Double-incision mini-invasive technique for BTB harvesting: its superiority in reducing anterior knee pain following ACL reconstruction

Patellar bone defect grafting does not reduce anterior knee pain after bone-patellar tendon-bone anterior cruciate ligament reconstruction

PURPOSE

Donor site morbidity is the main drawback to using bone-patellar tendon-bone (BPTB) as a graft in anterior cruciate ligament (ACL) reconstruction. The objective of the study was to determine whether refilling the patellar bone defect after BPTB harvesting with autograft bone decreased kneeling pain to a greater degree when compared with a group in which bone defect is left unaddressed.

METHODS

This is a randomised single-blinded controlled study. Forty patients were randomised into two groups; group 1: Patellar bone defect filled with autologous bone; group 2: Bone defect left undressed. Pain was measured by means of pressure algometry (PA). Functional outcomes were measured with the Kujala and Victorian Institute of Sport Assessment-Patella (VISA-P) score. Magnetic resonance imaging (MRI) was done to measure bone buildup between groups at the 1-year follow-up.

RESULTS

No differences were observed in the different algometry measurements and the scores were assessed at 3, 6 and 12 months postoperatively. The ratio of void filled remained consistently higher (p = 0.003) in group 1 when compared to group 2.

CONCLUSIONS

Although refilling the lower pole of the patella with autologous bone from the harvested BPTB autograft loads the bone defect, it does not reduce pain at the donor site 1 year after surgery.

LEVEL OF EVIDENCE

Therapeutic study level 1.

The impact of bone graft type used to fill bone defects in patients undergoing ACL reconstruction with bone-patellar tendon-bone (BPTB) autograft on kneeling, anterior knee pain and knee functional outcomes

PURPOSE

Multiple different materials are used for filling bone defects following bone-patellar tendon-bone (BPTB) graft ACL reconstruction surgery. The theoretical objective being to minimize kneeling pain, improve clinical outcomes and reduce anterior knee pain following surgery. The impact of these materials is assessed in this study.

METHODS

A prospective monocentric cohort study was conducted from January 2018 to March 2020. There were 128 skeletally mature athletic patients who underwent ACL reconstruction using the same arthroscopic-assisted BPTB technique, with a minimum follow-up of two years identified in our database. After obtaining approval from the local ethics committee, 102 patients were included in the study. Patients were divided into three groups based on type of bone substitute. The Bioactive glass 45S5 ceramic Glassbone™ (GB), collagen and hydroxyapatite bone void filler in sponge form Collapat® II (CP), and treated human bone graft Osteopure®(OP) bone substitutes were used according to availability. Clinical evaluation of patients at follow-up was performed using the WebSurvey software. A questionnaire completed in the 2nd post-operative year included three items: The ability to kneel, the presence of donor site pain, and the palpation of a defect. Another assessment tool included the IKDC subjective score and Lysholm score. These two tools were completed by patients preoperatively, and postoperatively on three occasions (6 months, 1 year, and 2 years).

RESULTS

A total of 102 patients were included in this study. In terms of Kneeling pain, the percentage of GB and CP patients' who kneel with ease were much higher than that of OP patients (77.78%, 76.5% vs 65.6%, respectively). All three groups experienced an important increase in IKDC and Lysholm scores. There was no difference in anterior knee pain between the groups.

CONCLUSION

The use of Glassbone® and Collapat II® bone substitutes reduced the incidence of kneeling pain compared to Osteopure®. There was no influence of the bone substitute type on the functional outcome of the knee or on the anterior knee pain at two years of follow.

Reduced Incidence of Revision Anterior Cruciate Ligament Reconstruction With Internal Brace Augmentation

Background

Revision rates and outcome measures after anterior cruciate ligament reconstruction (ACLR) with suture tape as an internal brace is not well-documented because of the emerging nature of the technique.

Hypothesis

ACLR with internal bracing (IB) would lead to decreased revision ACLR compared with traditional ACLR while exhibiting comparable patient outcomes.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 200 patients were included in this study. Patients aged between 13 and 39 years at the time of surgery who underwent primary autograft ACLR with IB between 2010 and 2020 and were enrolled in our institution's registry with a minimum of 2-year follow-up were identified and matched 1 to 1 with a non-internal brace (no-IB) group based on concomitant procedures and patient characteristics. Pre- and postoperatively, patients completed the Knee injury and Osteoarthritis Outcome Score, Marx activity rating scale, Veterans RAND 12-Item Health Survey, and visual analog scale for pain. Knee laxity measurements via the KT-1000 arthrometer were included in the pre- and postoperative objective clinical assessments.

Results

A total of 100 IB patients were matched with 100 no-IB patients based primarily on concomitant procedures and secondarily on patient characteristics. The IB group underwent significantly fewer revision ACLRs (1% vs 8%; P = .017). Even though the no-IB group had a significantly longer mean final follow-up time (48.6 months [95% CI, 45.4-51.7] vs 33.4 months [95% CI, 30.3-36.5]; P < .001), the time elapsed from the original ACLR to the revision did not differ significantly between groups, and the mean ages for the IB and no-IB groups were comparable (19 vs 19.9 years). All postoperative patient-reported outcome scores between the 2 groups were comparable and significantly improved postoperatively except for the Marx score, which significantly decreased stepwise for both groups postoperatively. KT-1000 measurements significantly improved in both groups after surgery with the IB and no-IB cohorts yielding comparable results at the manual maximum pull (0.97 vs 0.65 mm).

Conclusion

ACLR with IB resulted in a significantly decreased risk of revision ACLRs while maintaining comparable patient-reported outcomes. Therefore, incorporating an internal brace into ACLR appears to be safe and effective within these study parameters.

Anterior Cruciate Ligament Reconstruction Using Bone-Patella Tendon-Bone Autograft With Press-Fit Femoral Fixation: The Original Chambat Technique

Patellar tendon grafts have long been considered the gold standard for anterior cruciate ligament reconstruction (ACLR). This Technical Note describes ACLR using bone-patella tendon-bone (BPTB) autograft with press-fit femoral fixation using an outside-in drilling technique.

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.

Postoperative Pain Is Associated With Psychological and Physical Readiness to Return to Sports One-Year After Anterior Cruciate Ligament Reconstruction

Purpose

To identify whether any patient factors, injury factors, or symptom severity scores are associated with either psychological or physical readiness to return to sport after anterior cruciate ligament reconstruction (ACLR).

Methods

Consecutive patients with an ACL injury that required surgical treatment were included in this study. All patients completed the single-legged hop testing and the Anterior Cruciate Ligament Return to Sport Index (ACL-RSI) at 1 year postoperatively. Multivariable regression analysis models were used to determine whether an independent relationship existed between baseline patient factors (age, sex, BMI, preinjury Marx Activity Score), injury factors (meniscal tear and chondral injury), physical symptoms (Knee Injury and Osteoarthritis Outcome Score [KOOS] for pain and symptoms), and the dependent variables of physical and psychological readiness to return to sport (single-legged hop and ACL-RSI).

Results

Of the 113 patients who were included, 37% were female, and the mean age of our population was 28.2 years (SD = 8.1). Multivariable regression models demonstrated that patient-reported pain symptoms at 1 year postoperatively, as measured by the KOOS pain subscale, was significantly associated with both ACL-RSI score (Beta estimate: 1.11 [95% CI: .62-1.60] P < .001) and the ability to pass the single-legged hop test (OR: 1.07 [95% CI: 1.004-1.142] P = .037).

Conclusions

Patients with higher reported pain levels at 1 year following ACLR have lower psychological and physical readiness to return to sport.

Level of Evidence

Level 3, retrospective cohort study.

The patellar ligament: A comprehensive review

The patellar ligament (PL) is an epiphyseal ligament and is part of the extensor complex of the knee. The ligament has gained attention due to its clinical relevance to autograft and tendinopathy. A variety of anatomical variations of the PL such as aplasia, numerical variations, and vascularity are being reported recently by clinicians and anatomists. The aim of this literature was to review the available literature to provide a consensus regarding anatomic variations of the PL, neurovasculature surrounding the PL, histology of the PL, and various aspects of PL measurements with relevance to the surgical considerations and sex and age-related differences. A narrative review of the patellar ligament was performed by conducting a detailed literature search and review of relevant articles. A total of 90 articles on the patellar ligament were included and were categorized into studies based on anatomical variations, neurovasculature, morphometrics, microanatomy, sex and age-related difference, and ACL reconstruction. The anatomical variations and morphometrics of the PL were found to correlate with the frequency of strain injuries, tendinopathy, and efficacy of the PL autograft in anterior cruciate ligament reconstruction. The sex differences in PL measurements and the effect of estrogen on collagen synthesis explained a higher incidence of patellar tendinopathy in women. An awareness of its variations enables careful selection of surgical incisions, thereby avoiding complications related to nerve injury. Accurate knowledge of the PL microanatomy assists in understanding the mechanism of ligament degeneration, rupture, autograft harvesting, and ligamentization results.

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.

Evolution in ACL Autograft Harvesting Techniques: Transition to Minimally Invasive Autograft Harvesting

Surgical techniques for anterior cruciate ligament (ACL) reconstruction continue to evolve. Harvesting techniques for commonly used ACL autografts such as bone patellar tendon bone, hamstring, and quadriceps tendon have similarly continued to progress. Traditional larger incisions for graft harvesting that were described in the 1980s have given way to smaller or more minimally invasive techniques. Advantages of these techniques are primarily anatomy based and include the following: decreased nerve complaints such as hypoesthesia or dysesthesia, improved cosmesis, decreased surgical site pain or morbidity, and, in the case of hamstring harvesting, easier tendon identification. The current literature supports reproducible minimally invasive or modified graft harvesting techniques for bone patellar tendon bone, hamstring, and quadriceps tendon autografts. Specialized instrumentation is available to simplify the harvesting process. Each of these techniques is described in detail outlining surgical steps, technical considerations, and precautions. Knowledge and review of these techniques provides the surgeon with greater flexibility and options when choosing and harvesting autograft tissue for ACL reconstruction.

Minimally invasive harvesting of the quadriceps tendon: Technical note

The quadriceps tendon is gaining preference as an autograft over conventional grafts for the primary reconstruction of the anterior and posterior cruciate ligaments and of the medial patello-femoral ligament. In the past, the use of the quadriceps tendon was associated with considerable morbidity and less favourable outcomes compared to other grafts, specifically due to post-operative weakness of the quadriceps and other complications such as patellar fracture and rupture of the extensor apparatus. These problems are partially ascribable to the graft harvesting method used (large incision, bone block>2cm, and full-thickness tendon harvesting). Recent technical advancements have made reproducible harvesting of quadriceps grafts possible, thereby largely preventing the complications. In this study we describe an original quadriceps tendon harvesting technique in which a minimally invasive approach allows the collection of a sufficiently long graft, while sparing the deep layer of the quadriceps tendon. This technique decreases intra-operative morbidity and improves the post-operative outcomes.

Outcome of bone-patellar tendon-bone vs hamstring tendon autograft for anterior cruciate ligament reconstruction: A meta-analysis of randomized controlled trials with a 5-year minimum follow-up

BACKGROUND

Many systematic reviews have compared the short-term outcomes of anterior cruciate ligment (ACL)reconstruction with hamstring and patellar tendon autograft,but few differences have been observed. The purpose of this meta-analysis was to compare the medium-term outcome of bone-patellar tendon-bone and hamstring tendon autograft for anterior cruciate ligament reconstruction in terms of clinical function, knee stability, postoperativecomplications, and osteoarthritis changes.

METHODS

This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The PubMed, Embase, and the Cochrane Library databases were searched from inception to November 2, 2019. This meta-analysis included only randomized controlled trials that compared BPTB and HT autografts for ACL reconstruction with a 5-year minimum follow-up. The Cochrane Collaboration's risk-of-bias tool was used to estimate the risk-of-bias for all included studies. RevMan 5.3 software was used to performed statistical analysis of the outcomes.

RESULTS

Fifteen RCTs, involving 1298 patients (610 patients in the BPTB group and 688 patients in the HT group) were included. In terms of clinical function, no significant difference was found in the objective International Knee Documentation Committee score (OR = 0.94, 95%CI: 0.64-1.37, P = .75), Lysholm knee score (MD = -2.26, 95%CI: -4.56 to 0.05, P = .06), return to preinjury activity level (OR = 1.01, 95%CI: 0.67-1.52, P = .96), and Tegner activity level (OR = 0.03, 95%CI: -0.36 to 0.41, P = .89). There was no statistically significant difference in the Lachman test (OR = 0.86, 95%CI: 0.5-1.32, P = .50), pivot-shift test (OR = 0.68, 95%CI: 0.44-1.06, P = .09), and side-to-side difference (MD = -0.32, 95%CI: -0.81 to 0.16, P = .19). As for postoperative complications and OA changes, there were no statistically significant difference in flexion loss (OR = 1.09, 95%CI: 0.47-2.54, P = .85) and OA changes (OR = 0.76, 95%CI: 0.52-1.10, P = .15), but we found significant differences in favor of the HT group in the domains of kneeling pain (OR = 1.67, 95%CI: 1.04-2.69, P = .03), anterior knee pain (OR = 2.90, 95%CI: 1.46-5.77, P = .002), and extension loss (OR = 1.75, 95%CI: 1.12-2.75, P = .01). There was a significant difference in favor of the BPTB group in the domain of graft failure (OR = 0.59, 95%CI: 0.38-0.91, P = .02).

CONCLUSIONS

Based on the results above, HT autograft is comparable with the BPTB autograft in terms of clinical function, postoperative knee stability, and OA changes, with a medium-term follow-up. The HT autograft for ACL reconstruction carries a lower risk of complications, such as anterior knee pain, kneeling pain, and extension loss, but an increased incidence of graft failure. Patients should be informed of the differences when deciding on graft choice with their physician.

Saphenous nerve injury after anterior cruciate ligament reconstruction: Reduced numbness area after ligamentoplasty using quadriceps tendon compared with hamstring tendon

PURPOSE

Injury to the infra-patellar branches of the saphenous nerve (IPBSN) is the main neurological complication of anterior cruciate ligament (ACL) reconstruction procedures. Surgical technique using quadriceps tendon (QT) autograft allows a less invasive tibial approach potentially protecting the IPBSN. The aim of this study was to compare the numbness surface of the cutaneous area supplied by the IPBSN after ACL reconstruction using either hamstring tendon (HT) or QT autografts.

METHODS

This was a retrospective comparative cohort study including 51 patients who underwent ACL reconstruction (27 QT and 24 HT) between January 2017 and April 2018. A sensory clinical evaluation was performed on each patient: length of the tibial scar, eventual numbness surface area and the type of sensory disorder were reported. To be considered as an IPBSN lesion, the numbness area had to spread at least one-centimeter away from the scar.

RESULTS

The average follow-up was 15 months. In the HT group, the numbness area surface measured 21.2 ± 19 cm² (0-77) and the scar length was on average 31.3 ± 5.6 mm. In the QT group, the numbness area was reduced to 5 ± 10 cm² (P = .0007) as well as the scar length (13.3 ± 2.8 mm, P < .0001). We counted five (17.8%) and 19 (76%) real IPBSN lesions in the QT and HT groups, respectively (P = .0002). Hypoesthesia was the main sensory disorder observed (87.5%).

CONCLUSION

Numbness area of the cutaneous surface supplied by the IPBSN after ACL reconstruction is reduced using QT autograft compared with HT autograft.

Complications After Anterior Cruciate Ligament Reconstruction and Their Relation to the Type of Graft: A Prospective Study of 958 Cases

BACKGROUND

Complications and adverse events after anterior cruciate ligament (ACL) reconstruction are well known, but they have been underestimated in previous studies.

PURPOSE

To describe the complications and adverse events after ACL reconstruction within a 2-year follow-up and analyze them in relation to the type of graft.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

From 2000 to 2012, 958 patients with an isolated ACL injury underwent surgery by a single knee surgeon. ACL reconstruction was performed with the medial portal technique for the femoral tunnel and the use of bone-patellar tendon-bone (BPTB) or hamstring tendon graft. Patients were reviewed at 6 weeks and 3, 6, 12, and 24 months after surgery with the International Knee Documentation Committee score, plain radiographs, and the KT-1000 arthrometer.

RESULTS

Of 958 patients enrolled, 147 (15%) were lost at last follow-up. The 2 groups (bone-patellar tendon-bone [n = 257] and hamstring [n = 554]) were similar regarding the mean age at the time of surgery and preoperative anterior laxity. The main complications were as follows: anterior knee pain (n = 130 of 811, 16%), stiffness (n = 72, 8.8%), secondary meniscal lesions (n = 59, 7.2%), pain attributed to fixation (n = 79, 9.7%), ACL rerupture (n = 47, 5.7%), contralateral ACL ruptures (n = 24, 3%), patellar fractures (n = 3, 0.3%), infections (n = 9, 1%), and thromboembolic complications (n = 5, 0.6%). There was no significant difference between the grafts with respect to the frequency of joint stiffness, secondary meniscal lesions, or anterior knee pain. During the first 2 postoperative years, the percentage of patients with anterior knee pain was higher in the patellar tendon group (23.3% vs 12.6%, P < .001); however, this difference was not significant after the 2-year interval (3.1% vs 2.5%, P = .63). The percentage of patients with a rerupture of the graft was significantly lower in the patellar tendon group than in the hamstring group (25 of 811 [3.1%] vs 57 of 811 [7%], P = .023). Similar results were recorded regarding the pain related to the hardware material (7 of 811 [0.8%] in the BPTB group vs 113 of 811 [13.9%] in the hamstring group, P = .001). The percentage of ACL ruptures contralateral to the repair was higher in the patellar tendon group (41 of 811 [5%] vs 17 of 811 [2%], P = .016).

CONCLUSION

The total rate of complications after an ACL reconstruction was 39%, and the surgical revision rate for any reason was 28%. Problems with the hardware material were more frequent in the hamstring group, leading to an increased rate of surgical revision. Anterior knee pain was initially higher in the patellar tendon group, but there was no significant difference in a 2-year interval. The rerupture rate was statistically higher in the hamstring group.

Beta-Tricalcium Phosphate Block for Donor Site Morbidity of the Patella in Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Graft

Purpose

This study aimed to investigate anterior knee symptoms in patients who underwent anterior cruciate ligament (ACL) reconstruction using bone-patellar tendon-bone (BPTB) graft followed by implantation of a beta-tricalcium phosphate (β-TCP) block as a bone void filler.

Materials and Methods

We retrospectively reviewed 84 cases of synthetic bone grafting using a β-TCP block for the patellar bone defect in ACL reconstruction with a BPTB autograft. Computed tomography of the operated knee was performed immediately after the surgery to evaluate whether the grafted β-TCP block protruded forward from the anterior surface of the patella. On the basis of the results, the cases were divided into a protrusion group (n=31) and a non-protrusion group (n=53). Anterior knee symptoms at 12 months postoperatively and absorption of the grafted β-TCP block were compared between the two groups.

Results

Except for patellofemoral crepitus, there was no significant difference in anterior knee symptoms between the two groups (p>0.05). The incidence of patellofemoral crepitus was significantly lower in the protrusion group than in the non-protrusion group (p=0.027). The groups showed no significant difference in β-TCP absorption.

Conclusions

The present study demonstrated that the protrusion of β-TCP that was used as a bone void filler had no adverse effects.

Quantifying anterior knee pain during specific activities after using the bone-patellar tendon-bone graft for arthroscopic anterior cruciate ligament reconstruction

Background/objective

There has been much debate about the optimal graft choice for an anterior cruciate ligament (ACL) reconstruction. Anterior knee pain is a common donor site problem when using a bone-patellar tendon-bone (BPTB) graft. However, knowledge of the characteristics of anterior knee pain during different daily activities is still limited. This study aimed to determine the incidence of anterior knee pain and to quantify the degree of pain during a range of daily living activities.

Methods

Thirty-five patients who were scheduled to undergo an ACL reconstruction with an autologous BPTB graft between February 2015 and December 2016 were enrolled. A visual analogue scale (VAS) for pain was recorded during each of the following activities: ascending at 30-degree slope, ascending and descending stairs, running, jumping, squatting, kneeling, sitting cross-legged, and sitting one-legged. Demographic data, the range of motion, the area of decreased sensation, and the IKDC score were collected and compared 3 and 6 months postoperatively.

Results

The 35 male patients had a mean age of 29.7 years. Postoperatively, the mean IKDC scores were 58.1 ± 9.8 at 3 months and 72.7 ± 10.5 at 6 months. The incidences of overall anterior knee pain were 62.9% and 34.3% at the 3- and 6-month time points. Kneeling was the only activity that produced severe pain. At 3 months postoperatively, kneeling's mean VAS pain score was 3.9 ± 2.9 (2.9, 4.9; 95% CI for mean for 17 patients [48.5%] with considerable pain), whereas at 6 months postoperatively, it was 2 ± 2.5 (1.2–2.9; 95% CI for mean for 9 patients [25.7%] with considerable pain). The area of numbness of the proximal leg decreased from 12.8 ± 18.3 cm² (6.4, 19.2; 95% CI for mean) to 3.2 ± 9.1 cm² (0.1, 6.5; 95% CI for mean) at 3 and 6 months postoperatively.

Conclusions

Kneeling was the most challenging activity in terms of creating considerable levels of anterior knee pain in patients who had undergone an ACL reconstruction using a BPTB graft. Other knee activities, however, did not create moderate or severe degrees of anterior knee pain. Both anterior knee pain and numbness at the proximal leg improved over time.

Trial registration number: TCTR2018–0630002.

Complications following harvesting of patellar tendon or hamstring tendon grafts for anterior cruciate ligament reconstruction: Systematic review of literature

Anterior cruciate ligament (ACL) reconstruction can be performed with an autograft, which is most often harvested from the patient's hamstring tendon (HT) or patellar tendon (PT). However, autograft harvesting leads to morbidity that is by no means insignificant. A systematic review of literature was performed to define the incidence of complications related to graft harvesting and the methods to prevent these complications. In March 2017, a systemic review of literature was performed using the keywords"harvesting", "harvest", "morbidity", "complication", "cruciate ligament". No time limit was applied. The studies had to be written in French or English with their abstract available online. This initial search based on the title and abstract identified 133 articles. Two independent observers analyzed each article entirely, including the references. In all, 36 articles were retained. The main complication of HT harvesting was sensory deficit because of damage to the infrapatellar branches of the saphenous nerve. This complication occurred in 39.7% to 88% of patients. This risk can be reduced by using a horizontal or oblique incision. The main complication following PT harvesting is anterior knee pain, reported in up to 46% of patients. There are substantial numbers of short-, medium- and long-term complications related to the harvesting of the two main ACL autografts. Effective means of prevention exist to reduce the risk of these complications.

LEVEL OF EVIDENCE

II Systematic review of literature.

Anterior Cruciate Ligament Reconstruction With Bone-Patellar Tendon-Bone Graft Through a Rectangular Bone Tunnel Made With a Rectangular Retro-dilator: An Operative Technique

Good clinical results have been reported with anatomic anterior cruciate ligament (ACL) reconstructions in which rectangular bone-patellar tendon-bone (BTB) grafts were fixed into rectangular bone tunnels made at anatomic ACL insertion sites of the femur and tibia (anatomic rectangular tunnel BTB ACL reconstruction). Notwithstanding these good results, some problems have remained unsolved, including procedural complexity and risk of damage to the femoral posterior tunnel wall, damage to nerves and blood vessels, and damage to cartilage. The purpose of this report is to present our technique of ACL reconstruction with BTB graft through a rectangular bone tunnel made with a rectangular retro-dilator. Our procedure may become a safe option for anatomic rectangular tunnel BTB ACL reconstruction because of the following advantages: (1) bone tunnels can be created more safely and accurately than in methods using transtibial and far medial portals, (2) the bone tunnel preparation procedure is less invasive than the standard outside-in method, (3) technical failure-related risks are lower because the guidewire is inserted only once, and (4) the operation time is shorter because the method is a single-bundle procedure.

Nerve injury during anterior cruciate ligament reconstruction: A comparison between patellar and hamstring tendon grafts harvest

BACKGROUND

Tendon harvesting for anterior cruciate ligament reconstruction often injures sensory branches of the saphenous nerve. The reports on the prevalence of these injuries are scarce, while the implications on patient satisfaction are not known. Our objective was to compare the prevalence of sensory nerve injuries in patellar to hamstring autograft harvesting for anterior cruciate ligament reconstructions and follow up their postoperative course.

METHODS

Between 2012 and 2014, patients who had a primary anterior cruciate ligament reconstruction with bone patellar tendon bone or hamstring autografts were included (n=94). We evaluated and compared demographic details, level of activity and postoperative sensation disturbances between both groups. Data was analyzed retrospectively.

RESULTS

The mean postoperative follow-up time was 23months. At the last follow-up 46 (77%) patients of the patellar tendon group and 22 (58%) of the hamstring tendons group reported on reduced sensation; however, in both groups a quarter of these patients experienced full recovery within an average of seven to eight months. There were more patients in the hamstring tendons group that reported on partial recovery. In most cases midline incisions for patellar tendons harvesting injured the infrapatellar branch and medial incisions for hamstring tendons harvesting injured the sartorial branch of the saphenous nerve.

CONCLUSIONS

Harvesting tendon autografts for anterior cruciate ligament reconstructions by vertical incisions had high prevalence of saphenous nerve branches injury with a minor possibility for complete recovery within the first year. The loss of sensation was perceived by patients as a minor complication.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Prevalence and clinical implications of nerve injury during bone patellar tendon bone harvesting for anterior cruciate ligament reconstruction

PURPOSE

Tendon harvesting for anterior cruciate ligament (ACL) reconstruction often injure sensory branches of the saphenous nerve (SN). Our purpose was to estimate the prevalence and postoperative course of sensory nerve injuries in bone patellar tendon bone (BPTB) autograft harvesting for ACL reconstruction.

METHODS

Between 2012 and 2014, patients who had primary ACL with BPTB autograft were included ( n = 60) and interviewed specifically for sensory loss and its recovery. The surface area of sensory loss was documented. Evaluation also included demographic details, level of activity, and description of postoperative sensation disturbances.

RESULTS

The mean postoperative follow-up time was 24 ± 14 months. At the last follow-up, 46 (77%) patients reported on postoperative reduced sensation; however, only 35 (58%) remained with sensation loss. The most involved region of reduced sensation was of the infrapatellar branch of the SN. Three patients claimed they regret to have had the surgery specifically because of sensation loss and kneeling difficulties, while all others did not.

CONCLUSION

Primary ACL reconstruction using the midline incision for harvesting the middle third of the patellar tendon autograft has a high prevalence of sensory nerve injury with a minor possibility for complete recovery within the first year. However, sensory loss secondary to this injury does not impair normal daily activities in these patients.

Anterior Cruciate Ligament Reconstruction Using a Bone-Patellar Tendon-Bone Autograft to Avoid Harvest-Site Morbidity in Knee Arthroscopy

Although anterior cruciate ligament reconstruction using a bone-patellar tendon-bone (BPTB) autograft has many advantages (e.g., high strength and solid fixation), there are also several complications (e.g., anterior knee pain or kneeling pain) due to harvest-site morbidity associated with the use of this graft type compared with the use of hamstring tendon. Therefore the ultimate goal of anterior cruciate ligament reconstruction using a BPTB graft is to minimize harvest-site morbidity. We have used a technique for harvesting central-third BPTB grafts that involves only a 3-cm-long, longitudinal, curved incision in the medial tibial tuberosity for both graft harvesting and fixation. The purpose of this report is to describe the technique, which can avoid the harvest-site morbidities associated with BPTB autografts during knee arthroscopy. We believe that this less invasive reconstruction may reduce the harvest-site morbidities associated with BPTB grafts because it allows for BPTB graft harvesting without incising the synovial bursa or paratenon and mitigates scarring and adhesion formation.

Knee pain after anterior cruciate ligament reconstruction: evaluation of a rehabilitation protocol

INTRODUCTION

Anterior knee pain (AKP) is a rare and difficult complication following anterior cruciate ligament (ACL) reconstruction. This disabling pain is persistent with conventional rehabilitation protocols. The aim of this work is to validate a new rehabilitation protocol that may improve the patients and allow return to daily activities including sports.

MATERIALS AND METHODS

Forty-three patients identified with functional AKP after ACL reconstruction was enrolled in the rehabilitation protocol between 2009 and 2011. The series included twenty-six patients with hamstring grafting and seventeen patients with patellar tendon transplant. This study compares the functional outcomes and pain scores before and after the isokinetic protocol until the last follow-up at an average of 25.7 months after surgery. The evaluation was performed according to the International Knee Documentation Committee (IKDC) and included a pain assessment using the visual analog scale. Statistical analysis used Student's t-test for unpaired data and the Pearson correlation test for the variables. The IKDC scores were compared by the Wilcoxon test.

RESULTS

Functional outcomes and pain are significantly improved (p<0.0001). The average IKDC score improved with 28 points and the pain improved with 3.2 points on the visual analog scale (VAS). The results are correlated with the follow-up time (p=0.008) but not correlated with the delay between the surgery and the beginning of the isokinetic protocol.

DISCUSSION

Isokinetic rehabilitation provides a significant improvement in the knee function as measured by the IKDC score and by the VAS, regardless of the painful period preceding the program. The function improvement continues after the end of the protocol, but the pain may not completely disappear. The isokinetic rehabilitation program may resume functional AKP related to muscular deficit and may be used as the starter of other physical therapy protocols.

LEVEL OF EVIDENCE

IV.

Anterior cruciate ligament reconstruction with fascia lata using a minimally invasive arthroscopic harvesting technique

Anterior cruciate ligament (ACL) reconstruction using the fascia lata has undergone a number of technical modifications since the work of Hey-Groves, MacIntosh, and Jaeger. Arthroscopy has simplified this technique, notably in the positioning of the tunnels. Minimally invasive harvesting through two lateral proximal and distal approaches considerably reduces cosmetic problems. The femoral tunnel is made from the outside to the inside using a specific targeting device, and the transplant harvest site is closed using the Jaeger procedure so as not to weaken lateral knee stabilizing structures. This procedure consists in opening the lateral intermuscular septum 1cm from the femur to let it shift laterally and allow the transplant harvesting area to be closed. This technique uses a fascia lata transplant, the harvesting of which has shown few iatrogenous complications but requires rigorous adherence to certain rules.

Bone-patellar tendon-bone graft via a single minimally-invasive approach versus a classical approach in anterior cruciate ligament reconstruction: a prospective study

Harvesting the patellar ligament for anterior cruciate ligament reconstructions can be a source of anterior knee pain and hypoesthesia of the lateral side of the knee. We analyzed the feasibility of a minimally-invasive technique via a single patellar approach and postulate that it reduces anterior pain and limits the hypoesthesia area.

PATIENTS AND METHODS

A prospective, comparative, non-randomized, single-center study was conducted on two groups: one undergoing surgery with the classical anteromedial approach, the other with the minimally-invasive approach. Each group included 20 patients. Both series were reviewed between the 6th and 8th month after surgery. The revision was clinical, radiological, and ultrasonographic.

RESULTS

The grafts harvested via the classical approach in all 20 cases presented good characteristics, versus eight out of 18 for the grafts harvested via the minimally-invasive approach. A prominent anterior tibial tuberosity improved the quality of the tibial bone block. A hypoesthesia zone was found in 16 cases out of 18 in the classical approach group, it measured a mean 10.3 ± 5.6 cm(2). A surface area of 3 cm(2) was noted in one case from the minimally-invasive group. No significant difference was found for the subjective and objective IKDC and Lille patellofemoral scores between the two groups. Anterior pain was present in four patients in the classical group and six in the minimally-invasive group.

DISCUSSION

The minimally-invasive technique reduces the risk of cutaneous hypoesthesia. It does not prevent anterior pain related to harvesting the patellar tendon and a good-quality transplant can be obtained if the anterior tibial tuberosity is prominent.

LEVEL OF EVIDENCE

Level III: case-control study.

Mini-invasive technique for bone patellar tendon bone harvesting: its superiority in reducing anterior knee pain following ACL reconstruction

Arthroscopically-assisted ACL-reconstructions are currently reliable, reproducible. Residual anterior knee symptoms however, especially after patellar-BTB graft use, are not uncommon occurrences. Contributing factors are numerous and include injury to the saphenous nerve infrapatellar branches and/or histologic changes at the harvest site. The use of mini invasive harvesting technique decreases the risk of injury to the saphenous nerve infrapatellar branches while preserving the peritenon. The double-incision approach significantly reduces the mid-term incidence of anterior knee pain after ACL-reconstruction. Additionally, this technique markedly decreases the occurrence of sensory disorders and the extent of hypoesthesia. We thus advocate the use of a double-incision graft harvesting technique in ACL-reconstruction using a patellar-bone-tendon-bone transplant.

Anterior cruciate ligament reconstruction creating the femoral tunnel through the anteromedial portal. Surgical technique

The anterior cruciate ligament reconstruction is a common procedure that improves stability and function of the knee. The surgical technique continues to evolve and many issues are still under debate. These mainly include: (1) graft selection (patellar tendon, hamstring, quadriceps tendon, or allografts), (2) surgical technique (double versus single bundle), and (3) femoral tunnel drilling. Currently, the most controversial one is the femoral tunnel drilling (transtibial vs. anteromedial portal drilling). Common opinion is that drilling the femoral tunnel through the anteromedial (AM) allows a more anatomic placement of the graft and a better rotational stability; therefore, this technique is gaining in popularity compared with the transtibial drilling despite a greater difficulty and the risk of medial condyle damage, tunnel back wall blowout, and inadequate socket length. The aim of this article is to describe the surgical technique of the anterior cruciate ligament reconstruction (single and double bundle), drilling the femoral tunnel through the AM portal.