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Engler ID, Chang AY, Kaarre J, Shannon MF, Curley AJ, Smith CN, Hughes JD, Lesniak BP, Musahl V. Revision Rates After Primary Allograft ACL Reconstruction by Allograft Tissue Type in Older Patients. Orthop J Sports Med 2023; 11:23259671231198538. [PMID: 37731958 PMCID: PMC10508052 DOI: 10.1177/23259671231198538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/19/2023] [Indexed: 09/22/2023] Open
Abstract
Background While there is extensive literature on the use of allograft versus autograft in anterior cruciate ligament (ACL) reconstruction, there is limited clinical evidence to guide the surgeon in choice of allograft tissue type. Purpose To assess the revision rate after primary ACL reconstruction with allograft and to compare revision rates based on allograft tissue type and characteristics. Study Design Cohort study; Level of evidence, 3. Methods Patients who underwent primary allograft ACL reconstructions at a single academic institution between 2015 and 2019 and who had minimum 2-year follow-up were included. Exclusion criteria were missing surgical or allograft tissue type data. Demographics, operative details, and subsequent surgical procedures were collected. Allograft details included graft tissue type (Achilles, bone-patellar tendon-bone [BTB], tibialis anterior or posterior, semitendinosus, unspecified soft tissue), allograft category (all-soft tissue vs bone block), donor age, irradiation duration and intensity, and chemical cleansing process. Revision rates were calculated and compared by allograft characteristics. Results Included were 418 patients (age, 39 ± 12 years; body mass index, 30 ± 9 kg/m2). The revision rate was 3% (11/418) at a mean follow-up of 4.9 ± 1.4 years. There were no differences in revision rate according to allograft tissue type across Achilles tendon (3%; 3/95), BTB (5%; 3/58), tibialis anterior or posterior (3%; 5/162), semitendinosus (0%; 0/46), or unspecified soft tissue (0%; 0/57) (P = .35). There was no difference in revision rate between all-soft tissue versus bone block allograft (6/283 [2%] vs 5/135 [4%], respectively; P = .34). Of the 51% of grafts with irradiation data, all grafts were irradiated, with levels varying from 1.5 to 2.7 Mrad and 82% of grafts having levels of <2.0 Mrad. There was no difference in revision rate between the low-dose and medium-to high-dose irradiation cohorts (4% vs 6%, respectively; P = .64). Conclusion Similarly low (0%-6%) revision rates after primary ACL reconstruction were seen regardless of allograft tissue type, bone block versus all-soft tissue allograft, and sterilization technique in 418 patients with mean age of 39 years. Surgeons may consider appropriately processed allograft tissue with or without bone block when indicating ACL reconstruction in older patients.
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Affiliation(s)
- Ian D. Engler
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Central Maine Healthcare Orthopedics, Central Maine Medical Center, Lewiston, Maine, USA
| | - Audrey Y. Chang
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Janina Kaarre
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Michael F. Shannon
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andrew J. Curley
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Clair N. Smith
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jonathan D. Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bryson P. Lesniak
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Hulet C, Sonnery-Cottet B, Stevenson C, Samuelsson K, Laver L, Zdanowicz U, Stufkens S, Curado J, Verdonk P, Spalding T. The use of allograft tendons in primary ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2019; 27:1754-1770. [PMID: 30830297 DOI: 10.1007/s00167-019-05440-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 02/22/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE Graft choice in primary anterior cruciate ligament (ACL) reconstruction remains controversial. The use of allograft has risen exponentially in recent years with the attraction of absent donor site morbidity, reduced surgical time and reliable graft size. However, the published evidence examining their clinical effectiveness over autograft tendons has been unclear. The aim of this paper is to provide a current review of the clinical evidence available to help guide surgeons through the decision-making process for the use of allografts in primary ACL reconstruction. METHODS The literature in relation to allograft healing, storage, sterilisation, differences in surgical technique and rehabilitation have been reviewed in addition to recent comparative studies and all clinical systematic reviews and meta-analyses. RESULTS Early reviews have indicated a higher risk of failure with allografts due to association with irradiation for sterilisation and where rehabilitation programs and post-operative loading may ignore the slower incorporation of allografts. More recent analysis indicates a similar low failure rate for allograft and autograft methods of reconstruction when using non-irradiated allografts that have not undergone chemically processing and where rehabilitation has been slower. However, inferior outcomes with allografts have been reported in young (< 25 years) highly active patients, and also when irradiated or chemically processed grafts are used. CONCLUSION When considering use of allografts in primary ACL reconstruction, use of irradiation, chemical processing and rehabilitation programs suited to autograft are important negative factors. Allografts, when used for primary ACL reconstruction, should be fresh frozen and non-irradiated. Quantification of the risk of use of allograft in the young requires further evaluation. LEVELS OF EVIDENCE III.
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Affiliation(s)
- Christophe Hulet
- Department of Orthopedics and Traumatology, Caen University Hospital, Avenue Cote de Nacre, 14000, Caen, France
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hôpital Privé Jean Mermoz, Lyon, France
| | - Ciara Stevenson
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK
| | - Kristian Samuelsson
- Sahlgrenska University Hospital, Mölndal, Sweden
- Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lior Laver
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK
| | - Urszula Zdanowicz
- Carolina Medical Center, Pory 78, 02-757, Warsaw, Poland
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Suite 300, Pittsburgh, PA, 15219-3110, USA
| | - Sjoerd Stufkens
- Academic Medical Center Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Jonathan Curado
- Department of Orthopedics and Traumatology, Caen University Hospital, Avenue Cote de Nacre, 14000, Caen, France
| | - Peter Verdonk
- Antwerp Orthopedic Center, Monica Hospitals, Antwerp, Belgium
| | - Tim Spalding
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK.
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Aynardi M, Zahoor T, Mitchell R, Loube J, Feltham T, Manandhar L, Paudel S, Schon L, Zhang Z. Orthotopic Transplantation of Achilles Tendon Allograft in Rats: With or without Incorporation of Autologous Mesenchymal Stem Cells. Cell Transplant 2019; 27:245-255. [PMID: 29637821 PMCID: PMC5898692 DOI: 10.1177/0963689717745891] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The biology and function of orthotopic transplantation of Achilles tendon allograft are unknown. Particularly, the revitalization of Achilles allograft is a clinical concern. Achilles allografts were harvested from donor rats and stored at -80 °C. Subcutaneous adipose tissue was harvested from the would-be allograft recipient rats for isolation of mesenchymal stem cells (MSCs). MSCs were cultured with growth differentiation factor-5 (GDF-5) and applied onto Achilles allografts on the day of transplantation. After the native Achilles tendon was resected from the left hind limb of the rats, Achilles allograft, with or without autologous MSCs, was implanted and sutured with calf muscles proximally and calcaneus distally. Animal gait was recorded presurgery and postsurgery weekly. The animals were sacrificed at week 4, and the transplanted Achilles allografts were collected for biomechanical testing and histology. The operated limbs had altered gait. By week 4, the paw print intensity, stance time, and duty cycle (percentage of the stance phase in a step cycle) of the reconstructed limbs were mostly recovered to the baselines recorded before surgery. Maximum load of failure was not different between Achilles allografts, with or without MSCs, and the native tendons. The Achilles allograft supplemented with MSCs had higher cellularity than the Achilles allograft without MSCs. Deposition of fine collagen (type III) fibers was active in Achilles allograft, with or without MSCs, but it was more evenly distributed in the allografts that were incubated with MSCs. In conclusion, orthotopically transplanted Achilles allograft healed with host tissues, regained strength, and largely restored Achilles function in 4 wk in rats. It is therefore a viable option for the reconstruction of a large Achilles tendon defect. Supplementation of MSCs improved repopulation of Achilles allograft, but large animal models, with long-term follow up and cell tracking, may be required to fully appreciate the functional benefits of MSCs.
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Affiliation(s)
| | | | - Reed Mitchell
- 3 MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Jeffrey Loube
- 3 MedStar Union Memorial Hospital, Baltimore, MD, USA
| | | | | | | | - Lew Schon
- 3 MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Zijun Zhang
- 3 MedStar Union Memorial Hospital, Baltimore, MD, USA
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Weber AE, Mayer EN, Nathani A, Chen DX, Kelly AM, Rodeo SA, Bedi A. How Variable Are Achilles Allografts Used for Anterior Cruciate Ligament Reconstruction? A Biomechanical Study. Am J Sports Med 2018; 46:1870-1876. [PMID: 29741921 DOI: 10.1177/0363546518768780] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Allograft tendon used in anterior cruciate ligament reconstruction (ACLR) requires sterilization before implantation. Low-dose gamma irradiation is a means of sterilization that may minimize tissue damage. PURPOSE To quantify the variability in mechanical properties between low-dose irradiated Achilles tendon allografts used for ACLR. STUDY DESIGN Descriptive laboratory study. METHODS A total of 15 intact outer-third Achilles tendon allograft specimens were collected from the remains of full Achilles allografts used for intraoperative ACLR at a single hospital. All grafts were obtained from a single tissue bank and underwent proprietary disinfection and low-dose gamma irradiation (1.5-2.5 Mrad). Biomechanical testing was carried out to measure tendon elongation, failure location during tensile testing, maximum stress, maximum strain, and modulus of elasticity. The mean and standard deviation were calculated for each outcome measure, and the variability between specimens was calculated by the coefficient of variation (CV). The effect of donor age on graft material properties was examined by use of linear regression. One-way analysis of variance was performed to compare differences in the mechanical properties across failure locations. RESULTS During cyclic testing, tendon elongation averaged 1.4% ± 1.6% with a CV of 118%. During failure testing, the maximum stress averaged 12.2 ± 4.1 MPa, maximum strain averaged 21.0% ± 6.3%, and modulus of elasticity averaged 95.5 ± 30.8 MPa. The CVs for maximum stress, maximum strain, and modulus of elasticity were 34%, 30%, and 32%, respectively. Ten tendons failed in the midsubstance and 5 failed at the tendon-bone enthesis. No differences were noted in mechanical properties between grafts that failed in the midsubstance versus those that failed at the enthesis. Donor age did not correlate with allograft elongation during cyclic load or any of the material property measures during failure testing. CONCLUSION The variabilities in the material properties and graft elongation during cyclic loading of Achilles tendon allografts used in ACLR fall within the range of properties reported in the literature for other ACLR allografts. Material properties do not differ by donor age or graft failure location observed during failure testing. CLINICAL RELEVANCE Surgeons should be aware that there exists considerable variation in the mechanical properties of Achilles allograft tendons used for ACLR. This variability is difficult to detect by tissue bank screening or the treating surgeon's inspection and may contribute to the heterogeneity in outcomes of allograft ACLR.
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Affiliation(s)
- Alexander E Weber
- Section of Sports Medicine, Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, USA
| | - Erik N Mayer
- Section of Sports Medicine, Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, USA
| | - Amit Nathani
- Section of Sports Medicine, Medsport, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Dan X Chen
- Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Anne M Kelly
- Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Scott A Rodeo
- Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Asheesh Bedi
- Section of Sports Medicine, Medsport, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Katagiri H, Koga H, Muneta T. Review of Shino et al (1984) on anterior cruciate ligament reconstruction using allograft in the dog. J ISAKOS 2018. [DOI: 10.1136/jisakos-2017-000131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Can a Biodegradable Implanted Bilayered Drug Delivery System Loaded with BMP-2/BMP-12 Take an Effective Role in the Biological Repair Process of Bone-Tendon Injuries? A Preliminary Report. JOURNAL OF PHARMACEUTICS 2017; 2017:7457865. [PMID: 28660091 PMCID: PMC5474233 DOI: 10.1155/2017/7457865] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 03/20/2017] [Indexed: 12/18/2022]
Abstract
Background Use of biodegradable and biocompatible materials in the orthopedic surgery is gaining popularity. In this research, the rate of controlled release of a bilayered prototype biomaterial designed to promote osteoblastic and tenoblastic activity was calculated using pharmacochemical methods. Methods The first part of the design, composed of a sodium tetraborate, polyvinyl alcohol, and starch based hydrogel, was loaded with bone morphogenic protein-2. The second part which was composed of a sodium tetraborate, polyvinyl alcohol, and chitosan based hydrogel was loaded with bone morphogenic protein-12. Osteochondral and tendon tissue specimens were obtained from patients with a diagnosis of gonarthrosis and primary bone cells and tendon cells cultures were prepared following treatment with collagenase enzyme. Cell samples were collected from the groups by means of an invert light microscope and environmental scanning electron microscope underwent at the 1st and 21st days. The level of osteogenic differentiation was measured by the activity of alkaline phosphatase. For the statistical evaluation of the obtained data, groups were compared with post hoc Tukey test following analysis of variance. Level of significance was accepted to be <0,01. Results Both osteogenic and tenogenic stimulation were observed in the cultured specimens. In comparison to the control groups, the rate of proliferation of healthy cells was found to be higher in the groups to which the design was added (p < 0.01). Conclusions Our research is a preliminary report that describes a study conducted in an in vitro experimental setting. We believe that such prototype systems may be pioneers in targeted drug therapies after reconstructional surgeries.
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Niu Y, Niu C, Wang X, Liu J, Cao P, Wang F, Niu J. Improved ACL reconstruction outcome using double-layer BPTB allograft compared to that using four-strand hamstring tendon allograft. Knee 2016; 23:1093-1097. [PMID: 27802924 DOI: 10.1016/j.knee.2016.06.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 06/14/2016] [Accepted: 06/23/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND This study compared the clinical outcomes of anterior cruciate ligament reconstruction using double-layer bone-patellar tendon-bone (DBPTB) allografts and four-strand hamstring (4SHS) grafts. METHODS This prospective randomized controlled trial included 101 patients. Of these, 50 patients received DBPTB allografts, and 51 received 4SHS grafts. Evaluations included KT-1000 arthrometer measurements, Lachman tests, pivot-shift tests, the International Knee Documentation Committee (IKDC) classification and Lysholm scores at three year postoperative follow-up. RESULTS Two DBPTB patients (four percent) and nine 4SHS patients (17.6%) had graft failures, which was significantly different (P=0.028). The DBPTB group had significantly better Lachman test, IKDC knee score and Lysholm score results than the 4SHS group (P<0.05). However, these differences were below the threshold for clinical significance. CONCLUSIONS DBPTB allografts had fewer graft failures at three years than 4SHS grafts for anterior cruciate ligament reconstruction; and there were statistically significant differences but not clinically significant differences between DBPTB and 4SHS grafts in terms of the KT1000 test, IKDC and Lysholm scores.
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Affiliation(s)
- Yingzhen Niu
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Hebei, China
| | - Chao Niu
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Hebei, China
| | - Xiaomeng Wang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Hebei, China
| | - Junhang Liu
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Hebei, China
| | - Pengkai Cao
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Hebei, China
| | - Fei Wang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Hebei, China.
| | - Jinghui Niu
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Hebei, China
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Makhni EC, Padaki AS, Petridis PD, Steinhaus ME, Ahmad CS, Cole BJ, Bach BR. High Variability in Outcome Reporting Patterns in High-Impact ACL Literature. J Bone Joint Surg Am 2015; 97:1529-42. [PMID: 26378269 DOI: 10.2106/jbjs.o.00155] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND ACL (anterior cruciate ligament) reconstruction is one of the most commonly performed and studied procedures in modern sports medicine. A multitude of objective and subjective patient outcome measures exists; however, nonstandardized reporting patterns of these metrics may create challenges in objectively analyzing pooled results from different studies. The goal of this study was to document the variability in outcome reporting patterns in high-impact orthopaedic studies of ACL reconstruction. METHODS All clinical studies pertaining to ACL reconstruction in four high-impact-factor orthopaedic journals over a five-year period were reviewed. Biomechanical, basic science, and imaging studies were excluded, as were studies with fewer than fifty patients, yielding 119 studies for review. Incorporation of various objective and subjective outcomes was noted for each study. RESULTS Substantial variability in reporting of both objective and subjective measures was noted in the study cohort. Although a majority of studies reported instrumented laxity findings, there was substantial variability in the type and method of laxity reporting. Most other objective outcomes, including range of motion, strength, and complications, were reported in <50% of all studies. Return to pre-injury level of activity was infrequently reported (24% of studies), as were patient satisfaction and pain assessment following surgery (8% and 13%, respectively). Of the patient-reported outcomes, the International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores were most often reported (71%, 63%, and 42%, respectively). CONCLUSIONS Substantial variability in outcome reporting patterns exists among high-impact studies of ACL reconstruction. Such variability may create challenges in interpreting results and pooling them across different studies.
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Affiliation(s)
- Eric C Makhni
- Departments of Orthopaedics and Sports Medicine, Rush University Medical Center, 1611 West Harrison, Suite 300, Chicago, IL 60612. E-mail address for E.C. Makhni:
| | - Ajay S Padaki
- Columbia University Medical Center, 622 West 168th Street, PH-1130, New York, NY 10032
| | - Petros D Petridis
- Columbia University Medical Center, 622 West 168th Street, PH-1130, New York, NY 10032
| | | | - Christopher S Ahmad
- Columbia University Medical Center, 622 West 168th Street, PH-1130, New York, NY 10032
| | - Brian J Cole
- Departments of Orthopaedics and Sports Medicine, Rush University Medical Center, 1611 West Harrison, Suite 300, Chicago, IL 60612. E-mail address for E.C. Makhni:
| | - Bernard R Bach
- Departments of Orthopaedics and Sports Medicine, Rush University Medical Center, 1611 West Harrison, Suite 300, Chicago, IL 60612. E-mail address for E.C. Makhni:
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Lubowitz JH, Provencher MT, Poehling GG. Climbing the level of evidence ladder: prospective, comparative-effectiveness knee ACL and PCL research. Arthroscopy 2013; 29:399-400. [PMID: 23544682 DOI: 10.1016/j.arthro.2012.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 12/10/2012] [Indexed: 02/02/2023]
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