All-Inside Quadrupled Semitendinosus Autograft Shows Stability Equivalent to Patellar Tendon Autograft Anterior Cruciate Ligament Reconstruction: Randomized Controlled Trial in Athletes 24 Years or Younger

Anterior Cruciate Ligament Reconstruction Utilizing Double Adjustable-Loop Suspensory Fixation Devices Provides Good Clinical Outcomes in Patients under the Age of 40 Years at Two-Year Follow-Up

Background: Anterior cruciate ligament reconstruction (ACLR) using double adjustable fixation gained popularity in the last decade due to its minimally invasive technique. However, suspensory fixation devices could be related to recurrent instability, poor clinical outcomes, and patient dissatisfaction. The present study aims to evaluate the clinical outcomes following ACLR using double adjustable-loop suspensory fixation devices in the demanding population of young patients. Methods: Between 2019 and 2022, 95 patients with knee post-traumatic anterior cruciate ligament insufficiency were treated with primary ACLR using semitendinosus quadrupled graft and double adjustable-loop suspensory fixation devices and followed for at least two years. Concomitant lesions were also treated at the same surgical time. The knee examination form of the International Knee Documentation Committee (IKDC) was used to assess clinical evaluation, and the return to physical activities using the Tegner Activity Scale was recorded. Patient-reported objective measures (PROMs) were also evaluated, including the IKDC subjective and Lysholm scores. Results: Sixty-six males and twenty-nine females with a mean age of 23.8 (range 18-37) and a mean BMI of 24.9 (SD ± 2.42) kg/m2 were included in this study. All patients were evaluated clinically as normal or nearly normal at the final follow-up. PROMs also significantly improved postoperatively (p < 0.05) compared to the preoperative values. The Tegner Activity Scale increased from 2 to 7, the IKDC mean score improved from 43.9 (±8.9) to 93.3 (±12.3), and the modified Lysholm from 47.3 (±11.1) to 92.9 (±16.6). No complications or adverse events were recorded. Conclusions: Anterior cruciate ligament reconstruction utilizing double adjustable-loop suspensory fixation devices provides good clinical and functional outcomes in young patients at a two-year follow-up.

Risk for Revision ACLR After Primary All-Inside Quadrupled Semitendinosus Hamstring Tendon Autograft ACLR With Independent Suture Tape Augmentation: A Retrospective Cohort Study

Background

The rate of failed anterior cruciate ligament reconstruction (ACLR) remains high in the younger and more active patient populations. Suture tape augmentation (STA) in addition to ACLR may reduce the risk for revision surgery.

Purpose/Hypothesis

The purpose of this study was to compare patient outcomes between patients who underwent primary all-inside quadrupled semitendinosus hamstring tendon autograft (QST-HTA) ACLR with and without STA. It was hypothesized that the STA cohort would demonstrate a lower incidence of subsequent revision ACLR while maintaining comparable patient-reported outcomes.

Study Design

Cohort study; Level of evidence, 3.

Methods

All patients ≤40 years of age who received primary all-inside QST-HTA ACLR with and without independent STA augmentation were identified. The following validated patient-reported outcome measures (PROMs) were collected: visual analog scale for pain, Single Assessment Numeric Evaluation, Knee injury and Osteoarthritis Outcome Score subscales, and Tegner activity scale. KT-1000 arthrometer measurements were collected pre- and postoperatively. Cox proportional hazards model and nominal logistic regression analysis were used to assess additional variables associated with revision ACLR.

Results

A total of 104 patients with a mean age of <22 years were included in the final data analysis (STA: 36 patients; control: 68 patients). Significantly fewer patients in the STA group sustained a graft failure necessitating revision surgery at the final follow-up (5.6% vs 24%; relative risk, 0.24 [95% CI, 0.06-0.97]; P = .017). Four-year graft survival was significantly higher in the STA group (97.2% vs 82.4%; P = .031). All PROMs significantly improved postoperatively except for Tegner levels, which decreased in both groups compared with their preinjury levels (P < .001). Return to sports was similar in both groups with >70% of patients returning to their previous level of competition. Regression analysis demonstrated increased risk for revision ACLR in younger patients, high school athletes, and those with higher postoperative activity levels.

Conclusion

QST-HTA ACLR with STA was associated with reduced risk for revision ACLR compared with nonaugmented QST-HTA ACLR in this young patient population. Furthermore, the addition of suture tape did not appear to affect postoperative patient-reported and return-to-sports outcomes.

Functional Outcomes of Bone-Patellar Tendon-Bone Versus Quadrupled Semitendinosus and Gracilis Autografts for Anterior Cruciate Ligament Reconstruction

Introduction Anterior cruciate ligament reconstruction (ACLR) with autografts has been available for decades; however, the choice of graft is still debated. Here, we compared the functional outcomes of the two most widely used autografts, bone-patella tendon-bone (BPTB) and quadruple-stranded semitendinosus/gracilis (ST/G) autografts, at six months following ACLR. Materials and methods This prospective study was performed in the Department of Orthopedics of Yenepoya Medical College and Hospital located in Mangalore, Karnataka, India, a tertiary care institute over a period of 18 months (November 2018 to April 2020). The study included 38 adult patients who underwent ACLR and were randomly divided into two groups: BPTB autograft (n=19) or ST/G autograft (N=19). The patients were followed up at one-, three-, and six months. Postoperatively, surgical morbidity, knee stability functional outcome on Lysholm score, and knee range of motion (ROM) were assessed. Results The groups were homogenous and comparable regarding age, sex, side of ACL affected, duration of tear to treatment, and muscle wasting (all p-values > 0.05). At six months, the majority of the patients had a tibial translation of 0-2 mm on the Lachman test and anterior drawer test, and the groups did not differ significantly (both p-values > 0.05). Additionally, at six months, both groups demonstrated a significant increase in mean Lysholm score and mean ROM (both p-values < 0.001). However, the groups did not differ in mean Lysholm score and mean ROM at baseline and any of the follow-up visits (all p-values > 0.05). Conclusion At six months, ACLR with BPTB and ST/G autografts produced significant and comparable knee stability, functional outcome, and ROM.

ACL Reconstruction Using Quadrupled Semitendinosus Versus Double-Stranded Semitendinosus and Gracilis Autograft: 2-Year Results From a Prospective Randomized Controlled Study

BACKGROUND

A disadvantage of using hamstring tendon autograft consisting of the semitendinosus and gracilis tendons for anterior cruciate ligament reconstruction is pain from tendon harvesting and persistent hamstring weakness. In the tendon-sparing all-inside technique, a quadrupled semitendinosus graft and adjustable-loop cortical fixation are suggested to give less postoperative flexion deficits while displaying overall similar clinical results to the traditional hamstring technique. However, there are a limited number of high-quality studies comparing these techniques with inconsistent results.

PURPOSE

To investigate differences between the all-inside (quadrupled semitendinosus) and traditional hamstring (double-stranded semitendinosus and gracilis) technique regarding (1) self-reported function, (2) hamstring strength, and (3) knee laxity.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 98 patients were randomized to either the all-inside or the traditional hamstring technique. Perioperatively, duration of surgery and graft size were obtained. The International Knee Documentation Committee 2000 Subjective Knee Form score, Knee injury and Osteoarthritis Outcome Score, Tegner Activity Scale score, knee laxity (KT-1000 arthrometer side-to-side difference and pivot shift), range of motion, isokinetic knee strength, and hop test score were collected preoperatively and 2 years postoperatively. Return-to-sport readiness was evaluated 9 months postoperatively.

RESULTS

A total of 89 patients completed 2-year follow-up, 45 patients with the all-inside technique and 44 patients with the traditional hamstring technique. There were no significant differences between groups in any of the outcome measures 2 years after surgery, but there was a tendency in the all-inside group toward having increased anterior translation (mean, 3.6 mm vs 2.7 mm), a higher number of revision surgeries (5 patients vs 2 patients), and more patients having +1 and +2 pivot-shift values (29 vs 18 patients) when compared with the traditional group.

CONCLUSION

The all-inside technique yields equivalent results to the traditional hamstring technique 2 years after surgery and should be considered a reliable technique to use for ACL reconstruction. Sparing the gracilis tendon does not lead to less persistent hamstring weakness. Long-term follow-up is needed to further determine whether the tendency of increased anterior translation seen at 2 years postoperatively will lead to a higher risk of graft failure.

Less Subsequent Revision Anterior Cruciate Ligament (ACL) Reconstruction Following Primary Bone-Patellar Tendon-Bone ACL Reconstruction with Suture Tape Augmentation-A Retrospective Comparative Therapeutic Trial With 5-Year Follow-up

PURPOSE

To investigate patient outcomes, including revision rate, following primary bone patellar-tendon bone autograft (BPTB) anterior cruciate ligament reconstruction (ACLR) with and without suture tape augmentation (STA) in a young and active cohort.

METHODS

All eligible patients who received primary BPTB ACLR with a minimum of 2-year follow-up were included in this retrospective cohort study. All patients receiving STA were augmented with the same device. Patients completed the following patient-reported outcome measures (PROMs): the visual analog scale, the Single Assessment Numeric Evaluation, the Knee Injury and Osteoarthritis Outcome Score subscales, and the Tegner activity scale. Anteroposterior knee laxity was assessed using a KT-1000 arthrometer preoperatively and 1-year postoperatively. Posterior tibial slope, femoral tunnel angle, and tibial tunnel placement were calculated for all patients. Subsequent surgical interventions and return to sport (RTS) were obtained from each patient.

RESULTS

One hundred fourteen patients (52 BPTB ACLR with STA, 62 traditional BPTB ACLR) with a mean patient age <19 years and a mean final follow-up of ≥5 years were included. Compared with the control group, the STA group demonstrated significantly less subsequent revision ACLR (0 vs. 5, P = .036). All PROMs and KT-1000 measurements improved at final follow-up (P < .001) and were comparable between groups. There were no differences seen in either posterior tibial slope or graft tunnel placement between groups. More than 85% of the patients were able to return to the sport that led to their injury at full capacity with no differences seen in RTS rate, time to RTS, or level of competition between groups.

CONCLUSIONS

Compared with traditional BPTB ACLR, additional STA appeared to safely and effectively lead to less subsequent revision ACLR while maintaining acceptable PROMs and objective joint laxity measurements in a young and active patient population.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Technique for All-Inside Anterior Cruciate Ligament Reconstruction Using Quadrupled Semitendinosus and Gracilis Autograft

Anterior cruciate ligament (ACL) injuries are common to athletes and non-athletes alike. Whereas the literature has historically supported bone-patellar tendon-bone as the gold standard for active patients who elect to undergo ACL reconstruction, other studies have suggested that soft-tissue grafts do not increase the risk of rerupture. Because graft diameter has a direct effect on revision rates, we share a technique for all-inside ACL reconstruction using quadrupled semitendinosus and gracilis autograft that allows for a predictable, robust graft. Reproducible steps of graft harvesting, tunnel preparation, graft passage, and fixation are shared to achieve a robust anatomic reconstruction.

The reverse fragility index: RCTs reporting non-significant differences in failure rates between hamstring and bone-patellar tendon-bone autografts have fragile results

PURPOSE

The reverse fragility index (RFI) is a novel metric to appraise the results of studies reporting statistically non-significant results. The purpose of this study was to determine the statistical robustness of randomized controlled trials (RCTs) reporting non-significant differences in anterior cruciate ligament reconstruction (ACLR) graft failure rates, defined as re-rupture/revision ACLR rate, between hamstring tendon (HT) and bone-patellar tendon-bone (BTB) autografts by calculating RFIs.

METHODS

A systematic review was performed to identify RCTs that compared HT to BTB grafts for ACLR through January 2022. Studies reporting non-significant differences in graft re-rupture and revision ACLR rate (n.s.) were included. The RFI, defined as the fewest number of event reversals needed to change the non-significant graft re-rupture/revision outcome to statistically significant (P < 0.05), was recorded for each study. In addition, the number of studies in which the loss to follow-up exceeded the RFI was recorded.

RESULTS

Among the 16 included RCTs, the median (interquartile range [IQR]) sample size was 71 (64-114), and the median (IQR) total number of graft re-rupture/revision ACLR events was 4 (4-6). The median (IQR) graft re-rupture/revision ACLR rate was 4.3% (3.0-6.4) overall, 4.1% (2.6-6.7) in the BTB group, and 5.4% (3.0-6.3) in the HT group. The median (IQR) RFI was 3 (3-4), signifying that a reversal of the outcome in 3 patients in one arm was needed to flip the studies' result from non-significant to statistically significant (P < 0.05). The median (IQR) number of participants lost to follow-up was 11 (3-13), and 13 (81.3%) of the included studies had a loss to follow-up greater than the studies' RFI.

CONCLUSION

The results of RCTs reporting statistically non-significant re-rupture/revision ACLR rates between HT and BTB autografts would become significant if the outcome were reversed in a small number of patients-a number that was less than the loss to follow-up in the majority of studies. Thus, the neutrality of these studies is fragile, and a true statistically significant difference in re-rupture/revision rates may have been undetected.

LEVEL OF EVIDENCE

Level I.

Suture-tape augmentation of anterior cruciate ligament reconstruction: a prospective, randomised controlled trial (STACLR)

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction aims to restore anteroposterior and rotatory stability to the knee following ACL injury. This requires the graft to withstand the forces applied during the process of ligamentisation and the rehabilitative period. We hypothesise that the use of suture tape augmentation of single bundle ACL reconstruction (ACLR) will reduce residual knee laxity and improve patient-reported outcomes at 2-year follow-up. We will conduct a 1:1 parallel arm single-centre randomised controlled trial comparing suture tape augmented ACLR to standard ACLR technique.

METHODS

The study design will be a parallel arm 1:1 allocation ratio randomised controlled trial. Sixty-six patients aged 18 and over waitlisted for primary ACLR will be randomised. Patients requiring osteotomy and extra-articular tenodesis and who have had previous contralateral ACL rupture or repair of meniscal or cartilage pathology that modifies the post-operative rehabilitation will be excluded. The primary outcome measure will be the side-to-side difference in anterior tibial translation (measured on the GNRB arthrometer) at 24 months post-surgery. GNRB arthrometer measures will also be taken preoperatively, at 3 months and 12 months post-surgery. Secondary outcomes will include patient-reported outcome measures (PROMs) collected online, including quality of life, activity and readiness to return to sport, complication rates (return to theatre, graft failure and rates of sterile effusion), examination findings and return to sport outcomes. Participants will be seen preoperatively, at 6 weeks, 3 months, 12 months and 24 months post-surgery. Participants and those taking arthrometer measures will be blinded to allocation.

DISCUSSION

This will be the first randomised trial to investigate the effect of suture-tape augmentation of ACLR on either objective or subjective outcome measures. The use of suture-tape augmentation in ACLR has been associated with promising biomechanical and animal-level studies, exhibiting equivalent complication profiles to the standard technique, with initial non-comparative clinical studies establishing possible areas of advantage for the technique. The successful completion of this trial will allow for an improved understanding of the in situ validity of tape augmentation whilst potentially providing a further platform for surgical stabilisation of the ACL graft.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry ACTRN12621001162808. Universal Trial Number (UTN): U1111-1268-1487. Registered prospectively on 27 August 2021.

Return to Sport After Anterior Cruciate Ligament Reconstruction Requires Evaluation of >2 Functional Tests, Psychological Readiness, Quadriceps/Hamstring Strength, and Time After Surgery of 8 Months

PURPOSE

The purpose of this study was to examine the factors commonly used to determine readiness for return to sport (RTS) in the ACL reconstruction (ACL-R) patient population and assess which were most influential to successfully returning to sport and avoiding re-tear.

METHODS

The PUBMED, EMBASE and Cochrane Library databases were queried for studies related to RTS in ACL-R. Inclusion and exclusion criteria were applied to identify studies with greater than 1-year outcomes detailing the rate of return and re-tear given a described RTS protocol. Data of interest were extracted, and studies were stratified based on level of evidence and selected study features. Meta-analysis or subjective synthesis of appropriate studies was used to assess more than 25 potentially significant variables effecting RTS and re-tear.

RESULTS

After initial search of 1503 studies, 47 articles were selected for inclusion in the final data analysis, including a total of 1432 patients (31.4% female, 68.6% male). A meta-analysis of re-tear rate for included Level of Evidence 1 studies was calculated to be 2.8%. Subgroups including protocols containing a strict time until RTS, strength testing, and ≥2 dynamic tests demonstrated decreased RTS and re-tear heterogeneity from the larger group. Time to RTS, strength testing, dynamic functional testing, and knee stability were also found to be among the most prevalent reported criteria in RTS protocol studies.

CONCLUSIONS

This study suggests a multifactorial clinical algorithm for successful evaluation of RTS. The "critical criteria" recommended by the authors to be part of the postoperative RTS criteria include time since surgery of 8 months, use of >2 functional tests, psychological readiness testing, and quadriceps/hamstring strength testing in addition to the modifying patient factors of age and female gender.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV studies.

Short graft anterior cruciate ligament reconstruction: Current concepts

Short graft anterior cruciate igament reconstruction is increasing in popularity for performing a primary ACLR. The short graft coupled with the all-inside technique using closed sockets and suspensory fixation at both femoral and tibial ends are its defining features. The outcomes of this technique have been comparable to well established transportal ACLR techniques. It has the benefits of preserved hamstring strength and less pain attributed to transtibial drilling. However, there is a learning curve involved and will require time before mastery of the technique. Furthermore, in combined osteotomy or multiligament surgery, the use of short graft anterior cruciate ligament reconstruction with sockets preserve bone stock and the single tendon harvest spares the other tendons for use in other ligament reconstruction.

Long-term quality of life, work limitation, physical activity, economic cost and disease burden following ACL and meniscal injury: a systematic review and meta-analysis for the OPTIKNEE consensus

OBJECTIVE

Determine the long-term health-related quality-of-life (HRQoL), work limitation, physical activity, health/economic cost and disease burden of traumatic ACL and/or meniscal injury. Findings will inform OPTIKNEE evidence-based consensus recommendations.

DESIGN

Random-effects meta-analysis evaluated HRQoL (SF-36/SF-12/VR-12 Physical Component Scores (PCS) and Mental Component Scores (MCS), EuroQol-5D (EQ-5D)) stratified by time postinjury, and pooled mean differences (95% CI) between ACL-injured and uninjured controls. Other outcomes were synthesised descriptively. Risk-of-bias (RoB) and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation) were assessed.

DATA SOURCES

MEDLINE, EMBASE, CENTRAL, SPORTDiscus, CINAHL searched inception: 22 November 2021.

ELIGIBILITY

Studies reporting HRQoL, work limitations, physical activity levels, health/economic costs or disease burden, ≥2 years post-ACL and/or meniscal injury.

RESULTS

Fifty studies were included (10 high-RoB, 28 susceptible-to-some-bias and 12 low-RoB). Meta-analysis (27 studies, very low certainty of evidence) estimated a pooled mean (95% CI) PCS of 52.4 (51.4 to 53.4) and MCS of 54.0 (53.0 to 55.0) 2-14 years post-ACL injury. Pooled PCS scores were worse >10 years (50.8 (48.7 to 52.9)) compared with 2-5 years (53.9 (53.1 to 54.7)) postinjury. Excluding high-RoB studies, PCS scores were worse in ACL-injured compared with uninjured controls (-1.5 (-2.9 to -0.1)). Six studies (low certainty of evidence) informed a pooled EQ-5D score of 0.83 (0.81 to 0.84). Some individuals experienced prolonged work absenteeism and modified activities ≥2 years post-ACL injury. ACL injury was associated with significant direct and indirect costs, and early ACL reconstruction may be less cost-effective than rehabilitation. Only three studies evaluated meniscal injury outcomes (all evaluated HRQoL).

CONCLUSION

There is a very-low certainty of evidence that PCS scores ≥2 years post-ACL injury are worse than uninjured controls and decline over time, whereas MCS scores remain high. ACL injury can result in prolonged work absenteeism and high health/economic costs. Further studies are needed to determine the long-term burden of traumatic meniscal injury.

Comparative Results of Anterior Cruciate Ligament Reconstruction with Full Tibial Tunnel: Quadrupled Semitendinosus Suspensory Femoral and Tibial Fixation versus Quadrupled Semitendinosus and Gracilis Suspensory Femoral and Tibial Screw and Staple Fixation

This study compared the clinical outcomes of patients treated with described "modified all-inside" anterior cruciate ligament reconstruction (ACLR) technique with those of patients treated with suspensory femoral fixation and a bioabsorbable tibial interference screw with the ACLR technique. From 2017 to 2019, 98 patients who underwent ACLR surgery by two surgeons using either of the techniques were included in this study. Patients in group 1 were treated with the "modified all-inside" ACLR technique. In this technique, only the semitendinosus tendon was harvested as a four-strand graft and fixed to the tibia and femur with suspensory buttons. Patients in group 2 were treated with suspensory femoral fixation and a bioabsorbable tibial interference screw ACL reconstruction technique. Patients' functional outcomes were evaluated by the Lysholm score, Tegner activity scale, and International Knee Documentation Committee (IKDC) subjective score. Postoperative knee stability of the patients was evaluated using the Lachman test and the pivot-shift test. The mean ages of the patients were 31.1 (16-55) and 28.7 (18-48) years in groups 1 and 2, respectively. The average follow-up durations were 26 (20-30) and 25.9 (22-30) months for both groups. There was no significant difference between the preoperative and postoperative Lysholm's score, Tegner's activity score, and IKDC subjective score in groups 1 and 2. There were no major complications or reruptures in either group. ACLR incorporating the "modified all-inside" ACLR technique obtained significant clinical outcomes compared to ACLR with a suspensory femoral fixation and a bioabsorbable tibial interference screw.

Bone-patellar tendon-bone autograft maturation is superior to double-bundle hamstring tendon autograft maturation following anatomical anterior cruciate ligament reconstruction

PURPOSE

The primary purpose of this study was to evaluate the second-look arthroscopic findings 1 year postoperatively and magnetic resonance imaging (MRI) findings 2 years after anterior cruciate ligament reconstruction (ACLR) using bone-patellar tendon-bone autograft (BTB) or hamstring tendon autograft (HT). Secondary purpose included clinical results from physical examination, including range of motion, Lachman test, pivot shift test, and knee anterior laxity evaluation, and the clinical score for subjective evaluations at 2 years after surgery.

METHODS

Between 2015 and 2018, 75 patients with primary ACL injuries were divided into either the BTB group (n = 30) or HT group (n = 45). When using HT, an anatomical double-bundle ACLR was performed. BTB was indicated for athletes with sufficient motivation to return to sporting activity. Graft maturation on second-look arthroscopy was scored in terms of synovial coverage and revascularization. All participants underwent postoperative MRI evaluation 2 years postoperatively. The signal intensity (SI) characteristics of the reconstructed graft were evaluated using oblique axial proton density-weighted MR imaging (PDWI) perpendicular to the grafts. The signal/noise quotient (SNQ) was calculated to quantitatively determine the normalized SI. For clinical evaluation, the Lachman test, pivot shift test, KT-2000 evaluation, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS) were used.

RESULTS

Arthroscopic findings showed that the graft maturation score in the BTB group (3.6 ± 0.7) was significantly greater than that in the anteromedial bundle (AMB; 2.9 ± 0.2, p = 0.02) and posterolateral bundle (PLB; 2.0 ± 0.9, p = 0.001) in the HT group. The mean MRI-SNQs were as follows: BTB, 2.3 ± 0.5; AMB, 2.9 ± 0.9; and PLB, 4.1 ± 1.1. There were significant differences between BTB, AMB, and PLB (BTB and AMB: p = 0.04, BTB and PLB: p = 0.003, AMB and PLB: p = 0.03). Second-look arthroscopic maturation score and MRI-SNQ value significantly correlated for BTB, AMB, and PLB. No significant differences were detected in clinical scores. There was a significant difference (p = 0.02) in the knee laxity evaluation (BTB: 0.9 ± 1.1 mm; HT: 2.0 ± 1.9 mm).

CONCLUSION

BTB maturation is superior to that of double-bundle HT based on morphological and MRI evaluations following anatomical ACLR, although no significant differences were found in clinical scores. Regarding clinical relevance, the advantages of BTB may help clinicians decide on using the autograft option for athletes with higher motivation to return to sporting activity because significant differences were observed in morphological evaluation, MRI assessment, and knee anterior laxity evaluation between BTB and double-bundle HT.

LEVEL OF EVIDENCE

Level IV.

Anterior Cruciate Ligament Reconstruction With the All-Inside Technique: Equivalent Outcomes and Failure Rate at Three-Year Follow-Up Compared to a Doubled Semitendinosus-Gracilis Graft

Purpose: To compare in terms of failure rates, clinical and functional outcomes the all-inside anterior cruciate ligament (ACL) reconstruction with double suspensory fixation and quadrupled semitendinosus autograft with anteromedial portal doubled semitendinosus-gracilis autograft with suspensory femoral and tibial interference screw fixation.

Methods: Forty-four patients were sequentially allocated into two groups and followed up prospectively for a 3-year period. The first group was the all-inside group and the second was the “classic” AM portal with S-G graft. Each group comprised 22 patients. All patients underwent KT-1000 testing preoperatively and at a minimum of six months postoperatively. Visual pain analog was recorded preoperatively and during both the immediate postoperative period and throughout the follow-up. The Lysholm knee score was used comparing the preoperative and 24-month timepoints.

Results: The visual analog scale (VAS) pain scores showed a significant difference at two weeks (2.4 vs 1.8, p < 0.01 ) in favor of the all-inside group, but that difference disappeared in the later follow-up visits. Similarly, there was no significant difference with Lysholm knee scores at two years and the side-to-side anterior translation measured with the KT-1000. At the three-year mark, there were no failures in either of the groups.

Conclusion: The all-inside technique appears to be equivalent in terms of outcomes to the classic S-G technique, and given the less-invasive nature and versatility in graft choices is a safe and effective technique for primary ACL reconstruction.

Current and future of anterior cruciate ligament reconstruction techniques

In recent years, anterior cruciate ligament (ACL) reconstruction has generally yielded favorable outcomes. However, ACL reconstruction has not provided satisfactory results in terms of the rate of returning to sports and prevention of osteoarthritis (OA) progression. In this paper, we outline current techniques for ACL reconstruction such as graft materials, double-bundle or single-bundle reconstruction, femoral tunnel drilling, all-inside technique, graft fixation, preservation of remnant, anterolateral ligament reconstruction, ACL repair, revision surgery, treatment for ACL injury with OA and problems, and discuss expected future trends. To enable many more orthopedic surgeons to achieve excellent ACL reconstruction outcomes with less invasive surgery, further studies aimed at improving surgical techniques are warranted. Further development of biological augmentation and robotic surgery technologies for ACL reconstruction is also required.

All-Inside Anterior Cruciate Ligament Reconstruction Using Quadrupled Semitendinosus: Comparable 2-Year Outcomes in Male and Female Patients

PURPOSE

To determine 2-year functional outcomes using an all-inside quadrupled semitendinosus anterior cruciate ligament (ACL) reconstruction technique in male and female patients.

METHODS

A total of 100 patients who underwent quadrupled semitendinosus all-inside hamstring ACL reconstruction by a single surgeon were enrolled. Patient-reported outcome scores collected preoperatively and postoperatively included visual analog scale, Veterans Rand 12-Item Health Survey (VR-12; Physical and Mental), Marx Activity Scale, Knee Injury and Osteoarthritis Outcome Scores (KOOS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

RESULTS

A total of 100 ACL reconstructions comprising 62 female, and 38 male patients were included in this study. Mean graft diameter was 9.4 mm in female and 9.8 mm in male patients (range, 9-11). Outcome scores demonstrated improvement from preoperative to 2-year postoperative respectively: visual analog scale pain 3.18, 1.07, VR-12 physical 36.35, 52.64, VR-12 mental 53.96, 54.65, KOOS pain 59.17, 89.03, KOOS symptoms 52.64, 80.79, KOOS Activities of Daily Living 69.38, 95.4, KOOS Sport 28.97, 81.25, KOOS Quality of Life 27.54, 71.56, WOMAC Pain 71.56, 92.65, WOMAC Stiffness 60.55, 84.13, and WOMAC Function 69.38, 95.4. Marx activity score decreased from baseline (10.98) to 2 years' postoperatively (8.75). At 2 years, patient expectations were met or exceeded with regards to pain (94%), motion and strength (91%), normal function of daily living (95%), and return to sport (79%).

CONCLUSIONS

Anatomic all-inside quadrupled semitendinosus ACL reconstruction improves functional outcomes similarly to previous studies between baseline and clinical follow-up at 1-year and 2-years postoperatively and is comparable in both male and female patients.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Medical Journals Should Be a Forum for Disruptive Research

Disruptive innovation completely changes the traditional way that we operate and may only be realized in retrospect. For example, shoulder superior capsule reconstruction (SCR) is a complete change from the traditional methods of treating massive, irreparable rotator cuff tears and pseudoparalysis. Classic examples of disruptions in orthopaedic surgery include distraction osteogenesis, total hip joint replacement arthroplasty, and modern orthopaedic trauma care. Orthopaedic technologies that promise future disruption include artificial intelligence, surgical simulation, and orthopaedic biologics, including mesenchymal stromal cell (MSC) and gene therapy. Most of all, arthroscopic surgery completely changed the way we operate by using new methods and technology. Many never saw it coming. The challenge going forward is to motivate and foster new ideas and research that result in innovation and progress. Skepticism has a place, but not at the expense of transformative ideas, particularly as medical journals offer the alternative of prospective hypothesis testing using the scientific method, followed by unbiased peer review, and publication. Medical journals should be a forum for disruptive research.

Bone Grafting the Patellar Defect After Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction Decreases Anterior Knee Morbidity: A Systematic Review

PURPOSE

The aim of this systematic review was to evaluate the impact of bone grafting of patellar defects on reported anterior knee morbidity and subjective outcomes after bone-patellar tendon-bone autograft reconstruction of the anterior cruciate ligament.

METHODS

A systematic electronic search of MEDLINE, Embase, Web of Science, and the Cochrane Library was carried out. All English-language prospective randomized clinical trials published from January 1, 2000, to July 24, 2020, were eligible for inclusion. All studies addressing patellar defect grafting were eligible for inclusion regardless of the timing of surgery, graft type, surgical technique, or rehabilitation protocol.

RESULTS

A total of 39 studies with 1,955 patients were included for analysis. There were 796 patients in the no patellar grafting (NPG) group, with a mean age range of 22.7 to 33.0 years, and 1,159 patients in the patellar grafting (PG) group, with a mean age range of 17.8 to 34.7 years. The visual analog scale pain score ranged from 1.2 to 5.1 in the NPG group compared with 0.3 to 3.7 in the PG group. The proportion of patients with anterior knee pain ranged from 19% to 81% in the NPG group and from 15% to 32% in the PG group. Moderate to severe kneeling pain was reported in 22% to 57% of patients in the NPG group and 10% of those in the PG group. The percentage of patients with at least 3° of extension loss ranged from 4% to 43% in the NPG group and from 2% to 11% in the PG group.

CONCLUSIONS

PG favors decreased anterior knee pain, kneeling pain, and extension loss compared with non-grafted defects; however, the functional outcomes are comparable. Owing to the heterogeneity in reporting, statistical conclusions could not be drawn.

LEVEL OF EVIDENCE

Level II, systematic review of Level I and II studies.

Effectiveness of thicker hamstring or patella tendon grafts to reduce graft failure rate in anterior cruciate ligament reconstruction in young patients

PURPOSE

The purpose of this study was to determine the anterior cruciate ligament reconstruction (ACLR) failure rate in young patients utilizing the New Zealand (NZ) anterior cruciate ligament (ACL) Registry. The hypothesis was that the ACLR rupture rate would be lower for thicker hamstring graft and bone patellar tendon bone (BPB) grafts in comparison to the classic hamstring technique. The ACLR failure rate was assessed according to graft type and patients' sex.

METHODS

The NZ ACL registry was utilized to identify all patients aged 20 years or younger at the time of surgery who were skeletally mature and had a minimum 2-year follow-up. Graft ruptures, defined as an ACL revision, were identified according to graft type (traditional 4 strands hamstring semitendinosus and gracilis, 4 strands semitendinosus, 5-6 strands semitendinosus and gracilis, 7-8 strands semitendinosus and gracilis, bone-patella-bone graft).

RESULTS

Nine-hundred and ninety-two patients were included. At a mean follow-up of 38 months, 52 cases of graft rupture were recorded, (overall failure rate: 5.2%). The failure rate was not statistically influenced by the graft diameter. Patients with a thinner graft (< 8 mm-196 patients) had a similar failure rate (6%) to patients with a thicker graft (8 mm or more-485 patients) (6.2%). There was a lower failure rate in the BPB group (3.1%) versus all hamstrings group (6%) (ns). Finally, BPB in females had a lower failure rate than all hamstring constructs together (0% versus 5.1%; p = 0.023) CONCLUSION: In a young population traditional four-strand hamstring grafts, multiple strand configurations or BPB ACLR, whatever their size (> or < 8 mm), showed no significant difference in the failure rate in the NZ ACL registry. Female patients who had an ACL reconstruction with BPB graft had a significant lower failure rate than patients who had a hamstring graft.

LEVEL OF EVIDENCE

III.

Minimally Invasive Quad Harvest Featuring Endoscopic Closure and Preparation With Adjustable Suspensory Fixation Device Incorporated With Braided Suture

The quad tendon has increasingly became a very common option for anterior cruciate ligament reconstruction. Minimally invasive approaches are one of the many advantages to the quad tendon graft. One of the issues with a small incision is assuring appropriate proximal closure. In this technique, we use the arthroscope to view proximally and a Scorpion (Arthrex) device to close our proximal quad harvest. We also describe the updated preparation of the quad tendon with FiberTag TightRope (Arthrex) and FiberTag ABS (Arthrex). These implants have FiberTag incorporated to the suspensory devices that creates a stable construct that is faster to incorporate into the quad with the slotted clamp. Together, these updates to the preparation and harvest should make the construct more reproducible and decrease donor-site morbidity respectively.

Editorial Commentary: Graft Choice for Anterior Cruciate Ligament Reconstruction: Will There Ever Be a Correct Answer? Probably Not

Graft choice for anterior cruciate ligament reconstruction has been a great controversy in the sports medicine literature for the last 25 years. It has been well studied in the orthopaedic literature, with numerous randomized control trials and large database studies. There remain advantages and disadvantages to each autograft choice, primarily bone-patellar tendon-bone, quadrupled hamstring, as well as allograft. More recently, quadriceps autograft has also been studied as a suitable alternative. Most studies show nearly equivalent functional outcomes for autograft anterior cruciate ligament using bone-patellar tendon-bone and hamstring autografts in athletes younger than the age of 25 years, whereas allograft may be preferred for older athletes.