maintain a physiologically moist environment, and minimize bacterial infections at the wound site. The therapeutic efficacy of these wound dressings is influenced by the ratio of other polymers used in combination with alginate, the nature of cross linkers used, the time of crosslinking, nature of excipients used, the incorporation of nanoparticles, and antibacterial agents. This review provides a comprehensive overview of the different forms of wound dressings containing alginate, in vitro, and in vivo results.

Energy Absorption Contribution and Strength in Female Athletes at Return to Sport After Anterior Cruciate Ligament Reconstruction: Comparison With Healthy Controls

Background:

Female patients are more likely to suffer a second anterior cruciate ligament (ACL) injury after ACL reconstruction (ACLR) and return to sport (RTS) compared with healthy female controls. Few studies have examined the energy absorption contribution (EAC) that could lead to this subsequent injury.

Hypothesis:

The ACLR group would demonstrate an altered EAC between joints (hip, knee, and ankle) but no difference in quadriceps, hip abduction, or hip external rotation (ER) strength at the time of RTS.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A total of 34 female participants (ACLR: n = 17; control: n = 17) were enrolled in the study and matched for age and activity level. Jump landing performance for the initial 50 milliseconds of landing of a lateral-vertical jump was assessed using a 10-camera 3-dimensional motion capture system and 2 force plates. Isokinetic quadriceps strength was measured using a Biodex machine, and hip abduction and ER isometric strength were measured using a handheld dynamometer. All values were normalized to the participant’s height and weight. A 1-way multivariate analysis of variance was used to assess between-group differences in the EAC at the hip, knee, and ankle. Two 1-way analyses of variance were used to independently examine quadriceps, hip abduction, and hip ER strength between the groups.

Results:

Significant differences in the EAC were found between the groups for the involved hip (P = .002), uninvolved hip (P = .005), and involved ankle (P = .023). There were no between-group differences in the EAC for the involved or uninvolved knee or the uninvolved ankle. Patients who underwent ACLR demonstrated significantly decreased quadriceps strength on the involved limb (P = .02) and decreased hip ER strength on both the involved (P = .005) and uninvolved limbs (P = .002). No significant strength differences were found between the groups for the uninvolved quadriceps or for involved or uninvolved hip abduction.

Conclusion:

At RTS, patients who underwent ACLR utilized a greater hip EAC bilaterally and a decreased involved ankle EAC during a lateral-vertical jump. Furthermore, quadriceps strength on the involved limb and hip ER strength of bilateral lower extremities remained decreased. This could place greater stress on the ACL graft and ultimately lead to an increased injury risk.

Deep Venous Thrombosis Prophylaxis in Anterior Cruciate Ligament Reconstructive Surgery: What Is the Current State of Practice?

Background:

Venous thromboembolism (VTE) is a significant perioperative risk with many common orthopaedic procedures. Currently, there is no standardized recommendation for the use of VTE prophylaxis during anterior cruciate ligament (ACL) reconstruction. This study sought to evaluate the current prophylactic practices of fellowship-trained sports medicine orthopaedic surgeons in the United States.

Hypothesis:

Very few surgeons use perioperative VTE prophylaxis for ACL reconstructive surgery.

Study Design:

Survey.

Methods:

Surveys were emailed to the alumni networks of 4 large ACGME-accredited sports medicine fellowship programs. Questions were focused on their current use of chemical and nonchemical VTE prophylaxis.

Results:

Surveys were completed by 142 surgeons in the United States, yielding a response rate of 32%. Of those who responded, 50.7% stated that they routinely use chemical prophylaxis, with 95.5% of those using aspirin (acetylsalicylic acid [ASA]). There was no standardized dosing protocol, with respondents using ASA 325 mg once (46%) or twice daily (26%) or ASA 81 mg once (18%) or twice (10%) daily. The most common reason for not including chemical prophylaxis within the reconstruction procedure was that it is unnecessary given the low risk of VTE. Physicians also based their prophylaxis regimen more on their own clinical experience than concern for litigation.

Conclusion:

Half of all sports medicine fellowship–trained surgeons surveyed routinely use chemical VTE prophylaxis after ACL reconstruction, with more than 90% of those using ASA. Of those using ASA, there was no prevailing dosing protocol. For those not using chemical prophylaxis, the most important reason was that it was felt to be unnecessary due to the risks outweighing the benefits. Those who do not regularly use chemical prophylaxis would be willing to, however, if a patient had a personal or family history of clotting disorder or is currently on birth control. Additionally, clinical experience was the primary driver for a current prophylaxis protocol.

Clinical Relevance:

This survey study evaluating the use of VTE prophylaxis with ACL reconstruction lends clinical insight to the current practice of a large, geographically diverse group of fellowship-trained sports medicine orthopaedic surgeons in the United States.

Autogenous Hamstring-Bone Graft Preparation for Anterior Cruciate Ligament Reconstruction

Despite the popularity of anterior cruciate ligament (ACL) reconstruction procedures, the ideal graft for reconstruction remains a matter of controversy. The ideal graft for ACL reconstruction should have histologic and biomechanical characteristics similar to those of the native ACL; should be quickly and fully incorporated within the bony tunnels; should maintain its viscoelastic properties for a long time; should have minimal donor-site morbidity; should be of sufficient length and diameter; should have minimal adverse effects on the extensor mechanism; should have no risk of rejection or disease transmission; and should be cost-effective and readily available. Synthetic grafts are not widely accepted because of their dangerous complications. The main sources of grafts for ACL reconstruction are allografts and autografts. Each type of graft has its own relative advantages and disadvantages. Allografts are not available in every country, besides being expensive, and there are many concerns regarding disease transmission. Autografts, particularly bone-patellar tendon-bone (BPTB), and hamstring tendon grafts have been the standard for ACL reconstruction. The main advantage of autogenous BPTB grafts is the direct bone-to-bone healing in the tunnel, whereas the main disadvantages of such grafts are related to donor-site morbidity, anterior knee pain, and extensor mechanism dysfunction. The popularity of autogenous hamstring tendon grafts for ACL reconstruction is increasing, but there are still concerns regarding the slow soft tissue-to-bone healing, with delayed healing and incorporation of the graft. We describe a technique for ACL reconstruction with autogenous hamstring-bone graft, aiming to produce a type of graft that combines the main advantages of BPTB and hamstring grafts, with avoidance of the main disadvantages of these 2 most commonly used graft types in ACL reconstruction.

Does the Utilization of Allograft Tissue in Medial Patellofemoral Ligament Reconstruction in Pediatric and Adolescent Patients Restore Patellar Stability?

BACKGROUND

Medial patellofemoral ligament (MPFL) reconstruction is one of several surgical procedures used to treat patellofemoral instability. Use of allograft tissue can preserve autogenous tissue and may be preferable in patients with connective tissue disorders or ligamentous laxity. Although there are successful reports in adults, it is unclear if the use of allograft tissue in MPFL reconstruction can restore patellofemoral stability in children and adolescents.

QUESTIONS/PURPOSES

(1) Does allograft tissue in MPFL reconstruction in pediatric and adolescent patients restore patellar stability? (2) What complications were associated with allograft MPFL reconstructions in children and adolescents?

METHODS

Between June 2012 and August 2015, one surgeon (NKP) performed 26 MPFL reconstructions in 23 patients with gracilis allograft for traumatic patellar instability. Of those, 25 (96%) were available for followup more than 1 year later (mean, 24 months; range, 12-44 months). During this time, the surgeon suggested reconstruction to patients who had recurrent dislocation or subluxation after 6 weeks of bracing, physical therapy, and activity modification if they were noted to have a torn or attenuated MPFL on MRI. During that period, this was the only surgical technique the surgeon used to treat traumatic patellar instability. Patients undergoing concurrent bony procedures were ineligible for inclusion. The mean age of the patients in the series was 16.0 (± 2) years. Age, sex, skeletal maturity, presence of trochlear dysplasia, and additional arthroscopic procedures at the time of reconstruction were collected. Postoperative notes and imaging were reviewed for presence of complications defined as recurrent dislocation, recurrent subluxations, fractures, infection, or arthrofibrosis. These complications were identified by chart review by the senior surgeon (NKP) and study personnel (EH) not involved in clinical care of the patients or by patient-reported complications. Recurrent subluxation or dislocation was patient-reported at the time of the clinic visit or followup phone/email contact. Fractures were defined as any cortical disruption in the femur or patella that required treatment (change in postoperative protocol), infection requiring treatment (antibiotics and/or return to the operating room), or arthrofibrosis (stiffness that necessitated a change in the postoperative protocol or manipulation under anesthesia).

RESULTS

Ninety-two percent (23 of 25) of patients reported no further instability episodes after MPFL reconstruction. Sixteen percent (four of 25) of patients had complications: two repeat episodes of patellar instability, one patella fracture, and one symptomatic hardware requiring interference screw removal. No patients developed arthrofibrosis or infection.

CONCLUSIONS

In this small case series, we found that MPFL reconstruction using allograft tissue in children and adolescents resulted in a low risk of recurrent instability, perhaps comparable to what has been published by others who have used autograft tissue. Longer followup is needed, because in some orthopaedic applications, allograft ligaments have been observed to attenuate over time. Future studies might compare these techniques using patient-reported outcomes scores as well as use a control group of patients with autograft tissue.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

The evaluation of muscle recovery after anatomical single-bundle ACL reconstruction using a quadriceps autograft

PURPOSE

The purpose of this study was to reveal the degree of muscle recovery and report the clinical results of anatomical single-bundle ACL reconstruction using a quadriceps autograft.

METHODS

Twenty subjects undergoing anatomical single-bundle ACL reconstruction using a quadriceps autograft were included in this study. A 5-mm-wide, 8-cm-long graft, involving the entire layer of the quadriceps tendon, was harvested without bone block. The average graft diameter was 8.1 ± 1.4 mm. An initial tension of 30 N was applied. The femoral tunnel was created from the far-medial portal. Each femoral and tibial tunnel was created close to the antero-medial bundle insertion site. For the evaluation of muscle recovery (quadriceps and hamstring), a handheld dynamometer was used. The evaluation of muscle recovery was performed pre-operatively, and at 3, 6, 9, and 12 months after surgery. Muscle recovery data were calculated as a percentage of leg strength in the non-operated leg. Anterior tibial translation (ATT), pivot shift test, and IKDC score were evaluated.

RESULTS

The average quadriceps strength pre-operatively, and at 3, 6, 9, and 12 months after ACL reconstruction was 90.5 ± 19, 67.8 ± 21.4, 84 ± 17.5, and 85.1 ± 12.6 %, respectively. The average hamstring strength pre-operatively, and at 3, 6, 9, and 12 months after ACL reconstruction was 99.5 ± 13.7, 78.7 ± 11.4, 90.5 ± 19, and 96.7 ± 13.8 %, respectively. ATT pre-operatively and at 12 months after surgery was 5.4 ± 1.3 and 1.0 ± 0.8 mm, respectively. No subjects exhibited positive pivot shift after surgery. Within 6 months following surgery, quadriceps hypotrophy was observed in all subjects. However, the hypotrophy had recovered at 12 months following surgery. No subjects complained of donor site pain after surgery.

CONCLUSION

Anatomical single-bundle ACL reconstruction using a quadriceps autograft resulted in equivalent level of muscle recovery and knee stability when compared with previously reported ACL reconstruction using hamstrings tendon with no donor site complications.

LEVEL OF EVIDENCE

Case controlled study, Level III.

Anterior cruciate ligament reconstruction: principles of treatment

Anterior cruciate ligament (ACL) reconstruction is one of the most common procedures in sports medicine. Several areas of controversy exist in ACL tear management which have engaged surgeons and researchers in debates towards identifying an ideal approach for these patients.

This instructional review discusses the principles of ACL reconstruction in an attempt to provide guidelines and initiate a critical thinking approach on the most common areas of controversy regarding ACL reconstruction.

Using high-level evidence from the literature, as presented in randomised controlled trials, systematic reviews, and meta-analyses, operative versus conservative treatment, timing of surgery, and rehabilitation are discussed. Also, the advantages and disadvantages of the most common types of autografts, such as patellar tendon and hamstrings as well as allografts are presented.

Key considerations for the anatomical, histological, biomechanical and clinical data (‘IDEAL’) graft positioning are reviewed.

Cite this article: Paschos NK, Howell SM. Anterior cruciate ligament reconstruction: principles of treatment. EFORT Open Rev 2016;398-408. DOI: 10.1302/2058-5241.1.160032.

A Biomechanical Comparison of Allograft Tendons for Ligament Reconstruction

BACKGROUND

Allograft tendons are frequently used for ligament reconstruction about the knee, but they entail availability and cost challenges. The identification of other tissues that demonstrate equivalent performance to preferred tendons would improve limitations. Hypothesis/Purpose: We compared the biomechanical properties of 4 soft tissue allograft tendons: tibialis anterior (TA), tibialis posterior (TP), peroneus longus (PL), and semitendinosus (ST). We hypothesized that allograft properties would be similar when standardized by the looped diameter.

STUDY DESIGN

Controlled laboratory study.

METHODS

This study consisted of 2 arms evaluating large and small looped-diameter grafts: experiment A consisted of TA, TP, and PL tendons (n = 47 each) with larger looped diameters of 9.0 to 9.5 mm, and experiment B consisted of TA, TP, PL, and ST tendons (n = 53 each) with smaller looped diameters of 7.0 to 7.5 mm. Each specimen underwent mechanical testing to measure the modulus of elasticity (E), ultimate tensile force (UTF), maximal elongation at failure, ultimate tensile stress (UTS), and ultimate tensile strain (UTε).

RESULTS

Experiment A: No significant differences were noted among tendons for UTF, maximal elongation at failure, and UTϵ. UTS was significantly higher for the PL (54 MPa) compared with the TA (44 MPa) and TP (43 MPa) tendons. E was significantly higher for the PL (501 MPa) compared with the TP (416 MPa) tendons. Equivalence testing showed that the TP and PL tendon properties were equivalent or superior to those of the TA tendons for all outcomes. Experiment B: All groups exhibited a similar E. UTF was again highest in the PL tendons (2294 N) but was significantly different from only the ST tendons (1915 N). UTϵ was significantly higher for the ST (0.22) compared with the TA (0.19) and TP (0.19) tendons. Equivalence testing showed that the TA, TP, and PL tendon properties were equivalent or superior to those of the ST tendons.

CONCLUSION

Compared with TA tendons, TP and PL tendons of a given looped diameter exhibited noninferior initial biomechanical strength and stiffness characteristics. ST tendons were mostly similar to TA tendons but exhibited a significantly higher elongation/UTϵ and smaller cross-sectional area. For smaller looped-diameter grafts, all tissues were noninferior to ST tendons. In contrast to previous findings, PL tendons proved to be equally strong.

CLINICAL RELEVANCE

The results of this study should encourage surgeons to use these soft tissue allografts interchangeably, which is important as the number of ligament reconstructions performed with allografts continues to rise.

Do Muscle Strength Deficits of the Uninvolved Hip and Knee Exist in Young Athletes Before Anterior Cruciate Ligament Reconstruction?

Background:

Muscle strength of the involved limb is known to be decreased after injury. Comparison with the uninvolved limb has become standard of practice to measure progress and for calculation of limb symmetry indices (LSIs) to determine readiness to return to sport. However, some literature suggests strength changes in the uninvolved limb also are present after lower extremity injury.

Purpose:

To examine the uninvolved limb strength in a population of adolescent athletes after an anterior cruciate ligament (ACL) injury and compare strength values with those of the dominant limb in a healthy control group.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A total of 64 athletes were enrolled in this study, including 31with injured ACLs (mean age, 15.6 ± 1.4 years) and 33 healthy controls (mean age, 14.9 ± 1.9 years). The median time from injury to testing was 23 days for the ACL-injured group. Participants underwent Biodex isokinetic strength testing at 60 deg/s to assess quadriceps and hamstring strength. Isometric hip strength (abduction, extension, external rotation) was measured using a handheld dynamometer. The muscle strength of the uninvolved limb of the ACL-injured group was compared with that of the dominant limb of the healthy control group.

Results:

The results showed a significant difference in quadriceps muscle strength between the 2 study groups (P < .001). Isokinetic quadriceps strength of the uninvolved limb in the ACL group was significantly decreased by 25.5% (P < .001) when compared with the dominant limb of the control group.

Conclusion:

The results of this study demonstrate a decreased isokinetic strength of the quadriceps muscle in the uninvolved limb after ACL injury as compared with healthy controls. Consideration should be taken when using the uninvolved limb for comparison when assessing quadriceps strength in a population with an ACL injury.

Technique for Arthroscopic-Assisted Primary Anterior Cruciate Ligament Reconstruction Using Doubled Tibialis Anterior Tendon

Advances in surgical technique and our knowledge of anterior cruciate ligament (ACL) anatomy have resulted in a marked increase in options for ACL reconstruction. Currently, patient age and activity level, surgeon preference and experience, and cost are factors influencing the type of reconstruction recommended to address knee instability. We present a simplified transtibial method of ACL reconstruction using a single-bundle, doubled tibialis anterior allograft. This method uses fixation with a suspensory device on the femur and a bio-composite interference screw on the tibia. We recommend this simplified technique for primary ACL reconstruction because it minimizes total steps, thus limiting variance, maximizing efficiency, and reducing potential technical error.