Hamstring Graft Incorporation According to the Length of the Graft Inside Tunnels

Lateral extra-articular tenodesis does not enhance ACL graft healing, however, does reduce graft tunnel widening

PURPOSE

The study hypothesized that the addition of lateral extra-articular tenodesis (LEAT) in anterior cruciate ligament reconstruction (ACLR) had a significant effect on ACL graft healing.

METHODS

A total of 80 patients were divided into two cohorts matched for gender, age, body mass index, time from surgery to post-operative MRI and graft diameter. Forty patients underwent ACL reconstruction alone, while 40 underwent ACLR in addition to LEAT. Patients underwent a magnetic resonance imaging scan at 12 months post-surgery; tunnel apertures were measured using multiplanar reformation, graft healing was assessed using signal-to-noise quotient (SNQ) in three regions of interest and finally graft maturity and integration were classified using the Howell and Ge scale, respectively. In addition, clinical evaluation and patient-reported outcome measures were collected.

RESULTS

The mean femoral tunnel widening at 12 months post-surgery was 39.8 ± 14.0% in the ACLR + LEAT group and 55.2 ± 12.7% in the ACLR alone group (p < 0.05). The mean tibial tunnel widening was 29.3 ± 12.7% in the ACLR + LEAT group and 44.4 ± 12.1% in the ACLR group (p < 0.05). The mean adjusted graft SNQ was 9.0 ± 14.9 in the ACLR + LEAT group and 9.5 ± 11.4 in the ACLR group (n.s.).

CONCLUSION

At 1 year post-operatively, we noted significantly less femoral and tibial tunnel widening in the ACLR + LEAT group. LEAT did not result in a statistically significant effect on graft healing.

LEVEL OF EVIDENCE

Level III.

Association of Lateral Extra-Articular Tenodesis With Improved Graft Maturity on MRI 2 Years After ACL Reconstruction With Quadriceps Tendon Autograft in Skeletally Immature Athletes

Background

Quadriceps tendon autograft (QTA) has recently gained popularity in the treatment of anterior cruciate ligament (ACL) ruptures in pediatric patients. The addition of lateral extra-articular tenodesis (LET) to an ACL reconstruction (ACLR) has been found to reduce the risk of ACL retear in high-risk patients.

Purpose

To (1) compare ACL graft maturity using signal intensity ratios (SIRs) on magnetic resonance imaging (MRI) scans in skeletally immature patients undergoing ACLR with QTA either with or without concomitant LET and (2) evaluate LET safety by calculating the physeal disturbance-related reoperation rate in the ACLR+LET group.

Study Design

Cohort study; Level of evidence, 3.

Methods

The records of patients aged ≤18 years who underwent ACLR between 2015 and 2021 were reviewed retrospectively. Patients undergoing ACLR with QTA who had open distal femoral and proximal tibial physes on MRI scans and a minimum 2-year follow-up data were included. SIR values were measured on sagittal MRI scans by averaging the signal at 3 regions of interest along the ACL graft and dividing by the signal of the posterior cruciate ligament at its insertion. Statistical analysis was performed to evaluate differences in SIR values at 6 months, 1 year, and 2 years postoperatively in patients who underwent ACLR alone versus ACLR+LET.

Results

Overall, 29 patients were included in the study: 16 patients in the ACLR+LET group and 13 patients in the ACLR-only group. There were no significant differences in SIR values between groups at the 6-month or 1-year postoperative timepoints. At 2 years postoperatively, the median SIR of the ACLR+LET group was significantly lower than that of the ACLR-only group on both univariate (1.33 vs 1.86, respectively, P = .0012) and multivariate regression analyses adjusting for both sex and surgical technique (β = -0.49 [95% CI, -0.91 to -0.05]; P = .029). There were no cases of reoperation for physeal disturbance in patients who underwent ACLR+LET.

Conclusion

The addition of LET to an ACLR with QTA was associated with lower average SIR values and thus improved graft maturity at 2 years postoperatively compared with ACLR alone in skeletally immature patients. The addition of LET to an ACLR was found to be safe in skeletally immature patients.

Outcomes of hamstring graft with preserved tibial insertion for ACL reconstruction: systematic review and meta-analysis

PURPOSE

Evaluate the outcomes of ACL (Anterior Cruciate Ligament) reconstruction techniques that use a hamstring graft with a preserved tibial insertion and compare them to standard techniques.

METHODS

A systematic literature review and meta-analysis was done of the PubMed, MEDLINE, Cochrane and Ovid databases to identify published clinical studies on ACL reconstruction in which a non-detached hamstring tendon (NDHT) was used as a graft and to compare them to studies in which a detached hamstring tendon (DHT) or other techniques were used. The eligible studies were analyzed for the knee laxity, Lachman test, pivot shift test, joint range of motion, anterior drawer, pain, re-tear, revision surgery, Lysholm score, Tegner score, ACL-RSI scale, KOOS, IKDC, SNQ and Howell scale.

RESULTS

Twelve articles in which NDHT was used for ACL reconstruction were analyzed. There was no significant difference between NDHT and DHT in the Lachman > 1 (p = .07), pivot shift test > 1 (p = .40), re-tears (p = .62), pain (p = .85) and the Tegner score (p = .95). However, the outcomes were somewhat better with the NDHT technique for the Lachman (RR = 0.30; 95% CI 0.08-1.12), pivot shift test (RR = 0.50; 95% CI 0.10-2.49) and re-tears (RR = 0.66; 95% CI 0.13-3.42). The other criteria were not included in the meta-analysis because of lack of data or because specific outcome scores were used in each article.

CONCLUSION

NDHT techniques provide similar results to DHT for ACL reconstruction and tend to produce better stability and a lower re-tear rate.

Preserving the Semitendinosus Distal Attachment Is Associated With Improved Graft Remodeling After ACL Reconstruction

BACKGROUND

The semitendinosus (ST) tendon can be used by itself as a graft for anterior cruciate ligament (ACL) reconstruction. An increasing number of these procedures are being done while preserving the ST's tibial attachment, but there are no data on the remodeling of an attached ST (aST) graft.

PURPOSE

To compare graft remodeling on magnetic resonance imaging (MRI) scans at 1 year after ACL reconstruction between standard free ST graft and aST graft.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This prospective study enrolled 180 patients who were undergoing ACL reconstruction: 90 with the ST graft and 90 with the aST graft. The analysis was performed 1 year after the surgery. The main endpoint was the signal-to-noise quotient (SNQ) on MRI scans (T1-weighted sequence). The secondary endpoints were tibial tunnel widening (TTW), graft maturation (Howell classification), retear rate, new surgery rate, Simple Knee Value, Lysholm score, International Knee Documentation Committee (IKDC) score, postoperative Tegner score, difference between pre- and postoperative Tegner scores, ACL-Return to Sport after Injury (ACL-RSI), return-to-sports rate, and time to return to sports.

RESULTS

The mean adjusted SNQ was 1.18 (95% CI, 0.72-1.65) in the aST group and 3.88 (95% CI, 3.42-4.34) in the ST group (P < .001). The new surgery rate was 2.2% in the aST group and 10% in the ST group (P = .029). The median Lysholm score was significantly higher in the aST group (99; interquartile range [IQR], 95-100) than in the ST group (95; IQR, 91-99) (P = .004). The mean time to return to sports was significantly shorter in the aST group (248.73 ± 141.62 days) than the ST group (317.23 ± 144.69 days) (P = .002). No statistically significant difference was found between groups in the TTW (P = .503), Howell graft maturity grade (P = .149), retear rate (P > .999), Simple Knee Value (P = .061), postoperative Tegner score (P = .320), pre- to postoperative difference in Tegner score (P = .317), ACL-RSI (P = .097), IKDC score (P = .621), and return-to-sports rate (P > .999).

CONCLUSION

At 1 year postoperatively, remodeling of an ST graft assessed using MRI is better when its distal attachment is left intact.

Factors Affecting Graft Remodeling and Anterior Cruciate Ligament Reconstruction: MRI Study of 180 Knees

BACKGROUND

Several factors affect the retear rate after anterior cruciate ligament (ACL) reconstruction, but there are few data on which factors affect graft remodeling.

PURPOSE

To determine which factors are associated with the remodeling of an ACL graft.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A retrospective longitudinal study was conducted to investigate the relationship between various exposure factors and the occurrence of an "event": graft remodeling measured with the signal-to-noise quotient (SNQ). Data were collected prospectively and analyzed retrospectively for this study. The endpoint was the SNQ on magnetic resonance imaging at postoperative 1 year. The effect of the following parameters on SNQ was investigated: sex, smoking habits, age at surgery, body mass index, time to surgery, time to return to sports, type of sport (in-line, pivot, contact), type of graft (free semitendinosus [ST] or attached ST), and addition of lateral tenodesis.

RESULTS

An overall 180 patients were enrolled (90 with each technique). The following factors were significantly and independently associated with the SNQ: attached ST graft (β = -2.624668; P < .001), age at the time of surgery (β = -0.7948476; P = .012), and time elapsed between the injury event and surgery (β = -0.7137424; P = .046).

CONCLUSION

Leaving the ST graft attached distally, being older at the time of surgery, and having more time elapse between the injury event and ACL reconstruction surgery were significantly associated with better graft remodeling.

Comparison of Primary Repair of the Anterior Cruciate Ligament and Anterolateral Structures to Reconstruction and Lateral Extra-articular Tenodesis at 2-Year Follow-up

BACKGROUND

Lateral extra-articular procedures have been effective in reducing graft rupture rates after anterior cruciate ligament (ACL) reconstruction (ACLR), but the evidence supporting their role in ACL repair is sparse.

PURPOSE/HYPOTHESIS

The purpose was to compare clinical and radiological outcomes of ACLR and lateral extra-articular tenodesis (LET) (ACLR+LET) against combined repair of the ACL and anterolateral (AL) structures (ACL+AL Repair). It was hypothesized that patients undergoing ACL+AL Repair would have noninferior clinical and radiological outcomes with respect to International Knee Documentation Committee (IKDC) scores, knee laxity parameters, and magnetic resonance imaging (MRI) characteristics. Furthermore, it was hypothesized that patients undergoing repair would have significantly better Forgotten Joint Score-12 (FJS-12) values and shorter times to return to the preinjury level of sport, without any increase in the rate of ipsilateral second ACL injury.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Consecutive patients evaluated with an acute ACL tear were considered for study eligibility. ACLR+LET was only performed when intraoperative tear characteristics contraindicated ACL repair. Patient-reported outcome measures such as the IKDC score, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS); reinjury rates; anteroposterior side-to-side laxity difference; and MRI characteristics were reported at a minimum follow-up of 2 years. The noninferiority study was based on the IKDC subjective score; side-to-side anteroposterior laxity difference; and signal-to-noise quotient (SNQ). The noninferiority margins were defined using the existing literature. An a priori sample size calculation was performed using the IKDC subjective score as the primary outcome measure.

RESULTS

A total of 100 patients (47 ACLR+LET, 53 ACL+AL Repair) with a mean follow-up of 25.2 months (range, 24-31 months) were enrolled and underwent surgery within 15 days of injury. At the final follow-up, the differences between groups with respect to the IKDC score, anteroposterior side-to-side laxity difference, and SNQ did not exceed noninferiority thresholds. ACL+AL Repair was associated with a shorter time to return to the preinjury level of sport (ACL+AL Repair: mean, 6.4 months; ACLR+LET: mean, 9.5 months; P < .01), better FJS-12 values (ACL+AL Repair: mean, 91.4; ACLR+LET: mean, 97.4; P = .04), and a higher proportion of patients achieving the Patient Acceptable Symptom State (PASS) for the KOOS subdomains studied (Symptoms: 90.2% vs 67.4%, P = .005; Sport and Recreation: 94.1% vs 67.4%, P < .001; Quality of Life: 92.2% vs 73.9%, P = .01). There were no significant differences between groups with respect to ipsilateral second ACL injury rates (ACL+AL Repair group, 3.8% and ACLR+LET group, 2.1% [n = 1]; P = .63).

CONCLUSION

ACL+AL Repair yielded clinical outcomes that were noninferior to (or not significantly different from) ACLR+LET with respect to IKDC subjective, Tegner activity level, and Lysholm scores; knee laxity parameters; graft maturity; and rates of failure and reoperation. However, there were significant advantages of ACL+AL Repair, including a shorter duration of time to return to the preinjury level of sport, better FJS-12 values, and a higher proportion of patients achieving PASS for KOOS subdomains studied (Symptoms, Sport and Recreation, Quality of Life).

Intra-femoral tunnel graft lengths less than 20 mm do not predispose to early graft failure, inferior outcomes or poor function. A prospective clinico-radiological comparative study

PURPOSE

Increasing demands on skills with mounting pressures from expectations from arthroscopic anterior cruciate ligament (ACL) reconstructions requires precise knowledge of technical details by surgeons. One such element is the minimum length of graft in femoral tunnel to allow for adequate tendon-to-bone healing and early return to activities and sports. This has, however, remained an unanswered question.

PURPOSE

To study and compare clinico-radiological outcomes of ACL reconstructions in patients with < 20 mm of intra-femoral tunnel graft length with those measuring ≥ 20 mm.

METHODS

All eligible patients undergoing arthroscopic ACL reconstruction were sequentially divided into two groups based on the intra-femoral tunnel graft lengths (A: < 20 mm, n = 27; and B: ≥ 20 mm, n = 25). Exclusions were made for those > 45 years of age, with chondral and/or multi-ligamentous injuries and with systemic pathologies. All patients were postoperatively evaluated in clinics by physical examination and functional scoring (Lysholm and modified Cincinnati scores) at 3, 6 and 12-month intervals. Graft vascularity was assessed by signal-to-noise quotient ratio (SNQR) using magnetic resonance imaging (MRI) at 3 and 12 months.

RESULTS

No significant differences were noted in mean Lysholm and modified Cincinnati scores between the two groups at the end of 1 year. There were also no significant differences in graft maturation over time and SNQR at 3 and 12 months in the region of interest (ROI).

CONCLUSIONS

Intra-femoral tunnel graft length of less than 20 mm does not compromise early clinical and functional outcomes of ACL reconstructions.

Anterior Cruciate Ligament Reconstruction Using a 4-Strand Semitendinosus Tendon Graft or a Doubled Semitendinosus and Gracilis Tendon Graft: A 4.5-Year Prospective, Randomized, Double-Blind, Parallel-Group Study

BACKGROUND

Hamstring tendon grafts are the most common choice for anterior cruciate ligament (ACL) reconstruction (ACLR). Previous studies have provided evidence that offers conflicting opinions concerning the most favorable graft choice.

PURPOSE

To identify whether the use of a quadrupled semitendinosus tendon (ST) or doubled semitendinosus tendon and gracilis tendon (ST/G) graft provides comparable anterior tibial translation (ATT) with similar functional results and similar donor site morbidity.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

This was a prospective, patient- and surgeon-blinded, randomized trial set in a busy orthopaedic and traumatology department at a university hospital. Between 2015 and 2017, a total of 162 patients with ACL lesions were randomized to undergo ACLR with either a quadrupled ST or doubled ST/G graft. The primary endpoint was ATT assessed with the KT-1000 arthrometer. Clinical outcomes were assessed using the patient-reported outcome measures (PROMs) of the visual analog scale (VAS), International Knee Documentation Committee (IKDC) subjective evaluation form, Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner activity scale, and Lysholm knee scoring scale.

RESULTS

Preoperative demographic data, ATT, and PROM scores showed no significant differences. At 4.5 years, no significant differences were found between the ST and ST/G groups with respect to PROM scores and KT-1000 arthrometer, Lachman test, and pivot-shift test findings. Differences in functional results between groups were significant (muscle strength). Subgroup analysis revealed significantly increased ATT in female patients undergoing ACLR with a quadrupled ST graft during the 4.5-year observation period, as assessed by the KT-1000 arthrometer, as well as inferior KOOS, IKDC, Lysholm, and VAS scores.

CONCLUSION

This study showed a significant increase in ATT as well as inferior results on PROMs during a 4.5-year observation period in female patients undergoing ACLR with a quadrupled ST graft. In male patients, the study provided evidence of the noninferiority of ACLR with an ST graft, with no influence on donor site morbidity.

TRIAL REGISTRATION

clinicaltrials.gov: NCT03626883.

Adaptation of the Signal Noise Quotient MRI classification for graft ligamentization analysis following ATFL and CFL anatomical reconstruction: Validation of the SNQA

BACKGROUND

Chronic ankle instability is the most frequent clinical sign of an antero tibiofibular (ATFL) and/or calcaneo fibular ligament (CFL) tear. One common surgical technique is to use the distal tendon of the gracilis muscle to reconstruct both the ATFL and CFL. In the knee, the hamstring tendons used in anterior cruciate ligament (ACL) reconstruction may go through structural modifications called "ligamentization ". A noninvasive MRI technique has been developed using the Signal/Noise Quotient to compare the signal of the graft following reconstruction to that of the posterior cruciate ligament. To our knowledge no studies have ever evaluated radiographic changes in the graft over time. The main goal of this study was to develop a specific MRI protocol to evaluate graft remodeling following ATFL and CFL reconstruction over time.

METHODS

A prospective study of the changes in the MRI signal of the ATFL-CFL graft 3-months postoperatively was performed in 20 patients. The main outcome was a comparison of the graft signal to that of the peroneal fibular tendon and the surrounding noise to determine the Ankle SNQ (SNQA). MRI images were evaluated by two senior radiologists to assess inter-rater reliability and then 2 weeks later for the intra-rater reproducibility.

RESULTS

The intraclass correlation (ICC) showed excellent inter- and intra rater reliability for the ATFL SNQA (0.96 and 0.91, respectively); and for the CFL SNQA, the ICC was 0.97 and 0.99, respectively. Bland-Altman analysis showed very limited bias in the interpretation of SNQA.

CONCLUSION

This preliminary study confirmed the inter- and intra- rater reliability of a new tool using the SNQA.

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.

Effect of Joint Infection After Arthroscopic Single-Bundle ACL Reconstruction With Autologous Hamstring Tendon: A Retrospective Matched MRI Study

Background:

Joint infection after anterior cruciate ligament (ACL) reconstruction is a rare but serious complication.

Purpose:

To assess the effect of joint infection on the graft, cartilage, and bone tunnel using magnetic resonance imaging (MRI) after arthroscopic single-bundle ACL reconstruction with autologous hamstring tendons.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This retrospective matched cohort study included 26 patients who underwent arthroscopic single-bundle ACL reconstruction with hamstring tendon graft at the authors’ institute between January 2002 and December 2017 and developed postoperative joint infection. These patients were matched 1:3 to patients who did not sustain joint infection after ACL reconstruction (control group). MRI scans were collected at the time of follow-up. The following parameters were evaluated: graft signal-to-noise quotient (SNQ); graft signal intensity at the bone-graft interface and within the knee joint; bone tunnel enlargement at the tunnel aperture, midsection, and exit of the tibial and femoral tunnels; and cartilage integrity.

Results:

The average follow-up time was 47.8 months in the infection group and 48.5 months in the control group. Compared with the control group, the infection group had a significantly higher SNQ (20.01 ± 12.08 vs 7.61 ± 6.70; P = .014) as well as a higher signal intensity at the bone-graft interface (P = .037) and higher Howell grade (P = .031). The mean enlargement at the femoral tunnel aperture was 31.20% ± 26.76% in the infection group and 19.22% ± 20.10% in the control group (P = .037). The articular cartilage of the patellofemoral and lateral femorotibial joints showed more degenerative change in the infection group.

Conclusion:

Study findings indicated that graft ligamentization and incorporation graft maturity were inferior in patients who experienced a joint infection after ACL reconstruction compared with patients who did not.

Tibial tunnel expansion does not correlate with four-strand graft maturation after ACL reconstruction using adjustable cortical suspensory fixation

PURPOSE

Anterior cruciate ligament reconstruction (ACLR) using a short, quadrupled semitendinosus (ST-4) autograft, fixed  with an adjustable suspensory fixation (ASF), has several potential advantages. However, the construct is suspected to generate micromotion, tunnel widening and poor graft maturation. The aim of this study was to evaluate post-operative tibial tunnel expansion, graft maturation and clinical outcomes for this type of ACLR.

METHODS

One-hundred and forty-nine patients were reviewed at a minimum of 2 years following 4-ST ACLR, mean 25.6 ± 3.5 months [24-55], with clinical follow-up and MRI scans. Graft maturity of the intra-articular part of the graft and the tibial tunnel portion was assessed using Signal-to-Noise Quotient (SNQ) and Howell score. Tibial tunnel expansion, bone-graft contact and graft volume in the tibial tunnel were calculated from the MRI scans.

RESULTS

Mean tibial tunnel expansion was 13 ± 16.5% [12-122]. Mean SNQ for graft within the tibial tunnel was 3.8 ± 7.1 [ - 7.7 to 39] and 2.0 ± 3.5 [ - 14 to 17] for the intra-articular portion of the graft. The Howell score for graft within the tibial tunnel was 41% Grade I, 37% Grade 2, 20% Grade 3, 2% grade 4, and for the intra-articular part 61% Grade 1, 26% Grade 2, 13% Grade 3 and 1% Grade 4. The mean tibial tunnel bone-graft contact was 81 ± 23% [0-100] and mean graft volume was 80 ± 22% [0-100]. No correlation was found between tibial tunnel expansion and graft maturity assessed at both locations. Graft maturity was correlated with higher graft-bone contact and graft volume in the tibial tunnel (p < 0.05).

CONCLUSIONS

ST-4 ACLR with ASF had low levels of tunnel enlargement at 2 years. No correlation was found between graft maturation and tibial tunnel expansion. Graft maturity was correlated with graft-bone contact and graft volume in the tibial tunnel.

LEVEL OF EVIDENCE

Level III.

Magnetic Resonance Imaging Assessment of Hamstring Graft Healing and Integration 1 and Minimum 2 Years after ACL Reconstruction

BACKGROUND

An increase has been seen in the number of studies of anterior cruciate ligament reconstruction (ACLR) that use magnetic resonance imaging (MRI) as an outcome measure and proxy for healing and integration of the reconstruction graft. Despite this, the MRI appearance of a steady-state graft and how long it takes to achieve such an appearance have not yet been established.

PURPOSE

To establish whether a hamstring tendon autograft for ACLR changes in appearance on MRI scans between 1 and 2 years and whether this change affects a patient's ability to return to sports.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients with hamstring tendon autograft ACLR underwent MRI and clinical outcome measures at 1 year and at a final follow-up of at least 2 years. MRI graft signal was measured at multiple regions of interest using oblique reconstructions both parallel and perpendicular to the graft, with lower signal indicative of better healing and expressed as the signal intensity ratio (SIR). Changes in tunnel aperture areas were also measured. Clinical outcomes were side-to-side anterior laxity and patient-reported outcome measures (PROMs).

RESULTS

A total of 42 patients were included. At 1 year, the mean SIR for the graft was 2.7 ± 1.2. Graft SIR of the femoral aperture was significantly higher than that of the tibial aperture (3.4 ± 1.3 vs 2.6 ± 1.8, respectively; P = .022). Overall, no significant change was seen on MRI scans after 2 years; a proximal graft SIR of 1.9 provided a sensitivity of 96% to remain unchanged. However, in the 6 patients with the highest proximal graft SIR (>4) at 1 year, a significant reduction in signal was seen at final follow-up (P = .026), alongside an improvement in sporting level. A significant reduction in aperture area was also seen between 1 and 2 years (tibial, -6.3 mm², P < .001; femoral, -13.3 mm², P < .001), which was more marked in the group with proximal graft SIR >4 at 1 year and correlated with a reduction in graft signal. The patients had a high sporting level; the median Tegner activity score was 6 (range, 5-10), and a third of patients scored either 9 or 10. Overall, PROMs and knee laxity were not associated with MRI appearance.

CONCLUSION

In the majority of patients, graft SIR on MRI did not change significantly after 1 year, and a proximal graft SIR <2 was a sensitive indicator for a stable graft signal, implying healing. Monitoring is proposed for patients who have a high signal at 1 year (proximal graft SIR >4), because a significant reduction in signal was seen in the second year, indicative of ongoing healing, alongside an improvement in sporting level. A reduction in tunnel aperture area correlated with a reduction in graft SIR, suggesting this could also be a useful measure of graft integration.

Knee Anterolateral Ligament Reconstruction With Knotless Soft Anchor: Shallow Fixation Prevents Tunnel Convergence

We describe an independent anterolateral ligament reconstruction technique using the gracilis tendon that can be added to any type of anterior cruciate ligament (ACL) reconstruction procedure. No additional tunnels are drilled. The dual-strand graft is attached to the bone cortex with a nonmetallic, knotless anchor using minimally invasive incisions. For the ACL reconstruction, the semitendinosus is attached to the femur with an ENDOBUTTON and to the tibia with a BioComposite interference screw. The ACL remnant is preserved to improve ligamentization, and the ACL graft is pedicled to the tibia to encourage its vascularization.

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.

MRI Signal Intensity of Quadriceps Tendon Autograft and Hamstring Tendon Autograft 1 Year After Anterior Cruciate Ligament Reconstruction in Adolescent Athletes

BACKGROUND

Hamstring tendon autograft (HTA) is a common graft choice for anterior cruciate ligament (ACL) reconstruction (ACLR) in skeletally immature patients. Recently, the use of quadriceps tendon autograft (QTA) has shown superior preliminary outcomes in this population.

PURPOSE

To evaluate graft maturity by comparing magnetic resonance imaging (MRI) signal intensity of HTA versus QTA used in primary ACLR.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All patients under the age of 18 years who underwent a primary ACLR by the senior authors using either an HTA or a QTA were retrospectively reviewed. A total of 70 skeletally immature patients (37 in the HTA group and 33 in the QTA group) with an available MRI at 6 and 12 months postoperatively were included. Signal intensity ratio (SIR) was measured on sagittal MRI by averaging the signal at 3 regions of interest along the ACL graft and dividing by the signal of the tibial footprint of the posterior cruciate ligament. Statistical analysis was performed to determine interrater reliability and differences between time points and groups.

RESULTS

Age, sex, and type of surgery were not associated with any differences in SIR. There was no significant difference in SIR between groups on the 6-month MRI. However, the SIR of the QTA group was significantly less than in the HTA group on the 12-month MRI (2.33 vs 2.72, respectively; P = .028). Within the HTA group, there was no significant difference in SIR at either MRI time point. In the QTA group, there was a significant decrease in SIR between the 6-month and 12-month postoperative MRI (2.70 vs 2.33, respectively; P = .045).

CONCLUSION

These findings suggest improved graft maturation, remodeling, and structural integrity of the QTA compared with the HTA between 6 and 12 months postoperatively. This provides evidence that, at 1 year postoperatively, QTA may have a superior rate of incorporation and synovialization as compared with the HTA.

Graft tunnel integration occurs early in the tibial tunnel compared with the femoral tunnel after anterior cruciate ligament reconstruction with preserved insertion hamstring tendon graft

Background

Preservation of hamstring tendon insertion at the time of anterior cruciate ligament (ACL) reconstruction is a well-known technique; however, its effect on graft integration is not well studied. The present study was conducted to study the graft integration inside the tibial and femoral tunnels, respectively, after ACL reconstruction using hamstring tendon graft with preserved insertion.

Methods

Twenty-five professional athletes who underwent ACL reconstruction using hamstring tendon graft with preserved tibia insertion were enrolled in the study. Functional outcomes were checked at final follow-up using Lysholm score and Tegner activity scale. Magnetic resonance imaging (MRI) was done at 8 months and 14 months follow-up to study the graft tunnel integration of the ACL graft at both tibial and femoral tunnels.

Results

The mean Fibrous interzone (FI) score (tibial tunnel) decreased from 2.61 (1–5) at 8 months to 2.04 (1–4) at 14 months follow-up (p = 0.02). The mean FI score (femoral side) decreased from 3.04 (2–5) at 8 months to 2.57 (2–4) at 14 months (p = 0.02).

Conclusions

Graft integration occurs early in the tibial tunnel as compared with the femur tunnel with preserved insertion hamstring tendon autograft.

Trial registration CTRI/2019/07/020320 [registered on 22/07/2019]; http://www.ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=33884&EncHid=&modid=&compid=%27,%2733884det%27

Effect of Modified Lemaire Anterolateral Extra-articular Tenodesis on the Magnetic Resonance Imaging Maturity Signal of Anterior Cruciate Ligament Hamstring Graft

BACKGROUND

Lateral extra-articular tenodesis (LET) is one of the most widely used procedures to restore anterolateral stability. Clinical outcomes after the addition of LET to anterior cruciate ligament (ACL) reconstruction (ACLR) have been widely investigated; however, the potential influence of LET on the ACL ligamentization process has not been examined.

PURPOSE/HYPOTHESIS

The purpose was to use 10-month postoperative magnetic resonance imaging (MRI) scans to determine whether the maturity of grafts after hamstring autograft ACLR was affected by concomitant LET. The hypothesis was that when modified Lemaire lateral extra-articular tenodesis (MLLET) was performed, the MRI parameters of ACL graft maturity would be modified.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The study included patients treated between December 2017 and December 2018 who had undergone anatomic 3-strand hamstring tendon autograft ACLR, with or without concomitant MLLET, and had undergone MRI 10 months postoperatively. Thus, the study included 30 patients who had isolated ACLR and 22 patients who had ACLR plus MLLET. The 2 groups were comparable based on all criteria analyzed. To evaluate graft maturity, the signal-to-noise quotient (SNQ) was measured in 3 regions of interest of the proximal, midsubstance, and distal ACL graft. Lower SNQ ratios indicate less water content and, theoretically, better maturity and healing of the graft.

RESULTS

The mean ± SD for SNQ was 4.62 ± 4.29 (range, 3.12-6.19) in the isolated ACLR group and 7.59 ± 4.68 (range, 4.38-8.04) in the ACLR plus MLLET group (P = .012). Upon comparing the mean values of the 3 portions between the 2 groups, we found a significant difference between the 2 groups for the proximal and middle portions (P = .007 and P = .049, respectively) but no difference in the distal portion (P = .369).

CONCLUSION

At the 10-month follow-up, hamstring tendon autografts for anatomic ACLR with MLLET did not show the same MRI signal intensity compared with isolated hamstring anatomic ACLR.

Influence of femoral tunnel exit on the 3D graft bending angle in anterior cruciate ligament reconstruction

Purpose

To quantify the influence of the femoral tunnel exit (FTE) on the graft bending angle (GBA) and GBA-excursion throughout a full range of motion (ROM) in single-bundle anterior cruciate ligament (ACL) reconstruction.

Methods

Three-dimensional (3D) surface models of five healthy knees were generated from a weight-bearing CT obtained throughout a full ROM (0, 30, 60, 90, 120°) and femoral and tibial ACL insertions were computed. The FTE was simulated for 16 predefined positions, referenced to the Blumensaat's line, for each patient throughout a full ROM (0, 30, 60, 90, 120°) resulting in a total of 400 simulations. 3D GBA was calculated between the 3D directional vector of the ACL and the femoral tunnel, while the intra-articular ACL insertions remained unchanged. For each simulation the 3D GBA, GBA-excursion, tunnel length and posterior tunnel blow-out were analysed.

Results

Overall, mean GBA decreased with increasing knee flexion for each FTE (p < 0.001). A more distal location of the FTE along the Blumensaat's line resulted in an increase of GBA and GBA-excursion of 8.5 ± 0.6° and 17.6 ± 1.1° /cm respectively (p < 0.001), while a more anterior location resulted in a change of GBA and GBA-excursion of -2.3 ± 0.6° /cm (+ 0.6 ± 0.4°/ cm from 0–60° flexion) and 9.8 ± 1.1 /cm respectively (p < 0.001).

Mean tunnel length was 38.5 ± 5.2 mm (range 29.6–50.5). Posterior tunnel blow-out did not occur for any FTE.

Conclusion

Aiming for a more proximal and posterior FTE, with respect to Blumensaat’s line, reliably reduces GBA and GBA-excursion, while preserving adequate tunnel length. This might aid to reduce excessive graft stress at the femoral tunnel aperture, decrease femoral tunnel widening and promote graft-healing.

Level of Evidence

IV

No differences in clinical outcomes and graft healing between anteromedial and central femoral tunnel placement after single bundle ACL reconstruction

PURPOSE

The purpose of this study was to compare clinical outcomes and graft healing after anterior cruciate ligament (ACL) reconstruction with anteromedial and central femoral tunnel placement.

METHODS

During 2016 and 2018, 110 consecutive patients underwent single bundle ACL reconstruction; 85 patients met the inclusion criteria, and each patient underwent 3D-CT within 1 week and MRI 1.5 years after the operation. The central point of the femoral tunnel and signal/noise quotient (SNQ) of three regions of interest (ROI) in the intra-articular graft were measured to analyse the tunnel position and graft healing extent. Clinical assessments, including functional scores, KT-2000 arthrometer measurements and pivot-shift tests, were evaluated at the 2-year follow-up. Patients were divided into two groups depending on the femoral tunnel position: the anteromedial position group (Group A) and the centre position group (Group B).

RESULTS

Seventy-one patients were available for the 2-year follow-up and MRI examination: 34 patients in Group A and 35 patients in Group B, and 2 patients were excluded for an eccentric tunnel position. No graft failure occurred, and compared with the preoperative assessment outcomes, the outcomes of both groups improved at the final follow-up. Group A was significantly better than Group B regarding the KT-2000 arthrometer measurements (P = 0.031). No significant differences were observed in terms of functional scores, pivot-shift test results, or the SNQ between groups.

CONCLUSIONS

No differences in clinical outcomes or graft healing were found between AM and central femoral tunnel placements in single bundle ACL reconstruction. Therefore, satisfactory clinical outcomes, knee stability and graft healing can be obtained for both femoral tunnel placements.

LEVEL OF EVIDENCE

II.

Incidence and Risk Factors for Residual High-Grade Pivot Shift After ACL Reconstruction With or Without a Lateral Extra-articular Tenodesis

Background

Residual rotatory knee laxity at midterm follow-up after isolated anterior cruciate ligament reconstruction (ACLR) versus ACLR with lateral extra-articular tenodesis (LET) remains an issue.

Purpose/Hypothesis

To evaluate the outcomes of ACLR with or without additional LET at a minimum 2-year follow-up in patients with preoperative high-grade pivot shift (PS). Our hypothesis was that the addition of LET would decrease the risk of secondary meniscal injury and the presence of residual high-grade PS at follow-up.

Study Design

Cohort study; Level of evidence, 3.

Methods

A retrospective analysis performed at 3 sports medicine centers identified 266 study patients; all had a high-grade PS (grade 2 or 3) preoperatively and underwent isolated ACLR with or without LET. Four different ACLR techniques were used: single-strand quadrupled semitendinosus (ST4) ACLR without LET (ST4 group; n = 55), ST4 with anatomic LET (ST4+LET group; n = 77), bone-patellar tendon and modified Lemaire LET (BTB+LET group; n = 43), and quadriceps tendon and modified Lemaire LET (QT+LET group; n = 91). At follow-up, we evaluated for the presence of high-grade (grade ≥2) PS. Preoperative meniscal tears and their treatment were recorded.

Results

Overall, 185 (69.5%) patients had at least 1 meniscal tear at index surgery. The mean follow-up period was 44.3 months; 47 (17.7%) patients had a new meniscal tear and 64 (24%) patients had a high-grade PS at follow-up. Compared with meniscal repair, significant predictors for high-grade PS at follow-up were meniscectomy (odds ratio [OR] = 2.65 [95% CI, 1.19-5.63]; P = .02) and nonrepair of preoperative meniscal tear (OR = 3.26 [95% CI, 1.27-9.43]; P = .007). The appearance of a new symptomatic meniscal tear was the strongest significant predictor of high-grade PS at follow-up (OR = 4.31 [95% CI, 2.31-8.06]; P < .001). No significant correlation was observed between the addition of LET and the presence of high-grade PS at follow-up.

Conclusion

In the current study, 1 in 4 patients with high-grade PS before ACLR with or without LET was at risk of residual rotatory knee laxity at mean 44-month follow-up, regardless of the technique used. Repairing a pre-existing meniscal lesion was more effective than performing LET to decrease the presence of a high-grade PS at follow-up.

Magnetic Resonance Imaging 1 Year After Hamstring Autograft Anterior Cruciate Ligament Reconstruction Can Identify Those at Higher Risk of Graft Failure: An Analysis of 250 Cases

BACKGROUND

There is currently no analysis of 1-year postoperative magnetic resonance imaging (MRI) that reproducibly evaluates the graft of a hamstring autograft anterior cruciate ligament reconstruction (ACLR) and helps to identify who is at a higher risk of graft rupture upon return to pivoting sports.

PURPOSE

To ascertain whether a novel MRI analysis of ACLR at 1 year postoperatively can be used to predict graft rupture, sporting level, and clinical outcome at a 1-year and minimum 2-year follow-up.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Graft healing and integration after hamstring autograft ACLR were evaluated using the MRI signal intensity ratio at multiple areas using oblique reconstructions both parallel and perpendicular to the graft and tunnel apertures. Clinical outcomes were assessment of side-to-side laxity and International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Lysholm, and Tegner activity level scores at 1 year. Repeat outcome measures and detection of graft rupture were evaluated at a minimum of 2 years.

RESULTS

A total of 250 patients (42.4% female) underwent MRI analysis at 1 year, and assessment of 211 patients between 1 year and the final follow-up (range, 24-36 months) detected 9 graft ruptures (4.3%; 5 in female patients). A significant predictor for graft rupture was a high signal parallel to the proximal intra-articular graft and perpendicular to the femoral tunnel aperture (P = .032 and P = .049, respectively), with each proximal graft signal intensity ratio (SIR) increase by 1 corresponding to a 40% increased risk of graft rupture. A cutoff SIR of 4 had a sensitivity and specificity of 66% and 77%, respectively, in the proximal graft and 88% and 60% in the femoral aperture. In all patients, graft signal adjacent to and within the tibial tunnel aperture, and in the mid intra-articular portion, was significantly lower than that for the femoral aperture (P < .001). A significant correlation was seen between the appearance of higher graft signal on MRI and those patients achieving top sporting levels by 1 year.

CONCLUSION

ACLR graft rupture after 1 year is associated with MRI appearances of high graft signal adjacent to and within the femoral tunnel aperture. Patients with aspirations of quickly returning to a high sporting level may benefit from MRI analysis of graft signal. Graft signal was highest at the femoral tunnel aperture, adding further radiographic evidence that the rate-limiting step to graft healing occurs proximally.

Adjustable suspension versus hybrid fixation in hamstring autograft anterior cruciate ligament reconstruction

BACKGROUND

There has been increased use of adjustable suspensory fixation (ASF) for anterior cruciate ligament reconstruction (ACLR). Potential benefits are the ability to use a shorter graft and to prevent graft displacement and damage. The purpose of this study was to establish the efficacy of this fixation method and assess whether it leads to less tunnel widening, and avoids known complications of screw fixation.

METHODS

Thirty-eight patients who underwent ACLR with ASF on both the femoral and tibial sides met the inclusion criteria and were propensity matched demographically with 38 patients who underwent hybrid fixation with femoral suspensory and tibial screw and sheath. At one-year, KT-1000 knee laxity measurements were recorded and detailed MRI analysis looking at tunnel aperture widening, tunnel appearance, graft integration within the tunnels, and graft healing.

RESULTS

MRI comparison between ASF and hybrid cohorts revealed no significant differences in graft signal or integration, and clinically there were no differences in knee laxity between cohorts (mean 1.5 mm ± 2.0 and 1.5 mm ± 2.3 (n.s.) in the ASF and hybrid fixation respectively). Significantly less aperture tibial tunnel widening (2.2 mm versus 4.4 mm, p < 0.0001) and tibial cysts (2 versus 9, p = 0.047) were observed in the ASF cohort, whilst mean femoral tunnel widening was comparable between both cohorts (ASF 2.8 mm, hybrid 3.2 mm; n.s.).

CONCLUSIONS

Hamstring autografts for ACLR fixed using either ASF or a hybrid fixation technique provided comparable knee stability and MRI graft signal intensity. Tibial ASF demonstrated significantly less tibial aperture widening and tunnel cyst formation when compared to screw and sheath fixation.

Effect of Lateral Extra-articular Tenodesis on Anterior Cruciate Ligament Graft Incorporation

Background:

It has been shown that adding lateral extra-articular tenodesis (LET) to standard anterior cruciate ligament (ACL) reconstruction significantly decreases the loads on the ACL composite graft. To date, the possible effect of LET on ACL graft incorporation is not known.

Purpose:

To compare the incorporation in tibial bone tunnels of a standard quadrupled semitendinosus (ST4) graft to an ST4 graft plus LET at 1 year postoperatively using magnetic resonance imaging (MRI).

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A total of 62 patients who underwent ACL reconstruction were enrolled prospectively: 31 received an ST4 graft, and 31 received an ST4 graft plus LET. Graft incorporation was evaluated with MRI at the 1-year follow-up visit. The following parameters were evaluated: signal-to-noise quotient (SNQ), tibial tunnel widening, graft healing, and graft maturity according to the Howell scale. The primary endpoint was the SNQ of the ST4 graft at 1 year postoperatively; this parameter was adjusted because of unequal baseline characteristics between groups. Clinical and functional outcomes as well as incorporation of the graft were analyzed as secondary endpoints.

Results:

The mean adjusted SNQ was 0.5 ± 2.1 (95% CI, 0.4-4.6) in the ST4 + LET group and 5.9 ± 3.7 (95% CI, 4.7-7.0) in the ST4 group (P = .0297). The mean tibial tunnel widening was 73.7% ± 42.2% in the ST4 + LET group versus 77.5% ± 46.7% in the ST4 group (P = .5685). Howell grade I, indicative of better graft maturity, was statistically more frequent in the ST4 + LET group (P = .0379). No statistically significant difference was seen between groups in terms of graft healing (P = .1663). The Lysholm score was statistically higher in the ST4 + LET group (P = .0058). No significant differences were found between groups in terms of the International Knee Documentation Committee subjective score (P = .2683) or Tegner score (P = .7428). The mean SNQ of the LET graft at the 1-year follow-up visit was 2.6 ± 4.9.

Conclusion:

At 1 year postoperatively, the MRI appearance of ACL grafts showed generally better incorporation and maturation when combined with LET.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

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

RESULTS

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

CONCLUSION

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

Lower donor-site morbidity using QT autografts for ACL reconstruction

PURPOSE

Comparing scar cosmesis and regional hypoesthesia at the incision site between quadriceps tendon (QT), bone-patellar tendon-bone (BPTB), and hamstring tendon (HT) for anterior cruciate ligament (ACL) reconstruction.

METHODS

Ninety patients undergoing ACL reconstruction with QT, HT or BPTB were evaluated at 1-year post-op. Scar cosmesis was assessed using the patient and observer scar assessment scale (POSAS) and length of the incision. Sensory outcome was analyzed by calculating the area of hypoesthesia around the scar. The classical ACL reconstruction functional follow-up was measured using the Lysholm score and KOOS.

RESULTS

Concerning QT versus BPTB group, QT patients have a significantly lower mean POSAS (24.8 ± 6.3 vs. 39.6 ± 5.8; p < 0.0001), shorter mean incision (2.8 ± 0.4 cm vs. 6.4 ± 1.3 cm; p < 0.0001), lower extent of hypoesthesia (8.7 ± 5.1 cm² vs. 88.2 ± 57 cm²; p < 0.0001), and better Lysholm score (90.1 ± 10.1 vs. 82.6 ± 13.5; n.s.). No significant difference was seen in KOOS (90.7 ± 7.2 vs. 88.4 ± 7.0; n.s.). Concerning QT versus HT group, no significant difference was found regarding mean POSAS score (24.8 ± 6.3 vs. 31.8 ± 6.2; n.s.), mean length of the incision (2.8 ± 0.4 cm vs. 2.5 ± 0.6 cm; n.s.), KOOS (90.7 ± 7.2 vs. 89.8 ± 8.2; n.s.) and mean Lysholm score (90.1 ± 10.1 vs. 87.8 ± 0.6; n.s.). The mean measured area of hypoesthesia was significantly higher in the HT group (70.3 ± 77.1 cm² vs. 8.7 ± 5.1 cm²; p < 0.0001).

CONCLUSION

Quadriceps tendon harvesting technique has the safest incision by causing less sensory loss compared to BPTB and HT. It also has the advantage of a short incision with more cosmetic scar compared to BPTB, with no difference compared to HT. However, no significant difference in terms of functional outcome was shown between the three autografts. These findings provide surgeons evidence about their clinical practice and help with graft choice decisions.

LEVEL OF EVIDENCE

III.

Joint laxity and graft compliance increase during the first year following ACL reconstruction with short hamstring tendon grafts

PURPOSE

Evaluating joint laxity and graft compliance after ACL surgery may be used to quantify biomechanical graft properties during the ligamentization process. This study aimed to analyse the evolvement of joint laxity and graft compliance of short hamstring tendon grafts after ACL reconstruction (ACLR).

METHODS

Forty-seven patients that underwent ACLR were retrospectively enrolled. Joint laxity was quantified with a GNRB^® arthrometer before surgery, then at 15 days, at 1/3/6/9 months (M1-M9), at 1 year postoperatively and then again at the last mean follow-up (FU) of 14.7 ± 3.0 months. The side-to-side laxity difference (ΔL in mm) was measured at 30 and 60 N at every FU, additionally at 90 N from M3 on and at 134 N from M6 on. The side-to-side compliance difference (ΔC in µm/N) was calculated for each graft.

RESULTS

Mean ΔL and ΔC decreased significantly between preoperative and M1 for all applied forces (at 30 N, ΔL: 0.8 mm, p < 0.0001; ΔC: 25.9 µm/N, p < 0.001). Between M1 and M9, ΔL increased significantly at 30 N (p = 0.02) and 60 N (p < 0.001), while ΔC increased by 15.2 µm/N at 30 N (p = 0.003) and 14.9 µm/N at 60 N (p = 0.001). Between M9 and the last FU, there were no significant differences for ΔL and ΔC.

CONCLUSION

Joint laxity and graft compliance evolve during the first postoperative year with a phase between the first and ninth postoperative month of relative weakness. According to the established evolvement profile, return to pivoting or contact sports should be considered only after stabilization of joint laxity and graft compliance.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.

ACL hamstring grafts fixed using adjustable cortical suspension in both the femur and tibia demonstrate healing and integration on MRI at one year

PURPOSE

To present the clinical outcomes and magnetic resonance imaging (MRI) analysis of adjustable cortical suspensory fixation for the femur and tibia in hamstring autograft anterior cruciate ligament reconstruction.

METHODS

A cohort of 233 sequential patients was analysed for graft failure rate and subjective IKDC, Tegner and Lysholm scores. 144 validated 1-year MRIs assessed and correlated graft healing and tunnel widening.

RESULTS

At mean follow-up of 28 months ± 8.2 [median 26, range 12-49], the graft failure rate was 4.7%. Significant improvements were seen in all clinical scores (p < 0.001). MRI analysis showed 71% with fully integrated grafts in the tibia and 24% in the femur, with the remainder all showing greater than 50% integration. Graft signal was low and homogenous in 67% in the tibia, 29% in the intra-articular portion and 20% in the femur. One patient had greater than 50% high signal in the tibial graft and one in the intra-articular graft, all others demonstrated greater than 50% low signal. Both graft integration and signal were significantly better in the tibia than the femur (p < 0.01). Tunnel widening was 2.2 ± 1.4 mm and 2.7 ± 1.3 mm in the tibia and femur, respectively. Comparison of individual MRI appearances and overall clinical outcome at the same 12-month point demonstrated no consistent significant correlation.

CONCLUSION

Adjustable cortical suspensory fixation in both femoral and tibial tunnels provides good clinical outcomes and a low graft rupture rate. Grafts demonstrate healing with comparatively low tunnel widening. There was no consistent significant correlation between the appearances on MRI and clinical outcome.

LEVEL OF EVIDENCE

Case-control study, Level III.

Graft Size and Orientation Within the Femoral Notch Affect Graft Healing at 1 Year After Anterior Cruciate Ligament Reconstruction

BACKGROUND

The combined influence of anatomic and operative factors affecting graft healing after anterior cruciate ligament (ACL) reconstruction within the femoral notch is not well understood.

PURPOSE

To determine the influence of graft size and orientation in relation to femoral notch anatomy, with the signal/noise quotient (SNQ) of the graft used as a measure of graft healing after primary single-bundle ACL reconstruction.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 98 patients with a minimum 2-year follow-up after primary single-bundle ACL reconstruction with hamstring tendon autografts were included. Graft healing was evaluated at 1 year on magnetic resonance imaging (MRI) scan as the mean SNQ measured from 3 regions situated at sites at the proximal, middle, and distal graft. Patient characteristics, chondropenia severity score, tunnel sizes, tunnel locations, graft bending angle (GBA), graft sagittal angle, posterior tibial slope (PTS), graft length, graft volume, femoral notch volume, and graft-notch volume ratio (measured using postoperative 3-T high-resolution MRI) were evaluated to determine any association with 1-year graft healing. The correlation between 1-year graft healing and clinical outcome at minimum 2 years was also assessed.

RESULTS

There was no significant difference in mean SNQ between male and female patients (P > .05). Univariate regression analysis showed that a low femoral tunnel (P = .005), lateral tibial tunnel (P = .009), large femoral tunnel (P = .011), large tibial tunnel (P < .001), steep lateral PTS (P = .010), steep medial PTS (P = .004), acute graft sagittal angle (P < .001), acute GBA (P < .001), large graft volume (P = .003), and high graft-notch volume ratio (P < .001) were all associated with higher graft SNQ values. A multivariate regression analysis showed 2 significant factors: a large graft-notch volume ratio (P = .001) and an acute GBA (P = .004). The 1-year SNQ had a weak correlation with 2-year Tegner Activity Scale score (r = 0.227; P = .026) but no other clinical findings, such as International Knee Documentation Committee subjective and Lysholm scores and anterior tibial translation side-to-side difference.

CONCLUSION

The 1-year SNQ value had a significant positive association with graft-notch volume ratio and GBA. Both graft size and graft orientation appeared to have a significant influence on graft healing as assessed on 1-year high-resolution MRI scan.

Minimally Invasive Ultrasound-Guided Anterolateral Ligament Reconstruction With Autologous 2-Strand Gracilis Graft

We describe an ultrasound-guided anterolateral ligament (ALL) reconstruction technique that uses the gracilis tendon and can be added to any anterior cruciate ligament reconstruction technique. Preoperative ultrasound imaging is used to view the ruptured ALL and confirm the location of bony landmarks. Two minimally invasive incisions are made: one posterior to the lateral epicondyle and one posterior to the Gerdy tubercle. After anterior cruciate ligament graft fixation, the 2-strand gracilis tendon is introduced from the tibial incision, under the fascia lata, toward the femoral incision. The ALL graft is secured to the femur with a 5.5-mm anchor, positioned posteriorly and proximally to the lateral epicondyle. The distal end of the graft is tightened in full extension and fixed to the tibia with a ligament staple posterior to the Gerdy tubercle. This ALL technique requires no graft preparation.

Assessment of Anterior Cruciate Ligament Graft Maturity With Conventional Magnetic Resonance Imaging: A Systematic Literature Review

Background:

Magnetic resonance imaging (MRI) signal intensity (SI) measurements are being used increasingly in both clinical and research studies to assess the maturity of anterior cruciate ligament (ACL) grafts in humans. However, SI in conventional MRI with weighted images is a nonquantitative measure dependent on hardware and software.

Purpose:

To conduct a systematic review of studies that have used MRI SI as a proxy for ACL graft maturity and to identify potential confounding factors in assessing the ACL graft in conventional MRI studies.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review was conducted by searching the MEDLINE/PubMed, Scopus, and Cochrane Library electronic databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify studies that examined the healing of the intra-articular portion of the ACL graft by assessing SI on MRIs.

Results:

A total of 34 studies were selected for inclusion in this systematic review. The MRI acquisition techniques and methods to evaluate the ACL graft SI differed greatly across the studies. No agreement was found regarding the time frames of SI changes in MRI reflecting normal healing of the ACL tendon graft, and the graft SI and clinical outcomes after ACL reconstruction were found to be poorly correlated.

Conclusion:

The MRI acquisition and evaluation methods used to assess ACL grafts are very heterogeneous, impeding comparisons of SI between successive scans and between independent studies. Therefore, quantitative MRI-based biomarkers of ACL graft healing are greatly needed to guide the appropriate time of returning to sports after ACL reconstruction.

MRI study of the ligamentization of ACL grafts in children with open growth plates

INTRODUCTION

There is little published information on the ligamentization of pediatric anterior cruciate ligament (ACL) grafts. The aims of our study were to compare the MRI appearance of ACL grafts performed in a population with open growth plates to normal ACLs in adolescents and to determine whether the MRI signal in the grafts at 6 months could predict a retear. We hypothesized that ligamentization was a slow, gradual process.

MATERIAL AND METHODS

This was a prospective multicenter study of 100 ACL grafts (quadriceps tendon, hamstring tendon, fascia lata) in children 7 to 16 years of age. Of these, 65 intact grafts underwent one or more MRI examinations between 6 months and 2 years postoperative. MRI images were also analyzed in 7 patients who suffered a retear and in the intact ACL of 20 adolescents (15 to 18 years of age). The other 28 patients did not undergo an MRI during the postoperative phase. For each MRI, the signal-to-noise quotient (SNQ) was calculated in three different areas in the ACL (proximal, middle, distal) along with the Howell intra-articular and intra-tibial grades from I to IV. The Mantel-Haenszel Chi-square, Wilcoxon signed-rank test and Student's t-test were used to compare groups. The Lin concordance correlation coefficients were calculated for inter-rater consistency.

RESULTS

There was a difference in the SNQ between the three zones of a normal ACL. Most were Howell grade III (55% Howell III, 25% Howell II and 20% Howell I). For intact grafts, the SNQ improved significantly between 6 and 12 months and between 6 and 24 months. There was no difference in the SNQ between the three zones independent of the postoperative time point. The intra-articular Howell grade improved significantly between 6 and 24 months and between 12 and 24 months. The intra-tibial Howell grade improved significantly between 12 and 24 months. There were no significant differences between patients with intact grafts and those who suffered a retear. There were no differences between the various types of grafts used.

CONCLUSION

Normal ACLs in adolescents have inhomogeneous SNQ and Howell grades. The SNQ and Howell grades in ACL grafts are more homogeneous and continue to improve out to 2 years, but do not reach that of a normal ACL. The signal and appearance of an ACL graft and normal ACL are very different, and the MRI signal at 6 months postoperative is not predictive of retear.

LEVEL OF EVIDENCE

III, prospective study.

Graft bending angle affects allograft tendon maturity early after anterior cruciate ligament reconstruction

PURPOSE

The aim of this study was to clarify the association of the anterior cruciate ligament (ACL) graft bending angle and graft maturity of autograft and allograft tendons using high-resolution MRI.

METHODS

Patients with unilateral ACL reconstruction were invited to participate in this study, and they were examined using a 3.0-T MRI scan at 3, 6 and 12 months after the operation. Anatomic single-bundle ACL reconstruction was performed on 48 patients using the trans-portal technique, including 28 with autograft hamstring tendons and 20 with allograft tendons. To evaluate graft healing, the signal/noise quotient (SNQ) was measured in four regions of interest (ROIs) of the femoral tunnel, proximal, midsubstance and distal ACL grafts. The graft bending angle was defined as the angle between the femoral bone tunnel and the line connecting the femoral and tibial tunnel apertures. Graft SNQ and graft bending angle were assessed at 3, 6 and 12 months postoperatively, and the association between SNQ and the average graft bending angle was analyzed.

RESULTS

Generally, the mean graft bending angle of this cohort increased gradually with time. The SNQ value of each graft region increased from 3 to 6 months and then decreased from 6 to 12 months. In the whole cohort, the graft bending angle had a significant positive association with graft SNQ in the femoral tunnel or proximal site. In the allograft subgroup, the graft bending angle had a significant positive association with the graft SNQ in the femoral tunnel or proximal site at 6 months after surgery, while there was no association between the graft bending angle and SNQ at 12 months. In the autograft subgroup, the graft bending angle had a significant positive association with graft SNQ in the femoral tunnel or proximal site at 12 months after surgery.

CONCLUSION

Generally, the graft bending angle was correlated with a high signal intensity of the proximal graft in the early postoperative period for allograft tendons and in the late postoperative period for allograft tendons. This suggests that the biomechanical effect from the graft bending angle on graft healing may be different for allografts and autografts after ACL reconstruction.

LEVEL OF EVIDENCE

III.