Clinical comparison of fixation methods for patellar bone quadriceps tendon autografts in anterior cruciate ligament reconstruction: absorbable cross-pins versus absorbable screws

Adverse Events and Complications After Primary ACL Reconstruction With Quadriceps Tendon Autograft: A Systematic Review

Background

Anterior cruciate ligament reconstruction (ACLR) surgery with quadriceps tendon (QT) grafts, both with and without a patellar bone plug, have gained popularity in recent years in the primary and revision settings. Postoperative complications occur with the use of QT autografts.

Purpose

To systematically review the incidence of postoperative complications after primary ACLR QT autograft and compare complication rates in patients undergoing all-soft tissue QT grafts versus QT grafts with a patellar bone plug (QTPB).

Study Design

Systematic review; Level of evidence, 4.

Methods

A literature search using the 2020 PRISMA guidelines was performed by querying PubMed, Embase, and Scopus databases from database inception through August 2022. Included were evidence level 1 to 4 human clinical studies in English that reported complications after primary ACLR with QT autograft. The incidence of complications within the included studies was extracted. Differences in the incidence of postoperative complications between ACLR with QT with and without a patellar bone plug were calculated.

Results

A total of 20 studies from 2004 to 2022, comprised of 2381 patients (2389 knees; 68.3% male) with a mean age of 27 years (range, 12-58 years), were identified. The mean follow-up was 28.5 months (range, 6-47 months). The total incidence of complications was 10.3%, with persistent postoperative knee pain being the most common (10.8%). Patients who underwent ACLR with all-soft tissue QT grafts had a 2.7-times increased incidence of anterior knee pain (23.3% vs 8.6%) and reoperations (5.9% vs 3.2%) when compared with QTPB grafts (P < .01 for both). There was no appreciable difference in total complications, graft failures, ACLR revisions, cyclops lesions, or range of motion deficit (P > .05 for all). Patellar fractures occurred exclusively after QTPB (2.2%).

Conclusion

Complications after primary ACLR using QT autograft were recorded in 10.5% of knees, with anterior knee pain being the most common. No difference was reported in the overall incidence of complications with the use of the QT versus QTPB grafts; however, anterior knee pain was 2.7 times greater with use of a soft tissue quadriceps graft.

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

BACKGROUND

The best type of autograft for anterior cruciate ligament (ACL) reconstruction remains debatable.

HYPOTHESIS

Compared with bone-patellar tendon-bone (BPTB) and hamstring tendon (HT) autografts, the quadriceps tendon (QT) autograft has comparable graft survival as well as clinical function and pain outcomes.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

A systematic literature search was conducted in PubMed, Embase, Scopus, and the Cochrane Library to July 2020. Randomized controlled trials (RCTs) and observational studies reporting comparisons of QT versus BPTB or HT autografts for ACL reconstruction were included. All analyses were stratified according to study design: RCTs or observational studies.

RESULTS

A total of 24 studies were included: 7 RCTs and 17 observational studies. The 7 RCTs included 388 patients, and the 17 observational studies included 19,196 patients. No significant differences in graft failure (P = .36), the International Knee Documentation Committee (IKDC) subjective score (P = .39), or the side-to-side difference in stability (P = .60) were noted between QT and BPTB autografts. However, a significant reduction in donor site morbidity was noted in the QT group compared with the BPTB group (risk ratio [RR], 0.17 [95% CI, 0.09-0.33]; P < .001). No significant differences in graft failure (P = .57), the IKDC subjective score (P = .25), or the side-to-side stability difference (P = .98) were noted between QT and HT autografts. However, the QT autograft was associated with a significantly lower rate of donor site morbidity than the HT autograft (RR, 0.60 [95% CI, 0.39-0.93]; P = .02). A similar graft failure rate between the QT and control groups was observed after both early and late full weightbearing, after early and late full range of motion, and after using the QT autograft with a bone plug and all soft tissue QT grafts. However, a significantly lower rate of donor site morbidity was observed in the QT group compared with the control group after both early and late full weightbearing, after early and late full range of motion, and after using the QT autograft with a bone plug and all soft tissue QT grafts. No difference in effect estimates was seen between RCTs and observational studies.

CONCLUSION

The QT autograft had comparable graft survival, functional outcomes, and stability outcomes compared with BPTB and HT autografts. However, donor site morbidity was significantly lower with the QT autograft than with BPTB and HT autografts.

Postoperative Anterior Cruciate Ligament Reconstruction Quadricep and Patella Tendon Rupture, Infection, and Lysis of Adhesions Decreased Despite Changing Graft Trends Over the Past Decade

Purpose

To investigate recent trends in postoperative complications following anterior cruciate ligament (ACL) reconstruction.

Methods

Patients who underwent ACL reconstruction surgery were identified in a national insurance database and separated into 2 cohorts based on the date of their initial surgery comprising the years 2010 to 2012 and 2016 to 2018, respectively. Patients were matched 1:1 based on comorbidities and Elixhauser Comorbidity Index. All patients were assessed for postoperative complications within 18 months of surgery. Rate of complication was compared between cohorts.

Results

Overall, the all-cause complication rate was 2%. There were significantly more quadriceps tendon rupture, patella tendon rupture, lysis of adhesion, and infection in the early cohort. There were significantly more instances of deep vein thrombosis in the late cohort. We found no significant difference in manipulations under anesthesia between the 2 cohorts.

Conclusions

Patients who underwent surgery in the late cohort had lower rates of postoperative complications, except for deep vein thrombosis. The rate of postoperative quadriceps tendon rupture decreased despite considerable increase in the use of quadriceps tendon autograft.

Clinical Relevance

As there has been an increased use of quadriceps tendon autografts, but little is known about the postoperative complications after ACL reconstruction with these grafts. This information has the potential to improve patient outcomes.

Closure of the Quadriceps Tendon Autograft Harvest Site for Anterior Cruciate Ligament Reconstruction: A Systematic Review

BACKGROUND

The quadriceps tendon (QT) autograft is a commonly used and effective graft option for anterior cruciate ligament reconstruction (ACLR). Surgical techniques vary, and there is no current standard of care for management of the QT autograft harvest site.

PURPOSE

To examine the literature on patient-reported outcomes and complications after ACLR with a QT autograft and to further clarify the frequency with which the harvest site is closed and potential biomechanical implications.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed using multiple medical databases. Level 1 to 4 studies on patients undergoing ACLR with a QT autograft were included. There were 2 independent reviewers who analyzed all studies. Study quality was analyzed using the methodological index for non-randomized studies checklist.

RESULTS

Overall, 13 studies with a total of 650 patients were included. The mean patient age for all studies was 31 years (range, 14-59 years) with a mean follow-up of 21.2 months (range, 6-84 months). Of the 13 studies, 12 studies (92%) documented patient sex, comprising 331 female patients (55%) and 274 male patients (45%). There were 8 studies (62%) that reported the use of a bony QT autograft in 273 patients, and 5 studies (38%) reported the use of a soft tissue QT autograft in 377 patients. The graft length harvested was most commonly 7 to 8 cm, while the tendon width harvested was 10 mm. Moreover, 5 studies (38%) did not discuss closure of the harvest site, while 2 studies (15%) only closed the harvest site if a capsular rent was present. The surgical technique for harvest-site closure varied when reported in 7 studies (54%). Good to excellent clinical outcomes were reported in 80% of patients when the harvest site was closed.

CONCLUSION

Based on the results of this study, there is no consensus on whether the QT defect should be closed after harvesting the graft for ACLR. It has been reported that closure of the harvest site is performed if there is a capsular rent present. Several techniques are utilized to close the QT autograft harvest site; however, it is unclear if there is a difference in outcomes based on the technique used. Future studies should further clarify whether there are any biomechanical and clinical advantages to closing the QT autograft harvest site.

Quadriceps Tendon Anterior Cruciate Ligament Reconstruction: A Systematic Review of Postoperative Rehabilitation and Complication Profiles

PURPOSE

The purposes of this study are to explore current elements for postoperative rehabilitation protocol after quadriceps tendon-anterior cruciate ligament reconstruction (QT-ACLR), outline general timelines for progression of those elements, and explore their associated complication rates and profiles.

METHODS

In accordance with PRISMA guidelines, 5 online databases (EMBASE, MEDLINE, CINAHL, Cochrane, and PubMed) were searched and screened in duplicate using predetermined criteria for studies on the aforementioned patient population. Descriptive statistics are presented.

RESULTS

A total of 56 studies were included, with 31 studies using quadriceps tendon with bone block (B-QT) and 26 studies using all-soft tissue quadriceps tendon (S-QT). The majority of studies permitted full weightbearing and range of motion (ROM) within the first 12 postoperative weeks, and motion-controlled braces within 6 weeks. Isometric exercises were initiated within 1 week after surgery, closed-chain exercises within 12 weeks, and open-chain and sports-specific exercises within 36 weeks. Complication profiles were similar between graft types and included graft failure (1.2%-1.6%), cyclops syndrome (0.4%-0.7%), and persistent stiffness (0.9%).

CONCLUSIONS

Current postoperative rehabilitation strategies in ACLR with QT offer a complication profile comparable to those reported with other graft types. Based on the included rehabilitation regimen, these protocols should focus on early ROM, specifically on achieving full extension, alongside isometric quadriceps strengthening. Progression to closed- and open-chain exercises should follow in a progressive manner, similar to existing protocols in ACLR. Adjuncts such as motion-controlled bracing and continuous passive motion machines may be used if graft protection is prioritized. This review highlights the need for comparison of defined protocols against one another in the setting of QT-ACLR.

LEVEL OF EVIDENCE

IV, systematic review of Level I-IV studies.

A Comparison of Two-Year Anterior Cruciate Ligament Reconstruction Clinical Outcomes Using All-Soft Tissue Quadriceps Tendon Autograft With Femoral/Tibial Cortical Suspensory Fixation Versus Tibial Interference Screw Fixation

PURPOSE

To contribute to future quadriceps tendon harvest and fixation guidelines in the setting of anterior cruciate ligament reconstruction by comparing 2-year patient-reported subjective knee outcome scores and incidence of graft-related complications between the shorter harvest all-inside tibial-femoral suspensory fixation (TFSF) approach versus the longer harvest standard tibial interference screw fixation technique.

METHODS

Patients who underwent primary anterior cruciate ligament reconstruction with all soft tissue quadriceps tendon autograft from January 2017 to May 2019 were identified for inclusion. Patients were matched into 2 cohorts of 62 based on reconstruction technique. All patients completed baseline and minimum 2-year International Knee Documentation Committee, Tegner Activity Level, and Lysholm questionnaires and were queried regarding subsequent procedures and complications to the operative knee.

RESULTS

Average graft length for the all-inside TFSF was 69.55 (95% confidence interval 68.99-70.19) mm versus 79.27 (95% confidence interval 77.21-81.34) mm in the tibial screw fixation cohort (P = .00001). Two-year Lysholm scores were greater in the TFSF cohort (P = .04) but were not clinically significant. There was no difference in 2-year International Knee Documentation Committee (P = .09) or Tegner (P = .69) scores between cohorts, but more patients in the TFSF cohort returned to or exceeded their baseline activity level compared with the tibial screw fixation cohort (73% vs 61%, P = .25). Seven patients in the TFSF cohort versus 13 in the tibial screw fixation cohort reported anterior knee pain or kneeling difficulty (P = .22). There were no differences in reported complications.

CONCLUSIONS

All-inside soft-tissue quadriceps tendon autograft with TFSF resulted in clinically comparable subjective outcome scores at 2 years to tibial screw fixation. There were also no differences in complications or reports of anterior knee pain or kneeling difficulty. All-inside TFSF can be a viable alternative to tibial screw fixation for all-soft tissue quadriceps autograft.

LEVEL OF EVIDENCE

III, comparative therapeutic trial.

Bone Versus All Soft Tissue Quadriceps Tendon Autografts for Anterior Cruciate Ligament Reconstruction: A Systematic Review

PURPOSE

To examine existing literature on objective and patient-reported outcomes and complications after anterior cruciate ligament reconstruction (ACLR) with bone-quadriceps-tendon (B-QT) or soft tissue-quadriceps tendon (S-QT) to further clarify the role of graft type in primary ACLR.

METHODS

In accordance with PRISMA guidelines, PubMed, Embase, and Medline were searched in October 2019 for English-language, human studies of all evidence levels on patients undergoing primary ACLR with B-QT or S-QT autograft.

RESULTS

24 of 1,381 studies satisfied criteria, with 20 using B-QT (1,534 patients, mean age 29.6 years [range 14 to 59], mean follow-up 41.2 months [range 12 to 120]) and 5 using S-QT (181 patients, mean age 32.4 years [range 15 to 58), mean follow-up 25.5 months [range 12 to 46]). International Knee Documentation Committee (IKDC) scores were 67.3 to 89.5 with B-QT and 80.4 to 81.6 with S-QT. Lysholm scores were 85.7 to 97.4 with B-QT and 81.6 to 89.2 with S-QT. More B-QT patients demonstrated rotatory laxity on pivot shift compared with S-QT (0% to 39% versus 0%, respectively). The most common complication was graft rupture, and no differences were observed between graft choices (B-QT 0% to 9% versus S-QT 0% to 3.8%).

CONCLUSIONS

The main findings from this review report that more B-QT patients demonstrated postoperative rotatory instability than S-QT patients, and that there are no differences in graft rupture between the 2 graft choices. Although statistical conclusions may not be drawn because of heterogeneity in reporting, it appears that the B-QT group featured much wider major and minor complication profiles.

LEVEL OF EVIDENCE

IV, systematic review of level I-IV studies.

All inside full thickness quadriceps tendon ACL reconstruction: Long term follow up results

Purpose

The aim of this study is to evaluate results of anterior cruciate ligament reconstruction (ACL) using an All-Inside Full Thickness Quadriceps Reconstruction technique at 5 years follow up.

Methods

This is a Retrospective cohort study of patients undergoing ACL reconstruction. Inclusion criteria for this report were isolated primary ACL reconstructions without chondral lesions (Grade III/IV Outerbridge), using autologous full-thickness quadriceps tendon (FQT) graft with bone block, with an “all-inside” technique. Functional scales of Lysholm, IKDC, Tegner and objective results of side to side difference (KT1000) were used for this evaluation. Additionally, complications and comorbidities were also analyzed.

Results

Two hundred and ninety-one ACL reconstructions were retrospectively reviewed at 5 years postoperatively; 268 (92.1%) were men and 23 (7.90%) women. Lysholm Score improved from 64 (SD = 6.09) to 91 (SD = 6.05) points average. IKDC showed 59.79%, excellent and 3.4% good results. Arthrometric analysis showed that 259 knees (89%) had a difference of less than 3 mm. Median pre-injury Tegner score was 9 (Range 4–10), while final median Tegner activity level at 5 years was 8 (Range 4–10). Among comorbidities, 5.15% of the patients presented anterior knee pain. No visualization difficulties or significant hematomas were found.

Conclusion

Use of all inside FQT for ACL reconstruction in a young, high demand sports population, present at 5 years, good to excellent results, functionally and objectively, with low rates of complications and comorbidities.

Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Outcomes for Quadriceps Tendon Autograft Versus Bone-Patellar Tendon-Bone and Hamstring-Tendon Autografts

BACKGROUND

Comprehensive studies evaluating quadriceps tendon (QT) autograft for anterior cruciate ligament (ACL) reconstruction are lacking. The optimal choice of graft between bone-patellar tendon-bone (BPTB), hamstring tendon (HT), and QT is still debatable.

HYPOTHESIS

The current literature supports the use of QT as a strong autograft with good outcomes when used in ACL reconstruction.

STUDY DESIGN

Meta-analysis; Level of evidence, 2.

METHODS

A systematic search of the literature was performed in PubMed, MEDLINE, Cochrane, and Ovid databases to identify published articles on clinical studies relevant to ACL reconstruction with QT autograft and studies comparing QT autograft versus BPTB and HT autografts. The results of the eligible studies were analyzed in terms of instrumented laxity measurements, Lachman test, pivot-shift test, Lysholm score, objective and subjective International Knee Documentation committee (IKDC) scores, donor-site pain, and graft failure.

RESULTS

Twenty-seven clinical studies including 2856 patients with ACL reconstruction met the inclusion criteria. Comparison of 581 QT versus 514 BPTB autografts showed no significant differences in terms of instrumented mean side-to-side difference (P = .45), Lachman test (P = .76), pivot-shift test grade 0 (P = .23), pivot-shift test grade 0 or 1 (P = .85), mean Lysholm score (P = .1), mean subjective IKDC score (P = .36), or graft failure (P = .50). However, outcomes in favor of QT were found in terms of less donor-site pain (risk ratio for QT vs BPTB groups, 0.25; 95% CI, 0.18-0.36; P < .00001). Comparison of 181 QT versus 176 HT autografts showed no significant differences in terms of instrumented mean side-to-side difference (P = .75), Lachman test (P = .41), pivot-shift test grade 0 (P = .53), Lysholm score less than 84 (P = .53), mean subjective IKDC score (P = .13), donor-site pain (P = .40), or graft failure (P = .46). However, outcomes in favor of QT were found in terms of mean Lysholm score (mean difference between QT and HT groups, 3.81; 95% CI, 0.45-7.17; P = .03).

CONCLUSION

QT autograft had comparable clinical and functional outcomes and graft survival rate compared with BPTB and HT autografts. However, QT autograft showed significantly less harvest site pain compared with BPTB autograft and better functional outcome scores compared with HT autograft.

Quadriceps tendon autograft for arthroscopic knee ligament reconstruction: use it now, use it often

Traditional bone-patellar tendon-bone and hamstring tendon ACL grafts are not without limitations. A growing body of anatomic, biomechanical and clinical data has demonstrated the utility of quadriceps tendon autograft in arthroscopic knee ligament reconstruction. The quadriceps tendon autograft provides a robust volume of tissue that can be reliably harvested, mitigating the likelihood of variably sized grafts and obviating the necessity of allograft augmentation. Modern, minimally invasive harvest techniques offer the advantages of low rates of donor site morbidity and residual extensor mechanism strength deficits. New data suggest that quadriceps tendon autograft may possess superior biomechanical characteristics when compared with bone-patella tendon-bone (BPTB) autograft. However, there have been very few direct, prospective comparisons between the clinical outcomes associated with quadriceps tendon autograft and other autograft options (eg, hamstring tendon and bone-patellar tendon-bone). Nevertheless, quadriceps tendon autograft should be one of the primary options in any knee surgeon's armamentarium.

Anterior cruciate ligament reconstruction with quadriceps tendon-patellar bone allograft: matched case control study

Background

Quadriceps tendon-patellar bone (QTPB) autograft is an excellent graft option with good clinical outcome. Use of QTPB autografts have increased because they minimize donor-site morbidity including anterior knee pain, while providing adequate mechanical strength. Although, there were many clinical results about allografts that used in anterior cruciate ligament (ACL) reconstruction, it have never been reported about the clinical outcome of ACL reconstruction with QTPB allograft.

The purpose of this study is to evaluate the clinical outcome of ACL reconstruction with QTPB allograft and to compare with QTPB autograft. We hypothesized that ACL reconstruction with QTPB allograft had good functional outcomes and stability and no significant difference compared to the ACL reconstruction with QTPB autograft.

Methods

From February 2009 to January 2014, 213 cases who received ACL reconstruction with QTPB grafts were included. Forty-five patients who received ACL reconstruction with QTPB allograft were individually matched in age, sex, direction of the injured knee and body mass index (BMI) to a control group of 45 patients who received QTPB autograft. Clinical results were evaluated using International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner scale, Knee injury and Osteoarthritis Outcome Score (KOOS) and ligament laxity. An average follow-up time was 31.2 months.

Results

The functional scores and ligament laxity improved from initial to the last visit in those with ACL reconstruction with QTPB allograft (p < 0.05). No significant statistical difference was found in clinical outcomes and complications including re-rupture between the QTPB allograft and autograft groups (p > 0.05). Laxity using anterior drawer test, Lachman test and KT-2000 showed no significant difference. No significant difference was found between the two groups in quadriceps peak extension torque, except at 60° per second at 6 months.

Conclusion

QTPB allograft achieved good clinical outcome with no difference compared with QTPB autograft. QTPB allograft for ACL reconstruction is promising alternative to selected and compliant patients. Long-term follow-up needs to further evaluate the clinical outcomes and complications including re-rupture rate.

Is Quadriceps Tendon Autograft a Better Choice Than Hamstring Autograft for Anterior Cruciate Ligament Reconstruction? A Comparative Study With a Mean Follow-up of 3.6 Years

BACKGROUND

The quadriceps tendon (QT) autograft is known as an effective graft for anterior cruciate ligament (ACL) reconstruction and shows a similar functional outcome to the bone-patellar tendon-bone (BPTB) in randomized controlled trials, with a lesser incidence of complications. Up until now, only 2 studies have compared QT to hamstring tendon (HT) autograft.

HYPOTHESIS

The functional outcomes of the QT technique are at least as good as those of the HT technique, with the same morbidity.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Ninety-five patients underwent isolated ACL reconstruction between January 1 and December 31, 2012. Fifty underwent ACL reconstruction with the QT and 45 with the HT. The same surgical technique, fixation method, and postoperative protocol were used in both groups. The following parameters were evaluated: surgical revisions, functional outcome (Lysholm, Knee injury and Osteoarthritis Outcome Score [KOOS], Tegner, subjective International Knee Documentation Committee), joint stability (KT-1000, Lachman, pivot shift), anterior knee pain (Shelbourne-Trumper score), and isokinetic strength. Descriptive statistics are presented for these variables using the Student t test.

RESULTS

Eighty-six patients (45 QT, 41 HT) were reviewed with a mean follow-up of 3.6 ± 0.4 years; minimum follow-up was 3 years. There were 4 reoperations in the QT group (including 1 ACL revision) and 3 in the HT group (including 2 ACL revisions) ( P > .05). The Lysholm (89 ± 6.9 vs 83.1 ± 5.3), KOOS Symptoms (90 ± 11.2 vs 81 ± 10.3), and KOOS Sport (82 ± 11.3 vs 67 ± 12.4) scores were significantly better in the QT group than in the HT group. In terms of stability, the mean side-to-side difference was 1.1 ± 0.9 mm for the QT group and 3.1 ± 1.3 mm for the HT group based on KT-1000 measurements ( P < .005). The negative Lachman component was higher in the QT group than in the HT group (90% vs 46%, P < .005). There was a trend for the negative pivot-shift component to be higher in the QT group than in the HT group (90% vs 64%, P = .052). The Shelbourne-Trumper score was the same in both groups. There was no difference between groups in terms of isokinetic strength.

CONCLUSION

The use of a QT graft in ACL reconstruction leads to equal or better functional outcomes than does the use of an HT graft, without affecting morbidity.

Quadriceps tendon autograft for anterior cruciate ligament reconstruction: a comprehensive review of current literature and systematic review of clinical results

PURPOSE

The autograft of choice for anterior cruciate ligament (ACL) reconstruction remains controversial. Recently, there has been an increase in interest in the quadriceps tendon as an autologous graft option for ACL reconstruction. The purposes of this study were to provide an in-depth review of quadriceps tendon anatomy, histology, and biomechanics and to synthesize reported clinical outcomes of ACL reconstructions using quadriceps tendon autografts. We hypothesize that (1) published studies on the anatomic, histologic, and biomechanical data regarding the quadriceps tendon support its use as a graft option for ACL reconstruction and (2) clinical outcomes of ACL reconstruction using quadriceps tendon autograft have similar clinical outcomes to bone-patellar tendon-bone autografts with less donor-site morbidity.

METHODS

We performed a comprehensive review of the literature regarding the anatomy, histology, and biomechanical studies of the quadriceps tendon, as well as a systematic review of clinical studies (Level of Evidence I-III) evaluating outcomes after ACL reconstruction using quadriceps tendon autograft. Stability outcomes, functional outcomes, range of motion, patient satisfaction, morbidity, and complications were comprised.

RESULTS

Fourteen studies were included in the review of clinical results, including 1,154 ACL reconstructions with quadriceps tendon autograft. Six studies directly compared quadriceps tendon autografts (n = 383) with bone-patellar tendon-bone autografts (n = 484). Stability outcomes (Lachman, pivot-shift, and instrumented laxity testing), functional outcomes (International Knee Documentation Committee and Lysholm scores), overall patient satisfaction, range of motion, and complications were similar between quadriceps tendon and other graft options. Less donor-site morbidity was seen in patients who underwent quadriceps tendon ACL reconstructions.

CONCLUSIONS

Use of the quadriceps tendon autograft for ACL reconstruction is supported by current orthopaedic literature. It is a safe, reproducible, and versatile graft that should be considered in future studies of ACL reconstruction.

LEVEL OF EVIDENCE

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

Timing of surgery of the anterior cruciate ligament

PURPOSE

We aimed to perform a systematic review of the literature concerned with timing of surgery after anterior cruciate ligament injury.

METHODS

A systematic electronic search in Medline through PubMed, Embase, and the Cochrane Library was carried out in October 2011. All English-language randomized controlled clinical trials, prospective comparative cohort studies, and prognostic and diagnostic studies published from January 1995 to August 2011 were eligible for inclusion. All articles addressing timing of surgery were eligible for inclusion regardless of injury-to-surgery interval, graft type, surgical technique, or rehabilitation. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist guided the reporting and data abstraction. Methodologic quality of all included articles was carefully assessed.

RESULTS

We included 22 articles (3,583 patients) in the systematic review. Study design, research methodology, surgical technique, and outcome measurements differed greatly among included articles. The injury-to-surgery interval, classified as early and delayed, ranged from within 2 days to 7 months and 3 weeks to 24 years, respectively. Eight articles promoted early reconstruction, whereas the majority of articles found no difference in outcome between early and delayed surgery. Two articles were inconclusive.

CONCLUSIONS

There were few or no differences in subjective and objective outcomes related to timing of anterior cruciate ligament reconstruction.

LEVEL OF EVIDENCE

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

Outcomes for primary anterior cruciate reconstruction with the quadriceps autograft: a systematic review

PURPOSE

To determine the suitability of the quadriceps autograft in primary anterior cruciate ligament (ACL) reconstruction.

METHODS

A systematic review was undertaken to identify all clinical studies reporting on the use of the quadriceps tendon autograft in ACL reconstructions. Studies that reported on clinical and functional outcomes, morbidity and complications were selected.

RESULTS

Seventeen articles met our inclusion criteria with a total of 1,580 reconstructions studied. This included four comparative studies which compared the quadriceps tendon to either hamstring or patella tendon autografts. The quadriceps tendon autograft had clinical (Lachman, Pivot-shift testing) and functional outcomes (Lysholm and IKDC scores) similar to those reported for the patella tendon and hamstring grafts in the literature. Comparative studies also reported no significant difference between the grafts for any outcome measure.

CONCLUSIONS

The quadriceps tendon autograft is a promising alternative for primary ACL reconstructions with good outcomes and minimal donor site morbidity. Further studies are required, however, to determine whether the quadriceps graft is as good as or better than other autografts.

LEVEL OF EVIDENCE

IV.

EVALUATION OF THE RESULTS OF ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION USING FLEXOR TENDONS AND RIGID GUIDE TRANSVERSE SCREW

OBJECTIVE

The aim of this study was to analyze the results of ACL (anterior cruciate ligament) reconstruction using quadruple flexor tendons as grafts, with ligament fixation in the femur using a rigid guide transverse screw and in the tibia, using a cancellous screw with a fixing washer.

METHODS

173 knees (166 from males and seven from females) that had undergone surgery with ACL reconstruction using this technique between December 2002 and February 2007 were evaluated. The mean age was 30 years (from 13 to 56 years), and the mean follow-up time was 30 months (6-55 months). We divided the knees into three groups, which were assessed using the Lysholm scale: Group A with six months of follow-up; Group B with 12 months of follow-up; and Group C with 24 months of follow-up.

RESULTS

We evaluated the results, and groups A, B and C received 94, 95 and 95 points respectively on the Lysholm scale.

CONCLUSIONS

The surgical technique proved to be safe and easy to perform, with good results and a low complication rate. Also, its results were maintained throughout the study period of 24 months.

Intraoperative complications using the Bio-Transfix femoral fixation implant in anterior cruciate ligament reconstruction

The use of biodegradable Transfix femoral fixation technique is a safe and well-accepted method when performing anterior cruciate ligament reconstruction. We report on three cases of deformation and back out of the Bio-Transfix implant over the lateral, distal femoral cortex, with failure of the passing wire when advancing the graft into the femoral tunnel in one of these patients. Two of the patients presented with symptoms of iliotibial band friction syndrome, while the third patient was asymptomatic. The graft had clinically integrated demonstrating AP and rotational stability. The symptoms relieved after removal of the failed Bio-Transfix implants in the symptomatic patients. The aetiology of the implant failure and the alternative methods to avoid such complications are discussed.

Fracture of the tibial bone block after posterior cruciate ligament allograft reconstruction using double cross pins

We report the fracture of the tibial bone block after posterior cruciate ligament reconstruction using double cross pins for bone block fixation in the postoperative period. The possible reasons include the size of bone block,direction of cross pin or the quality of bone block. This case emphasizes the biomechanical properties and failure of modes of double cross pin.

Bioresorbable pins and interference screws for fixation of hamstring tendon grafts in anterior cruciate ligament reconstruction surgery: a randomized controlled trial

BACKGROUND

Biodegradable cross-pins have been shown to provide higher failure loads than do screws for fixation of hamstring tendons under laboratory conditions.

PURPOSE

To compare the clinical results of biodegradable pins (RigidFix) and interference screws (BioCryl) for fixation of hamstring grafts in arthroscopically assisted anterior cruciate ligament reconstruction. Study Design Randomized controlled trial; Level of evidence, 1.

METHODS

To test the hypothesis of a difference of 1.0 +/- 1.2 mm in anterior knee laxity between the two fixation options, 54 patients were randomly assigned to groups via a block randomization scheme and sealed envelopes. All patients underwent standardized hamstring graft reconstruction and had similar postoperative aftercare by an accelerated rehabilitation protocol. Measures assessed at baseline and after 1 and 2 years of follow-up included (1) the side-to-side difference in anterior laxity (KT-1000 arthrometer), (2) Short Form 36 physical and mental component scores, and (3) the International Knee Documentation Committee form scores.

RESULTS

After 1 and 2 years, 26 and 21 patients in the BioCryl group and 28 and 24 patients in the RigidFix group were available for follow-up examination. No significant difference was noted in instrumented anterior translation between BioCryl and RigidFix fixation: 1 year, 0.11 (95% CI, -0.60 to 0.82; P = .7537); 2 years, 0.33 (95% CI, -0.43 to 1.08 mm; P = .3849). Also, there were no significant differences in the mean physical and mental component scores and International Knee Documentation Committee form scores and in overall complication and surgical revision rates. A pin dislocation was classified as the sole procedure-specific serious adverse event.

CONCLUSION

Bioresorbable pins do not provide better clinical results than do resorbable interference screws for hamstring graft fixation in anterior cruciate ligament reconstruction surgery.

A prospective comparison of 3 hamstring ACL fixation devices--Rigidfix, BioScrew, and Intrafix--randomized into 4 groups with 2 years of follow-up

BACKGROUND

New devices for graft fixation in anterior cruciate ligament reconstruction are released to clinical use without clinical follow-up data.

HYPOTHESIS

There is similar clinical outcome after either cross-pin or absorbable interference screw fixation in anterior cruciate ligament reconstruction with hamstring tendons.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 1.

METHODS

A total of 120 patients were randomized into 4 different groups (30 each) for anterior cruciate ligament reconstruction with hamstring tendons: femoral Rigidfix cross-pin and Intrafix tibial expansion sheath with a tapered expansion screw; Rigidfix femoral and BioScrew interference screw tibial fixation, BioScrew femoral and Intrafix tibial fixation; or BioScrew fixation into both tunnels. The evaluation methods were clinical examination, knee scores, and instrumented laxity measurements.

RESULTS

Ten patients were completely lost to follow-up and 3 revisions were done before the 2-year follow-up, leaving 107 of 120 (89%) patients for analysis. No statistically significant differences between the groups were seen 2 years postoperatively, and all but 2 patients in the Rigidfix/Intrafix and Rigidfix/BioScrew groups, respectively, were classified into International Knee Documentation Committee A or B categories. A revision reconstruction was performed before the 2-year follow-up in 2 cases after a high-energy injury caused a rerupture (1 in Rigidfix/Intrafix and 1 in BioScrew/BioScrew groups). In addition, there were 4 nontraumatic failures revised before the 2-year follow-up (2 in Rigidfix/Intrafix and 1 each in Rigidfix/BioScrew and BioScrew/BioScrew).

CONCLUSION

There were no statistically or clinically relevant differences in the results 2 years postoperatively, and all 4 techniques improved patient performance.