Is there a higher failure rate of allografts compared with autografts in anterior cruciate ligament reconstruction: a systematic review of overlapping meta-analyses

Outcomes of ACL Reconstruction Utilizing Supercritical CO2-Sterilized Allografts

Background

Allograft tendons are perceived to have a high ACL graft failure rate in primary anterior cruciate ligament (ACL) reconstruction (ACLR). Historical series may be biased by graft processing methods that degrade the biomechanical properties of donor tendons such as irradiation. Supercritical carbon dioxide (SCCO2) is a validated method of terminally sterilizing biomaterials at physiological temperatures without irradiation, but in vivo use of SCCO2-processed tendon allografts for primary ACLR has not been reported to date.

Hypothesis

ACLR with SCCO2 allografts would result in acceptable failure rates, subjective knee scores, and clinical evaluation at 2 years postoperatively.

Study Design

Case series; Level of evidence, 4.

Methods

Patients underwent primary ACLR with terminally sterilized SCCO2-processed human gracilis, peroneus longus, semitendinosus, tibialis anterior, and tibialis posterior tendon allografts. Patient demographics were collected, along with tendon donor age and sex. At 1 year postoperatively, subjective International Knee Documentation Committee (IKDC) and ACL-Return to Sport After Injury (ACL-RSI) scores were collected, as well as clinical evaluation. At 2 years postoperatively, the IKDC and ACL-RSI scores were repeated, and return to sports and further knee injuries were recorded.

Results

A total of 144 patients with a medianage of 26 (IQR 14) years formed the study group. Patients were predominately male (58%). The loss to follow-up rate was 8% (n = 12). The mean age of allograft tendon donors was 37 (range 17-58) years, and the majority were male (83%). The mean allograft diameter was 8.9 ± 1.0 mm. At 2 years, ACL graft failureoccurred in 5% (n = 7). All graft failureswere in patients aged ≤25 years (P = .007). Neither donor age (≤40 or >40 years) nor donor sex was associated with graft failure (P > .05). The median IKDC subjective score was 95 and ACL-RSI score was 75. There were no revisions for sepsis within the first 2 years postoperatively.

Conclusion

SCCO2 processing of allograft tendons demonstrated satisfactory clinical and patient-reported outcomes at 24 months postoperatively in a consecutive series of patients with primary ACLR, with similar ACL graft failure rates and subjective knee scores compared with those reported in published series of hamstring tendon autograft and fresh frozen nonirradiated allograft.

Cartilage fragments combined with BMSCs-Derived exosomes can promote tendon-bone healing after ACL reconstruction

Anterior cruciate ligament reconstruction (ACLR) often fails due to the inability of tendon-bone integration to regenerate normal tissues and formation of fibrous scar tissues in the tendon-bone interface. Cartilage fragments and exosomes derived from bone mesenchymal stromal cells (BMSCs-Exos) can enhance enthesis healing. Nevertheless, the effects on the tendon-bone healing of ACLR remain unknown. This study found that BMSCs-Exos can promote the proliferation of chondrocytes in cartilage fragments, and activated the expression of chondro-related genes SOX9 and Aggrecan. The optimal effect concentration was 1012 events/uL. Besides, BMSCs-Exos could significantly upregulated the expression of BMP7 and Smad5 in cartilage fragments, and further enhanced the expression of chondrogenic genes. Moreover, this study established a rat model of ACLR and implanted the BMSCs-Exos/cartilage fragment complex into the femoral bone tunnel. Results demonstrated that the mean diameters of the femoral bone tunnels were significantly smaller in the BE-CF group than those in the CF group (p = 0.038) and control group (p = 0.007) at 8 weeks after surgery. Besides, more new bone formation was observed in the femoral tunnels in the BE-CF group, as demonstrated by a larger BV/TV ratio based on the reconstructed CT scans. Histological results also revealed the regeneration of tendon-bone structures, especially fibrocartilage. Thus, these findings provide a promising result that BMSCs-Exos/cartilage fragment complex can prevent the enlargement of bone tunnel and promote tendon-bone healing after ACLR, which may have resulted from the regulation of the BMP7/Smad5 signaling axis.

Minimally Invasive Knee Lateral Collateral Ligament Reconstruction Using Partial Biceps Femoris Tendon Autograft

Lateral collateral ligament (LCL) is known as an important ligament to restrain varus force of the knee, especially in 30° knee flexion. From the anatomical study, the insertion of LCL at proximal fibula is intimately close to the insertion of biceps femoris (BF) tendon. Since LCL is infrequently injured in isolation, and with limitation in availability of autograft and allograft, this study proposes the partial anterior BF tendon as an alternative autograft source to reconstruct the LCL. This could be performed either by minimally invasive procedure or standard open technique. The core concept is to preserve the posterior part of the BF tendon to protect the peroneal nerve, by which exploration of this nerve and the proximal fibula prior to LCL reconstruction could be exempted. Minimally invasive LCL reconstruction using this autograft would essentially reduce soft tissue injury, shorten the operative time, and enhance recovery of the reconstructed knee.

Comparison of clinical outcomes of using the nonirradiated and irradiated allograft for anterior cruciate ligament (ACL) reconstruction: A systematic review update and meta-analysis

BACKGROUND

This study was a systematic review comparing the clinical outcomes of using the nonirradiated and irradiated allograft for anterior cruciate ligament (ACL) reconstruction.

METHODS

A comprehensive literature search was conducted using multiple databases, including Medline, Embase, and Cochrane. All databases were searched from the earliest records through August 2019 using the following Boolean operators: irradiated AND nonirradiated AND ACL AND allograft. All prospective and retrospective controlled trials were retrieved that directly compared physical examination and knee function scores and patient-rated outcomes between the nonirradiated and irradiated allograft for ACL reconstruction.

RESULTS

Three prospective and 2 retrospective articles were identified by the search, and the findings suggested that the nonirradiated allografts were superior to the irradiated allografts based on improved knee joint functional scores and decreased failure rate, even though there was no significantly difference with respect to overall IKDC, range of motion, vertical jump test, and one-leg hop test.

CONCLUSIONS

Irradiated allograft should be limited to be used in ACL surgery and further research into new alternative sterilization techniques are needed to avoiding the disease transmission without interference with the biomechanical properties of the grafts.

Graft Choice for Anterior Cruciate Ligament Reconstruction in Women Aged 25 Years and Younger: A Systematic Review

CONTEXT

Although anterior cruciate ligament (ACL) tears are relatively common in athletic populations, few studies have systematically reviewed graft choice in young women.

OBJECTIVE

To quantitatively and qualitatively examine reported outcomes for graft choice in women aged 25 years and younger undergoing primary ACL reconstruction.

DATA SOURCE

A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. An electronic search in the PubMed (includes MEDLINE) and EMBASE databases was completed using a combination of key terms.

STUDY SELECTION

Studies were included if they reported graft choice outcomes in women aged 25 years and younger.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

The following information was extracted: title, author, year of publication, number of female patients and age, graft type, follow-up, and patient-reported outcome measures. The following outcome scores were identified as being reported or not reported by each study: graft failure, contralateral ACL (CACL) rupture, IKDC (International Knee Documentation Committee), graft survival (Kaplan-Meier), Lysholm, Tegner, KT-1000, kneeling pain, return to sport, and Lachman.

RESULTS

Of 1170 identified articles, 16 met inclusion criteria, reporting on 1385 female patients aged 25 years and younger. Comparison of 655 bone-patellar tendon-bone (BPTB) versus 525 hamstring tendon (HT) autografts showed significant differences in mean failure rate between BPTB autografts (6.13% ± 2.58%) and HT autografts (17.35% ± 8.19%), P = 0.001. No statistically significant differences in CACL failure rates were found between BPTB autografts and HT autografts (P = 0.25). Pooled results for IKDC were possible in 3 of the HT autograft studies, showing a mean score of 88.31 (95% CI 83.53-93.08). Pooled Lysholm score results were possible in 2 of the HT autograft studies, showing a mean score of 93.46 (95% CI 91.90-95.01).

CONCLUSION

In female patients aged 25 years and younger, BPTB autografts showed significantly less graft failure compared with HT autografts. However, BPTB autografts had comparable patient-reported outcomes compared with HT autografts with the available data. The overall state of evidence for graft choice in female patients aged 25 years and younger is low. Future studies should report statistics by age and sex to allow for further analysis of graft choice for this specific population that is known to be more vulnerable to ACL injury.

Failure and Complication Rates in Common Sports and Arthroscopic Procedures: Reality Check

Expectations following sports medicine and arthroscopic procedures have been elevated because of captivating modern-day media coverage of high-profile athletic injuries, surgery, and rapid return to sports. Unfortunately, this general perception may be misleading, and orthopedic sports medicine physicians must be aware of the harsh reality of the trials and tribulations associated with the subspecialty. The purpose of this review article is to provide an updated brief overview of the complications and failure rates associated with common arthroscopic procedures including rotator cuff repair, biceps tenodesis, Bankart procedure, Latarjet procedure, anterior cruciate ligament reconstruction, anterior cruciate ligament repair, meniscal repair, tibial tubercle osteotomy, and medial patellofemoral ligament reconstruction. Highlighting the complications is the first step toward early recognition, enhancing preventative measures, and successful management.

Optimizing anterior cruciate ligament reconstruction: Individualizing the decision-making process using data from the Kaiser Permanente ACLR Registry: 2018 OREF award paper

Despite years of study, controversy remains regarding the optimal graft for anterior cruciate ligament reconstruction (ACLR), suggesting that a single graft type is not ideal for all patients. A large community based ACLR Registry that collects prospective data is a powerful tool that captures information and can be analyzed to optimize surgery for individual patients. The studies highlighted in this paper were designed to optimize and individualize ACLR surgery and have led to changes in surgeon behavior and improvements in patient outcomes. Kaiser Permanente (KP) is an integrated health care system with 10.6 million members and more than 50 hospitals. Every KP member who undergoes an ACLR is entered into the Registry, and prospectively monitored. The Registry uses a variety of feedback mechanisms to disseminate Registry findings to the ACLRR surgeons and appropriately influence clinical practices and enhance quality of care. Allografts were found to have a 3.0 times higher risk of revision than bone-patellar tendon-bone (BPTB) autografts. Allograft irradiation >1.8 Mrad, chemical graft processing, younger patients, BPTB allograft, and male patients were all associated with a higher risk of revision surgery. By providing feedback to surgeons, overall allograft use has decreased by 27% and allograft use in high-risk patients ≤21 years of age decreased 68%. We have identified factors that influence the outcomes of ACLR. Statement of Clinical Significance: We found that information derived from an ACLR Registry and shared with the participating surgeons directly decreased the use of specific procedures and implants associated with poor outcomes.

All-Autograft Multiligament Knee Reconstruction of the Posterior Cruciate Ligament, Anterior Cruciate Ligament, and Posterolateral Corner (KD-IIIL)

Multiligament knee reconstruction constitutes a challenging entity. While allograft use gained popularity in this scenario because it can reduce surgery time and the risk of donor-site morbidities, in some places high-quality allografts are not readily available. In addition, allografts are subjected to some disadvantages compared with autografts, including slower biological incorporation and risk of disease transmission. Choosing and using wisely autografts to address these cases becomes valuable for these reasons. In this manuscript a technique is described for performing all-autograft multiligament knee reconstruction of the posterior cruciate ligament, anterior cruciate ligament and posterolateral corner.

A Systematic Review of Risk Factors for Anterior Cruciate Ligament Reconstruction Failure

Although most studies have introduced risk factors related to anterior cruciate ligament reconstruction failure, studies on combinations of high-risk factors are rare. To provide a systematic review of the risk factors of anterior cruciate ligament reconstruction failure to guide surgeons through the decision-making process, an extensive literature search was performed of the Medline, Embase and Cochrane Library databases. Studies published between January 1, 2009, and September 19, 2019, regarding the existing evidence for risk factors of anterior cruciate ligament reconstruction failure or graft failure were included in this review. Study quality was evaluated with the quality index. Ultimately, 66 articles met our criteria. There were 46 cases classified as technical factors, 21 cases as patient-related risk factors, and 14 cases as status of the knee joint. Quality assessment scores ranged from 14 to 24. This systematic review provides a comprehensive summary of the risk factors for anterior cruciate ligament reconstruction failure, including technical factors, patient-related factors, and the factors associated with the status of the knee joint. Emphasis should be placed on avoiding these high-risk combinations or correcting modifiable risk factors during preoperative planning to reduce the rate of graft rupture and anterior cruciate ligament reconstruction failure.

Clinical outcome after knee ligament reconstruction with tendon allografts

PURPOSE

The purpose of this study is to investigate the clinical outcome for patients after knee ligament reconstructions with allografts at a university hospital.

METHODS

A total of 33 patients received allografts for reconstructive knee surgery between 2007 and 2017. The follow up evaluation consisted of a clinical knee examination including evaluation of range of motion (ROM), lateral and medial laxity, the Lachman test, the Pivot shift test, the sag test, the posterior drawer test and checking for patellofemoral pain. The following patient-reported outcome measures (PROMs) were used; the Lysholm Function Score, the Tegner activity score, and the Knee injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

Twenty-one (64%) patients were available for the follow-up evaluation and the mean follow-up time was 4.8 years. A total of 16 out of 21 patients had multiligament injuries of which the ACL was the ligament most frequently ruptured. At the time of follow-up, 14 out of 16 patients (87%) with ACL injury had Lachman test grade 0 or grade 1 + , and 12 out of 13 (92%) had a pivot shift grade 0 or 1 + . The mean Lysholm Score was 74. All mean KOOS subscale values were ≥ 59 at the follow-up. The preoperative Tegner activity score was 3 (range, 1-6) and 4 (range, 2-6) at follow up. There were no deep postoperative infections. A total of 19 out of 21 patients (90%) reported that they would have undergone surgery again had they known the clinical outcome in advance.

CONCLUSIONS

The patients improved from the preoperative score to the follow-up score in the knee-related Quality of Life (QoL) KOOS subscale. None of the patients were diagnosed with deep postoperative infections.

Maturity Progression of the Entire Anterior Cruciate Ligament Graft of Insertion-Preserved Hamstring Tendons by 5 Years: A Prospective Randomized Controlled Study Based on Magnetic Resonance Imaging Evaluation

BACKGROUND

It has been reported that insertion-preserved hamstring tendon autografts (IP-HT) have better maturity than free hamstring tendon autografts (FHT) at 2 years after anterior cruciate ligament reconstruction (ACLR); however, whether insertion preservation improves the maturity of the entire autograft and clinical outcomes at 5 years after ACLR is still unclear.

PURPOSE

To investigate the clinical outcomes and maturity of different segments using insertion-preserved and free hamstring tendon autografts up to 5 years after ACLR.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

45 patients who underwent isolated ACLR with hamstring tendon autografts were enrolled and randomized into 2 groups. The study group had ACLR with IP-HT, whereas the control group had ACLR with FHT. The International Knee Documentation Committee and Tegner scores, Lysholm activity score, and KT-1000 arthrometer measurements were evaluated preoperatively and at 6, 12, 24, and 60 months postoperatively. Three-dimensional-reconstruction MRI examinations were performed at 6, 12, 24, and 60 months to evaluate the signal/noise quotient (SNQ) values of femoral tunnel graft, intra-articular graft, and tibial tunnel graft.

RESULTS

At 60 months, the SNQ values of the intra-articular and tunnel sections for the grafts in both groups showed no difference; the clinical outcomes were improved compared with before surgery (P < .001) and were similar in both groups. In the early stage, all graft segments in the IP-HT group had lower SNQ values than those of the FHT group. At 6 months, the entire graft in the FHT group and the femoral tunnel section in the IP-HT group had the maximum SNQ values, whereas the femoral tunnel graft had the highest SNQ value compared with intra-articular and tibial tunnel graft in each group. SNQ values of the intra-articular and tibial tunnel graft in the IP-HT group had no significant change within 60 months.

CONCLUSION

All patients had similar clinical outcomes and graft maturity at 60 months postoperatively. The SNQ values and progressions varied at different graft sites and were highest for the femoral tunnel graft. All significantly changing SNQ values reached the maximum value at 6 months. Compared with FHT autograft, the graft maturity of IP-HT autograft recovered earlier and appeared more stable within the 60-month follow-up; however, no significant association was found between graft maturity and clinical scores.

Transphyseal anterior cruciate ligament reconstruction using living parental donor hamstring graft: excellent clinical results at 2 years in a cohort of 100 patients

PURPOSE

To determine outcomes of transphyseal ACL reconstruction using a living parental hamstring tendon allograft in a consecutive series of 100 children.

METHODS

One hundred consecutive juveniles undergoing ACL reconstruction with a living parental hamstring allograft were recruited prospectively and reviewed 2 years after ACL reconstruction with IKDC Knee Ligament Evaluation, and KT1000 instrumented laxity testing. Skeletally immature participants obtained annual radiographs until skeletal maturity, and long leg alignment radiographs at 2 years. Radiographic Posterior tibial slope was recorded.

RESULTS

Of 100 juveniles, the median age was 14 years (range 8-16) and 68% male. At surgery, 30 juveniles were graded Tanner 1 or 2, 21 were Tanner 3 and 49 were Tanner 4 or 5. There were no cases of iatrogenic physeal injury or leg length discrepancy on long leg radiographs at 2 years, despite a median increase in height of 8 cm. Twelve patients had an ACL graft rupture and 9 had a contralateral ACL injury. Of those without further ACL injury, 82% returned to competitive sports, IKDC ligament evaluation was normal in 52% and nearly normal in 48%. The median side to side difference on manual maximum testing with the KT1000 was 2 mm (range - 1 to 5). A radiographic PTS of 12° or more was observed in 49%.

CONCLUSIONS

ACL reconstruction in the juvenile with living parental hamstring tendon allograft is a viable procedure associated with excellent clinical stability, patient-reported outcomes and return to sport over 2 years. Further ACL injury to the reconstructed and the contralateral knee remains a significant risk, with identical prevalence observed between the reconstructed and contralateral ACL between 12 and 24 months after surgery.

LEVEL OF EVIDENCE

III (Cohort Study).

Allograft Donor Characteristics Significantly Influence Graft Rupture After Anterior Cruciate Ligament Reconstruction in a Young Active Population

BACKGROUND

Graft selection in anterior cruciate ligament (ACL) surgery can be difficult in a young active population given their high rates of reinjury. Allografts allow for control over graft size and reduce morbidity of autograft harvest. There are mixed results about the use of allograft in the literature; however, the influence of the properties of the allograft on outcomes has not been considered.

HYPOTHESIS

ACL reconstruction with allografts from older donors will have a higher rate of graft rupture when compared with allograft from young donors.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients (N = 211) aged 13 to 25 years underwent primary ACL reconstruction with fresh-frozen nonirradiated allograft. Four graft types were used: patellar tendon, Achilles tendon, tibialis anterior, and tibialis posterior. Details were collected on allograft donor age and sex. At a minimum of 24 months, patients were evaluated for any further injuries and subjective analysis by International Knee Documentation Committee (IKDC) questionnaire.

RESULTS

ACL graft rupture occurred in 23.5%. When grafts were separated into single strand (patellar and Achilles tendon) and multistrand (tibialis anterior and posterior), there was a significantly higher rate of reinjury in the single-strand grafts (29.9% vs 11%; P = .014). Grafts from female donors aged ≥50 years had significantly higher rates of ACL graft rupture (52.6%; P = .003) with increased odds by 6.7 times when compared with grafts from male donors aged <50 years. There was no significant difference in mean IKDC scores among the groups based on the age and sex of the allograft donor.

CONCLUSION

The age and sex of the allograft donor and the morphology of the graft significantly influenced the rate of ACL graft rupture in young active patients. Tendons from female donors aged ≥50 years should be avoided given the higher rerupture rates as compared with male donors of any age and younger females.

Use of Allografts in Orthopaedic Surgery: Safety, Procurement, Storage, and Outcomes

The use of allografts has become a vital option for orthopaedic surgeons in the treatment of a variety of musculoskeletal lesions, ranging from osteochondral defects in the glenohumeral joint to meniscal deficiency in the young athlete. Nevertheless, barriers to treating a patient with an allograft-based procedure may arise from concerns over disease transmission, the navigation of tissue banks that supply allografts, the process of obtaining insurance approval, or optimal storage methods. This review serves to support orthopaedic surgeons in the incorporation of allografts into their practice by quelling these potential concerns. Fresh osteochondral allografts, fresh-frozen meniscal allografts, soft tissue allografts, and off-the-shelf cartilage products are the focus of this review amid broad overviews of allograft safety and tissue bank practices in the United States.

The use of allograft tendons in primary ACL reconstruction

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.

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.

Treatment of Lateral Epicondylitis With Autologous Blood, Platelet-Rich Plasma, or Corticosteroid Injections: A Systematic Review of Overlapping Meta-analyses

Background:

Previous meta-analyses have been conducted to compare outcomes of various treatment injections for lateral epicondylitis (LE), including corticosteroid injection (CSI) and autologous blood products such as autologous blood (AB) and platelet-rich plasma (PRP).

Purpose:

To conduct a systematic review of overlapping meta-analyses comparing different injection treatments (CSI, AB, PRP) for LE to determine which meta-analyses provide the best available evidence.

Study Design:

Systematic review; Level of evidence, 2.

Methods:

A systematic review was performed by searching PubMed, Embase, and the Cochrane Library to locate meta-analyses that compared clinical outcomes of CSI, AB, and PRP for the treatment of LE. Search terms included “injection,” “corticosteroid,” “platelet-rich plasma,” “autologous blood,” “tennis elbow,” “lateral epicondylitis,” and “meta-analysis.” Results were reviewed to determine study eligibility. Patient outcomes were extracted from these meta-analyses. Meta-analysis quality was assessed with the Oxman-Guyatt and Quality of Reporting of Meta-analyses (QUOROM) systems. The Jadad decision algorithm was then used to determine which meta-analyses provided the best level of evidence.

Results:

Nine meta-analyses (two level 1 studies, seven level 2 studies) containing 8656 patients met the eligibility criteria. Seven meta-analyses found that autologous blood products such as AB and PRP significantly improved pain and elbow function in the intermediate term (12-26 weeks), while 4 studies found that CSI effectively relieved pain and improved elbow function in the short term (<12 weeks). The study by Arirachakaran et al in 2016 received the highest QUOROM and Oxman-Guyatt scores; therefore, this meta-analysis appears to have the highest level of evidence. In addition, this study was rated the highest-quality study in this systematic review according to the Jadad decision algorithm. Lower-quality meta-analyses indicated that dosage, number of injections, and differences in therapeutic duration between CSI and autologous blood products may be essential factors in determining the appropriate treatment injection protocol for LE.

Conclusion:

The current best available evidence suggests that CSI improves functional outcomes and pain relief in the short term, while AB and PRP are the most effective treatments in the intermediate term.

Combined Anterior Cruciate Ligament, Medial Collateral Ligament, and Posterior Oblique Ligament Reconstruction Through Single Tibial Tunnel Using Hamstring Tendon Autografts

Combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries are the most common type of combined ligamentous injury of the knee. The optimal treatment for these combined injuries is controversial. Combined ACL and MCL-posterior oblique ligament (POL) reconstruction avoids late anteromedial rotatory instability and chronic valgus instability of the knee and decreases the increased stress on the ACL graft. Graft choice (hamstring tendon autograft, quadriceps bone-patellar tendon-bone autograft, or Achilles tendon allograft) and anatomic restoration of the medial and posteromedial corner of the knee are challenges of this combined reconstruction. This article describes a technique that allows combined ACL and MCL-POL reconstruction. The hamstring tendons from the contralateral limb are tripled and used as the ACL graft. The gracilis tendon from the ipsilateral limb is doubled and used as the MCL-POL graft. The semitendinosus tendon of the ipsilateral limb is preserved. After ACL reconstruction, the MCL-POL graft is suspended on the ACL graft at the distal end of the tibial tunnel and the graft limbs are used for open reconstruction of the MCL and POL. Three interference screws (Arthrex, Naples, FL) and 1 metal staple are used for graft fixation of this combined reconstruction.

5-Year Survival of Pediatric Anterior Cruciate Ligament Reconstruction With Living Donor Hamstring Tendon Grafts

BACKGROUND

It is well accepted that there is a higher incidence of repeat anterior cruciate ligament (ACL) injuries in the pediatric population after ACL reconstruction (ACLR) with autograft tissue compared with adults. Hamstring autograft harvest may contribute to the risk for repeat ACL injuries in this high functional demand group. A novel method is the use of a living donor hamstring tendon (LDHT) graft from a parent; however, there is currently limited research on the outcomes of this technique, particularly beyond the short term.

PURPOSE/HYPOTHESIS

The purpose was to determine the medium-term survival of the ACL graft and the contralateral ACL (CACL) after primary ACLR with the use of an LDHT graft from a parent in those aged less than 18 years and to identify factors associated with subsequent ACL injuries. It was hypothesized that ACLR with the use of an LDHT provides acceptable midterm outcomes in pediatric patients.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 2005 and 2014, 247 (of 265 eligible) consecutive patients in a prospective database, having undergone primary ACLR with the use of an LDHT graft and aged less than 18 years, were included. Outcomes were assessed at a minimum of 2 years after surgery including data on ACL reinjuries, International Knee Documentation Committee (IKDC) scores, and current symptoms, as well as factors associated with the ACL reinjury risk were investigated.

RESULTS

Patients were reviewed at a mean of 4.5 years (range, 24-127 months [10.6 years]) after ACLR with an LDHT graft. Fifty-one patients (20.6%) sustained an ACL graft rupture, 28 patients (11.3%) sustained a CACL rupture, and 2 patients sustained both an ACL graft rupture and a CACL rupture (0.8%). Survival of the ACL graft was 89%, 82%, and 76% at 1, 2, and 5 years, respectively. Survival of the CACL was 99%, 94%, and 86% at 1, 2, and 5 years, respectively. Survival of the ACL graft was favorable in patients with Tanner stage 1-2 at the time of surgery versus those with Tanner stage 3-5 at 5 years (87% vs 69%, respectively; hazard ratio, 3.7; P = .01). The mean IKDC score was 91.7. A return to preinjury levels of activity was reported by 59.1%.

CONCLUSION

After ACLR with an LDHT graft from a parent in those aged less than 18 years, a second ACL injury (ACL graft or CACL injury) occurred in 1 in 3 patients. The 5-year survival rate of the ACL graft was 76%, and the 5-year survival rate of the CACL was 86%. High IKDC scores and continued participation in sports were maintained over the medium term. Importantly, there was favorable survival of the ACL graft in patients with Tanner stage 1-2 compared with patients with Tanner stage 3-5 over 5 years. Patients with Tanner stage 1-2 also had a significantly lower incidence of second ACL injuries over 5 years compared with those with Tanner stage 3-5, occurring in 1 in 5 patients. Thus, an LDHT graft from a parent is an appropriate graft for physically immature children.

Anterior cruciate ligament reconstruction without the use of a tourniquet

INTRODUCTION

Anterior cruciate ligament tears are a common ligamentous knee injury and are usually managed with arthroscopic reconstruction surgery using a tourniquet. The employment of a tourniquet in the management of an anterior cruciate ligament tear has been a debatable topic for some time. Here, we discuss our technique in the reconstruction of anterior cruciate ligament tears without the use of a tourniquet.

MATERIALS AND METHODS

We performed 26 anterior cruciate ligament reconstruction surgeries using hamstring grafts without the use of a tourniquet. The outcomes measured were pain using the visual analogue scale, knee swelling, range of movement and bleeding.

RESULTS

Using this technique, we have noted considerable reduction in knee swelling and pain. In addition, there was considerable improvement in the range of movement postoperatively, and there were no bleeding complications noted.

CONCLUSIONS

We consider ACL reconstruction without a tourniquet to be an excellent alternative to conventional reconstruction with the use of tourniquet.

A Comparative Study of Clinical Outcomes and Second-Look Arthroscopic Findings between Remnant-Preserving Tibialis Tendon Allograft and Hamstring Tendon Autograft in Anterior Cruciate Ligament Reconstruction: Matched-Pair Design

Background

This study aimed to compare stability, functional outcome, and second-look arthroscopic findings after anterior cruciate ligament reconstruction between remnant-preserving tibialis tendon allograft and remnant-sacrificing hamstring tendon autograft.

Methods

We matched two groups (remnant-preserving tibialis tendon allograft group and hamstring tendon autograft group) in terms of demographic characteristics, associated injury, and knee characteristics. Each group consisted of 25 patients.

Results

Operation time was longer in the remnant-preserving tibialis tendon allograft group, but there was no significant intergroup difference in stability, clinical outcome, and second-look arthroscopic findings.

Conclusions

When an autograft is not feasible in anterior cruciate ligament reconstruction, the remnant-preserving technique can produce comparable results in terms of restoration of function, stability of the knee, and degree of synovium coverage at second-look arthroscopy compared to remnant-sacrificing hamstring autograft.

Bone-Patellar Tendon-Bone Versus Hamstring Tendon Autografts for Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review of Overlapping Meta-analyses

BACKGROUND

Previous meta-analyses have compared bone-patellar tendon-bone (BPTB) with hamstring tendon (HT) autografts for primary anterior cruciate ligament reconstruction (ACLR).

PURPOSE

To conduct a systematic review of overlapping meta-analyses comparing BPTB with HT autografts for ACLR to determine which meta-analyses provide the best available evidence.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review was performed by searching the PubMed and Cochrane Library databases. Search words included "anterior cruciate ligament" AND "patellar tendon" AND "hamstring tendon" AND "meta-analysis." Results were reviewed to determine study eligibility. Patient outcomes and postoperative complications were extracted from the included meta-analyses. Meta-analysis quality was assessed using the Oxman-Guyatt and Quality of Reporting of Meta-analyses (QUOROM) scores. The Jadad decision algorithm was then utilized to determine which meta-analyses provided the best level of evidence.

RESULTS

Sixteen meta-analyses containing an average of 1396 patients met the eligibility criteria. Most studies found BPTB autografts to provide superior stability but more postoperative complications, such as anterior knee pain and kneeling pain. Studies by Gabler et al (2016), Mohtadi et al (2011), and Xie et al (2015) received the highest Oxman-Guyatt and QUOROM scores, and therefore, these meta-analyses proved to provide the highest level of evidence. Additionally, Xie et al was selected as the highest-quality study in this systematic review based on the Jadad decision algorithm.

CONCLUSION

The current best evidence suggests that ACLR with BPTB autografts provides superior static knee stability and that there are fewer postoperative complications in ACLR with HT autografts.

Early Versus Delayed Motion After Rotator Cuff Repair: A Systematic Review of Overlapping Meta-analyses

BACKGROUND

Previous meta-analyses have been conducted to compare outcomes of early versus delayed motion after rotator cuff repair.

PURPOSE

To conduct a systematic review of overlapping meta-analyses comparing early versus delayed motion rehabilitation protocols after rotator cuff repair to determine which meta-analyses provide the best available evidence.

STUDY DESIGN

Systematic review.

METHODS

A systematic review was performed by searching PubMed and Cochrane Library databases. Search terms included "rotator cuff repair," "early passive motion," "immobilization," "rehabilitation protocol," and "meta-analysis." Results were reviewed to determine study eligibility. Patient outcomes and structural healing were extracted from these meta-analyses. Meta-analysis quality was assessed using the Oxman-Guyatt and Quality of Reporting of Meta-analyses (QUOROM) systems. The Jadad decision algorithm was then used to determine which meta-analyses provided the best level of evidence.

RESULTS

Seven meta-analyses containing a total of 5896 patients met the eligibility criteria (1 Level I evidence, 4 Level II evidence, 2 Level III evidence). None of these meta-analyses found immobilization to be superior to early motion; however, most studies suggested that early motion would increase range of motion (ROM), thereby reducing time of recovery. Three of these studies suggested that tear size contributed to the choice of rehabilitation to ensure proper healing of the shoulder. A study by Chan et al in 2014 received the highest QUOROM and Oxman-Guyatt scores, and therefore this meta-analysis appeared to have the highest level of evidence. Additionally, a study by Riboh and Garrigues in 2014 was selected as the highest quality study in this systematic review according to the Jadad decision algorithm.

CONCLUSION

The current, best available evidence suggests that early motion improves ROM after rotator cuff repair but increases the risk of rotator cuff retear. Lower quality meta-analyses indicate that tear size may provide a better strategy in determining the correct rehabilitation protocol.

Comparison of Knee Stability and Synovial Fluid Alterations in Anterior Cruciate Ligament Reconstruction With a Hamstring Autograft or an Allograft

This study compared knee stability and alterations in the composition of synovial fluid among patients who underwent arthroscopic anterior cruciate ligament (ACL) reconstruction with either a hamstring autograft or a hamstring allograft. This prospective cohort study enrolled 175 patients. Of these patients, 90 underwent hamstring tendon autograft ACL reconstruction. The remaining patients (n=85) underwent hamstring tendon allograft ACL reconstruction. All of the patients had a minimum of 1 year of follow-up (mean, 2.5 years). Side-to-side differences and the proportion of mononuclear cells in knee joint synovial fluid were measured at 5 time points (preoperatively and at postoperative weeks 1, 3, 6, and 12). During the early postoperative phase, side-to-side knee laxity was greater among the allograft group compared with the autograft group (P<.001). Additionally, among the allograft group, the proportion of mononuclear cells remained high at weeks 6 and 12 (mean, 90.0% and 88.9%, respectively) compared with a normal level in the autograft group (mean, 45.1% and 65.7%, separately). However, no significant difference was found between the 2 groups at final follow-up for range of motion, results of the Lachman test, results of the anterior drawer test, results of the pivot shift test, Lysholm score, bone tunnel enlargement, and graft failure rate (P>.05). These findings showed that, in the early postoperative phase, ACL reconstruction with a hamstring allograft resulted in greater knee laxity and immunologic response compared with the hamstring autograft group. However, at relatively long-term follow-up, both grafts achieved similar objective and subjective outcomes. [Orthopedics. 2017; 40(5):e892-e897.].

Increased Risk of Revision After Anterior Cruciate Ligament Reconstruction With Soft Tissue Allografts Compared With Autografts: Graft Processing and Time Make a Difference

BACKGROUND

The optimal graft for anterior cruciate ligament reconstruction (ACLR) remains controversial.

PURPOSE

To compare the risk of aseptic revision between bone-patellar tendon-bone (BPTB) autografts, hamstring autografts, and soft tissue allografts.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Prospectively collected ACLR cases reconstructed with BPTB autografts, hamstring autografts, and soft tissue allografts were identified using the Kaiser Permanente ACLR Registry. Aseptic revision was the endpoint. The type of graft and allograft processing method (nonprocessed, <1.8-Mrad irradiation with and without chemical processing [Allowash or AlloTrue], ≥1.8-Mrad irradiation with and without chemical processing, and chemical processing alone [BioCleanse]) were the exposures evaluated. Analyses were adjusted for age, sex, and race. Kaplan-Meier curves and Cox proportional hazards models were employed.

RESULTS

The cohort included 14,015 cases: there were 8924 (63.7%) male patients, there were 6397 (45.6%) white patients, 4557 (32.5%) ACLRs used BPTB autografts, 3751 ACLRs (26.8%) used soft tissue allografts, and 5707 (40.7%) ACLRs used hamstring autografts. The median age was 34.6 years for soft tissue allografts, 24.3 years for hamstring autografts, and 22.0 years for BPTB autografts. The crude nonadjusted revision rates were 85 (1.9%) in BPTB autograft cases, 132 (2.3%) in hamstring autograft cases, and 83 (2.2%) in soft tissue allograft cases. After adjusting for age, sex, and race, compared with hamstring autografts, a higher risk of revision was found with allografts with ≥1.8 Mrad without chemical processing after 2.5 years (hazard ratio [HR], 3.88; 95% CI, 1.48-10.12) and ≥1.8 Mrad with chemical processing after 1 year (HR, 3.43; 95% CI, 1.58-7.47) and with BioCleanse processed grafts at any time point (HR, 3.02; 95% CI, 1.40-6.50). Nonprocessed allografts and those irradiated with <1.8 Mrad with or without chemical processing were not found to have a different risk of revision compared with hamstring autografts. Compared with BPTB autografts, a higher risk of revision was seen with hamstring autografts (HR, 1.51; 95% CI, 1.15-1.99) and BioCleanse processed allografts (HR, 4.67; 95% CI, 2.15-10.16). Allografts irradiated with <1.8 Mrad with chemical processing (Allowash or AlloTrue) (HR, 2.19; 95% CI, 1.42-3.38) and without chemical processing (HR, 2.31; 95% CI, 1.40-3.82) had a higher risk of revision, as did allografts with ≥1.8 Mrad without chemical processing after 2 years (HR, 6.30; 95% CI, 3.18-12.48) and ≥1.8 Mrad with chemical processing (Allowash or AlloTrue) after 1 year (HR, 5.03; 95% CI, 2.30-11.00) compared with BPTB autografts. Nonprocessed allografts did not have a higher risk of revision compared with autografts. With the numbers available, direct comparisons between the specific allograft processing methods were not possible.

CONCLUSION

When soft tissue allografts are used for ACLR, processing and time from surgery affect the risk of revision. Tissue processing has a significant effect on the risk of revision surgery, which is most profound with more highly processed grafts and increases with increasing follow-up time. Surgeons and patients need to be aware of the increased risks of revision with the various soft tissue allografts used for ACLR.

Outcomes at a Minimum of 2 Years After Medial Collateral Ligament Reconstruction Using Partial-Thickness Quadriceps Tendon-Bone Autograft

This study reports outcomes at a minimum of 2 years after a technique using quadriceps tendon-bone autograft for medial collateral ligament reconstruction. This technique effectively restored medial stability in medial collateral ligament-deficient knees. It is particularly valuable when nonirradiated allograft is unavailable or harvesting medial knee restraints (semitendinosus) for medial collateral ligament reconstruction is to be avoided. [Orthopedics. 2017; 40(3):e557-e562.].

Increased Risk of Revision After Anterior Cruciate Ligament Reconstruction With Bone-Patellar Tendon-Bone Allografts Compared With Autografts

BACKGROUND

The use of allograft tissue for anterior cruciate ligament reconstruction (ACLR) remains controversial.

PURPOSE

To compare the risk of aseptic revision between bone-patellar tendon-bone (BPTB) autografts and BPTB allografts.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A retrospective cohort study of prospectively collected data was conducted using the Kaiser Permanente ACLR Registry. A cohort of patients who underwent primary unilateral ACLR with BPTB autografts and BPTB allografts was identified. Aseptic revision was the endpoint. The type of graft and allograft processing method (nonprocessed, <1.8-Mrad, and ≥1.8-Mrad irradiation) were the exposures of interest evaluated. Age (≤21 and ≥22 years) was evaluated as an effect modifier. Analyses were adjusted for age, sex, and race. Kaplan-Meier curves and Cox proportional hazards models were employed. Hazard ratios (HRs) and 95% CIs are provided.

RESULTS

The BPTB cohort consisted of 5586 patients: 3783 (67.7%) were male, 2359 (42.2%) were white, 1029 (18.4%) had allografts (nonprocessed: 155; <1.8 Mrad: 525; ≥1.8 Mrad: 288), and 4557 (81.6%) had autografts. The median age was 34.9 years (interquartile range [IQR], 25.4-44.0) for allograft cases and 22.0 years (IQR, 17.6-30.0) for autograft cases. The estimated cumulative revision rate at 2 years was 4.1% (95% CI, 2.9%-5.9%) for allografts and 1.7% (95% CI, 1.3%-2.2%) for autografts. BPTB allografts had a significantly higher adjusted risk of revision than BPTB autografts (HR, 4.54; 95% CI, 3.03-6.79; P < .001). This higher risk of revision was consistent with all allograft processing methods when compared with autografts and was also consistently higher in patients with allografts regardless of age.

CONCLUSION

When BPTB allograft tissue was used for ACLR, an overall 4.54 times adjusted higher risk of revision was observed compared with surgery performed with a BPTB autograft. Whether the tissue was irradiated with either high- or low-dose radiation, chemically processed, or not processed at all made little difference in the risk of revision. The differences in the revision risk were also consistent in younger and older patients. Surgeons and patients should be aware of the increased risk of revision when a BPTB allograft is used for ACLR.

Osteoarthritis in Football

Football is currently the most popular sporting activity in the world. Multiple reports have shown that a high incidence of osteoarthritis is found in football players. Evidence clearly shows that traumatic injury significantly predisposes players for such pathophysiology. Injuries are frequent in amateur as well as professional football players, with knee and ankle accounting for the most severe injuries. Many professional athletes lose playing time due to injuries and many are forced into early retirement. Posttraumatic osteoarthritis is a common finding among ex-football players with numbers well above the normal population. Today's surgical techniques are advanced and capable of restoring the joint to a certain extent. However, a restitution ad integrum is reached only in very rare cases. Professional football players that return to play after serious injuries perform their extremely strenuous activity on morphologically compromised joints. Incomplete rehabilitation and pressure to return to play after an injurious event clearly put the athlete at an even higher risk for joint degeneration. Prevention strategies, improved surgical management, strict rehabilitation, as well as future aspects such as early suppression of inflammation, personalized medicine, and predictive genomics DNA profiling are needed to reduce incidence and improve the health perspectives of football players.

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.

Should the Ipsilateral Hamstrings Be Used for Anterior Cruciate Ligament Reconstruction in the Case of Medial Collateral Ligament Insufficiency? Biomechanical Investigation Regarding Dynamic Stabilization of the Medial Compartment by the Hamstring Muscles

BACKGROUND

Semitendinosus and gracilis muscles are frequently harvested for autologous tendon grafts for cruciate ligament reconstruction. This study investigated the joint-stabilizing effects of these hamstring muscles in cases of insufficiency of the medial collateral ligament (MCL).

HYPOTHESES

First, both the semitendinosus and gracilis muscles can actively stabilize the joint against valgus moments in the MCL-deficient knee. Second, the stabilizing influence of these muscles decreases with an increasing knee flexion angle.

STUDY DESIGN

Controlled laboratory study.

METHODS

The kinematics was examined in 10 fresh-frozen human cadaveric knees using a robotic/universal force moment sensor system and an optical tracking system. The knee kinematics under 5- and 10-N·m valgus moments were determined in the different flexion angles of the (1) MCL-intact and (2) MCL-deficient knee using the following simulated muscle loads: (1) 0-N (idle) load, (2) 200-N semitendinosus (ST) load, and (3) 280-N (200/80-N) combined semitendinosus/gracilis (STGT) load.

RESULTS

Cutting the MCL increased the valgus angle under all tested conditions and angles compared with the MCL-intact knee by 4.3° to 8.1° for the 5-N·m valgus moment and 6.5° to 11.9° for the 10-N·m valgus moment ( P < .01). The applied 200-N simulated ST load reduced the valgus angle significantly at 0°, 10°, 20°, and 30° of flexion under 5- and 10-N·m valgus moments ( P < .05). At 0°, 10°, and 20° of flexion, these values were close to those for the MCL-intact joint under the respective moments (both P > .05). The combined 280-N simulated STGT load significantly reduced the valgus angle in 0°, 10°, and 20° of flexion under 5- and 10-N·m valgus moments ( P < .05) to values near those for the intact joint (5 N·m: 0°, 10°; 10 N·m: 0°, 10°, 20°; P > .05). In 60° and 90° of flexion, ST and STGT loads did not decrease the resulting valgus angle of the MCL-deficient knee without hamstring loads ( P > .05 vs deficient; P = .0001 vs intact).

CONCLUSION

In this human cadaveric study, semitendinosus and gracilis muscles successfully stabilize valgus moments applied to the MCL-insufficient knee when the knee is near extension.

CLINICAL RELEVANCE

In the valgus-unstable knee, these data suggest that the hamstring muscles should be preserved in (multi-) ligament surgery when possible.

Arthroscopic anatomic double-bundle ACL reconstruction using irradiated versus non-irradiated hamstring tendon allograft

PURPOSE

To analyse the clinical outcome of anatomic double-bundle anterior cruciate ligament (ACL) reconstruction with irradiated versus non-irradiated hamstring allograft.

METHODS

One hundred and twelve patients who met the inclusion and exclusion criteria of the study were prospectively randomized consecutively into irradiated hamstring tendon allograft (Ir-Allo) group and non-irradiated allograft (Non-ir-Allo) group. All surgeries were done by the same senior surgeon with double-bundle reconstruction technique. Before surgery and at follow-up points, patients were evaluated by the same observer according to clinical evaluations.

RESULTS

Eighty-three patients (Non-ir-Allo, 44; Ir-Allo, 39) fulfilled complete follow-up and got full clinical evaluations. The mean follow-up period was 5.7 years (ranging from 5.0 to 6.5 years). At the final follow-up, significant differences were found when comparing the results of the two groups according to Lachman test, ADT, pivot shift test and KT-2000 arthrometer testing (P < 0.05). According to KT-2000, 86.4 % of patients in the Non-ir-Auto group and 35.9 % in the Ir-Allo group had a side-to-side difference of <3 mm. According to the overall IKDC, functional, subjective evaluations and activity level testing, no significant differences were found between the two groups. Regarding the arthritic progression, there was significant difference between the two groups (Ir-Allo group: 30.8 %, Non-ir-Allo group: 11.4 %, P < 0.05).

CONCLUSION

A significant increase in anterior and rotational laxity in patients of the Ir-Allo group was found according to evaluations. No significant differences in activity level and functional scores were found between the two groups. We do not advocate the irradiated hamstring tendon allograft for ACL reconstruction.

LEVEL OF EVIDENCE

I.

Improved ACL reconstruction outcome using double-layer BPTB allograft compared to that using four-strand hamstring tendon allograft

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.

Long term results of bone-patella-tendon-bone ACL reconstruction

BACKGROUND

To assess outcomes of bone-patella-tendon-bone ACL-reconstruction at 18 years follow-up.

MATERIAL AND METHODS

Outcome measures included the IKDC clinical examination form and clinical scores. Radiographs were analyzed to determine the grade of osteoarthritis.

RESULTS

69% of the examined patients (n = 54) had a normal/nearly normal knee, 14% were abnormal and 17% severely abnormal with significant improvement (P ≤ 0.001). The mean Lysholm score was 87.7 ± 12.4 and the Tegner activity level was 5 ± 2. Osteoarthritic changes were present in 52%.

CONCLUSION

BPTB ACL-reconstruction provides a satisfactory outcome with a high incidence of radiographic osteoarthritic changes.

Combined Reconstruction of the Medial Collateral Ligament and Anterior Cruciate Ligament Using Ipsilateral Quadriceps Tendon-Bone and Bone-Patellar Tendon-Bone Autografts

The exclusive autograft choice for medial collateral ligament (MCL) reconstruction that has been described until today is the semitendinosus tendon. However, this has some potential disadvantages in a knee with combined MCL-anterior cruciate ligament (ACL) injury, including weakening of the hamstring's anterior restraining action in an already ACL-injured knee and nonanatomic distal MCL graft insertion when leaving the semitendinosus insertion intact at the pes anserinus during reconstruction. Moreover, because some surgeons prefer to use the hamstring for autologous ACL reconstruction, the contralateral uninjured knee hamstring needs to be harvested as a graft source for the MCL reconstruction if autografts and not allografts are the surgeons' preference. We describe a technique for performing combined reconstruction of the MCL and ACL using ipsilateral quadriceps tendon-bone and bone-patellar tendon-bone autografts. This technique of MCL reconstruction spares the hamstring tendons and benefits from the advantage provided by bone-to-bone healing on the femur with distal and proximal MCL tibial fixation that closely reproduces the native MCL tibia insertion.

Biomechanics of the anterior cruciate ligament: Physiology, rupture and reconstruction techniques

The influences and mechanisms of the physiology, rupture and reconstruction of the anterior cruciate ligament (ACL) on kinematics and clinical outcomes have been investigated in many biomechanical and clinical studies over the last several decades. The knee is a complex joint with shifting contact points, pressures and axes that are affected when a ligament is injured. The ACL, as one of the intra-articular ligaments, has a strong influence on the resulting kinematics. Often, other meniscal or ligamentous injuries accompany ACL ruptures and further deteriorate the resulting kinematics and clinical outcomes. Knowing the surgical options, anatomic relations and current evidence to restore ACL function and considering the influence of concomitant injuries on resulting kinematics to restore full function can together help to achieve an optimal outcome.

Anterior cruciate ligament reconstruction and rehabilitation: predictors of functional outcome

Surgical reconstruction of an injured anterior cruciate ligament (ACL) leads to full recovery of function and sports activity in a high percentage of cases. The aim of the present study was to analyze variables related to the patient, the surgical technique and the post-surgical rehabilitation methods, seeking to identify predictors of outcome and recovery time after ACL reconstruction. One hundred and four patients (81 M, 23 F) undergoing a step-based rehabilitation protocol after ACL reconstruction were evaluated. 43.2% of them had an isolated ACL lesion, whereas 56.8% had one or more concurrent injuries. Data relating to personal characteristics, surgery and post-operative management were collected and analyzed for correlation. Clinical outcome was evaluated with IKDC subjective score and the Tegner score, and the time to reach full recovery was noted as well. Young patients with a higher pre-injury Tegner activity level or who practice sport at professional level, no concurrent capsular lesions and no postoperative knee bracing had better clinical results and took shorter time to recover. Also, a higher percentage of on-the-field rehabilitation sessions, and absence of significant muscle strength deficits at the first knee isokinetic test emerged as rehabilitation-related factors leading to a better post-surgical outcome. Personal, surgical and rehabilitation factors should be considered in order to optimize patient management and maximize the expected results. Further studies are needed to find the strongest factors in different patients.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Increased Failure Rates After Anterior Cruciate Ligament Reconstruction With Soft-Tissue Autograft-Allograft Hybrid Grafts

PURPOSE

To compare the rate of failure between a group of patients who underwent anterior cruciate ligament (ACL) reconstruction with an autograft-allograft hybrid soft-tissue graft and a matched group of patients who underwent ACL reconstruction with hamstring autograft.

METHODS

From 2007 to 2012, 29 patients underwent hybrid ACL reconstruction performed by 4 fellowship-trained sports medicine surgeons at a single institution. Patients who underwent ACL reconstruction with hamstring autograft comprised the control group and were matched to patients in the hybrid group by sex, age, date of surgery, reconstruction technique, and method of femoral fixation. Graft failure was defined as revision ACL reconstruction or complete graft rupture on magnetic resonance imaging. Graft compromise was defined as magnetic resonance imaging evidence of partial graft rupture or arthroscopically identified partial graft rupture. Lysholm Knee Scoring Scale and International Knee Documentation Committee scores were obtained.

RESULTS

Both groups included 10 men and 19 women, with a mean postoperative follow-up period of 44.4 ± 16.9 months in the hybrid group and 48.0 ± 15.2 months in the control group. Follow-up was obtained in 25 of 29 patients (86.2%) in the hybrid group, and each was matched to 1 patient who received hamstring autograft. The failure rate was 13.8% (4 of 29 patients) in the hybrid group compared with 3.4% (1 of 29) in the control group (P = .160). An additional 27.6% of hybrid group patients (7 of 29) had compromised grafts as defined earlier, as compared with 1 (3.4%) of the control patients (P = .022). Thus the overall hybrid graft failure/compromise rate was 37.9% (11 of 29) compared with 6.9% (2 of 29) for the hamstring autograft group (P = .005). In the hybrid group, the Lysholm score (80.2 ± 12.1) was significantly lower than that in the control autograft ACL group (89.9 ± 11.8) (P = .030). The International Knee Documentation Committee score for the hybrid ACL group (71.26 ± 19.5) was significantly worse than that for the autograft ACL group (85.7 ± 13.0) (P = .012).

CONCLUSIONS

Allograft-autograft hybrid hamstring ACL grafts fail or become structurally compromised at a higher rate than matched autograft hamstring controls.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Editorial Commentary: Platelet-Rich Plasma Improves Knee Pain and Function in Patients With Knee Osteoarthritis

Systematic review of overlapping meta-analyses shows that platelet-rich plasma improves knee pain and function in patients with knee osteoarthritis. Ultimately, biologics hold promise for chondroprotection in addition to symptomatic relief.

Revision Risk After Allograft Anterior Cruciate Ligament Reconstruction: Association With Graft Processing Techniques, Patient Characteristics, and Graft Type

BACKGROUND

Allograft tissue is a common graft choice for anterior cruciate ligament reconstruction (ACLR). Allograft sterilization methods vary widely across numerous commercial tissue vendors. Multiple studies, despite being limited in sample size, have suggested a higher rate of clinical failure associated with the use of allograft tissue in ACLR when compared with autograft.

PURPOSE

To examine the association of graft processing techniques, patient characteristics, and graft type with risk of revision surgery after allograft ACLR.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective cohort study was conducted that used an integrated United States health care system's ACLR registry to identify primary unilateral cases in which allografts were used. Aseptic revision was the endpoint of the study. Allograft type, processing methods (irradiation dose, AlloWash, AlloTrue, BioCleanse), and graft donor age were assessed as potential risk factors for revision, with adjustment for patient age, sex, and body mass index (BMI) by use of survival analysis. Hazard ratios (HR) and 95% confidence intervals (CIs) were calculated.

RESULTS

A total of 5968 primary ACLR cases with allograft were included in the study, of which 3688 (61.8%) were male patients. The median age of the cohort at the time of surgery was 34.1 years (interquartile range, 24.1-42.9 years). The mean time to follow-up (±SD) was 2.1 ± 1.5 years. There were 3751 (62.9%) allograft ACLRs using soft tissue, 1188 (19.9%) with Achilles tendon, and 1029 (17.2%) with bone-patellar tendon-bone (BPTB). Graft processing groups included BioCleanse (n = 367), AlloTrue or AlloWash (n = 2278), irradiation greater than 1.8 Mrad (n = 1146), irradiation up to 1.8 Mrad (n = 3637), and no irradiation (n = 1185). There were 156 (2.6%) aseptic revisions. After adjustment for patient age, sex, and BMI, the use of BioCleanse (HR = 2.45; 95% CI, 1.36-4.40) and irradiation greater than 1.8 Mrad (HR = 1.64; 95% CI, 1.08-2.49) were associated with a higher risk of revision when compared with all other methods of processing. BPTB allografts were at higher risk of revision (HR = 1.79; 95% CI, 1.20-2.66) when compared with soft tissue allografts. Conversely, with every 5-year increase in age, the risk of revision was 0.67 (95% CI, 0.61-0.73) times lower. Male patients were found to be at higher risk of revision when compared with females (HR = 1.47; 95% CI, 1.04-2.07). The use of AlloWash or AlloTrue processing, patient BMI, and graft donor age did not affect revision rate significantly.

CONCLUSION

In the largest known study of its kind examining outcome after primary allograft ACLR, graft irradiation greater than 1.8 Mrad, BioCleanse graft processing, younger patient age, male patients, and BPTB allograft were all associated with a higher risk of clinical failure and subsequent revision surgery.

A Systematic Review of Failed Anterior Cruciate Ligament Reconstruction With Autograft Compared With Allograft in Young Patients

CONTEXT

The advantages of allograft anterior cruciate ligament reconstruction (ACLR), which include shorter surgical time, less postoperative pain, and no donor site morbidity, may be offset by a higher risk of failure. Previous systematic reviews have inconsistently shown a difference in failure prevalence by graft type; however, such reviews have never been stratified for younger or more active patients.

OBJECTIVE

To determine whether there is a different ACLR failure prevalence of autograft compared with allograft in young, active patients.

DATA SOURCES

EMBASE, MEDLINE, Cochrane trials registry.

STUDY SELECTION

Comparative studies of allograft versus autograft primary ACL reconstruction in patients <25 years of age or of high-activity level (military, Marx activity score >12 points, collegiate or semiprofessional athletes).

STUDY DESIGN

Systematic review with meta-analysis.

LEVEL OF EVIDENCE

Level 3.

DATA EXTRACTION

Manual extraction of available data from eligible studies. Quantitative synthesis of failure prevalence and Lysholm score (outcomes in ≥3 studies) and I (2) test for heterogeneity. Assessment of study quality using CLEAR NPT and Newcastle-Ottawa Scale (NOS).

RESULTS

Seven studies met inclusion criteria (1 level 1; 2 level 2, 4 level 3), including 788 patients treated with autograft tissue and 228 with various allografts. The mean age across studies was 21.7 years (64% male), and follow-up ranged between 24 and 51 months. The pooled failure prevalence was 9.6% (76/788) for autografts and 25.0% (57/228) for allografts (relative risk, 0.36; 95% CI, 0.24-0.53; P < 0.00001; I (2) = 16%). The number needed to benefit to prevent 1 failure by using autograft was 7 patients (95% CI, 5-10). No difference between hamstrings autograft and patella tendon autograft was noted. Lysholm score was reported in 3 studies and did not differ between autograft and allograft.

CONCLUSION

While systematic reviews comparing allograft and autograft ACLR have been equivocal, this is the first review to examine young and active patients in whom allograft performs poorly.

Scaffolds for tendon and ligament repair and regeneration

Enhanced tendon and ligament repair would have a major impact on orthopedic surgery outcomes, resulting in reduced repair failures and repeat surgeries, more rapid return to function, and reduced health care costs. Scaffolds have been used for mechanical and biologic reinforcement of repair and regeneration with mixed results. This review summarizes efforts made using biologic and synthetic scaffolds using rotator cuff and ACL as examples of clinical applications, discusses recent advances that have shown promising clinical outcomes, and provides insight into future therapy.