Long-term Comparison of Semitendinosus and Gracilis Tendon Versus Patellar Tendon Autografts for Anterior Cruciate Ligament Reconstruction: A 17-Year Follow-up of a Randomized Controlled Trial

Surgical Techniques in Primary ACL Reconstruction: Getting It Right the First Time

The ideal anterior cruciate ligament reconstruction (ACLR) is an individualized anatomic approach aimed at restoring the native structure and function of the knee. Surgeons are tasked with difficult decisions during operative planning, including the optimal graft choice for the patient and appropriate anatomic tunnel placement. Special considerations should additionally be given for skeletally immature patients and those at high-risk for failure, including younger, active patients participating in pivoting sports. The purpose of this review is to provide an overview of the individualized approach to ACLR, including the necessary preoperative and operative considerations to optimize patient outcomes.

Revision Anterior Cruciate Ligament Reconstruction and Associated Procedures

Failure of anterior cruciate ligament reconstruction (ACLR) is a common yet devastating complication due to inferior clinical outcomes associated with revision ACLR. Identifying the cause and associated risk factors for failure is the most important consideration during preoperative planning. Special attention to tunnel quality, concomitant injuries, and modifiable risk factors will help determine the optimal approach and staging for revision ACLR. Additional procedures including lateral extra-articular tenodesis and osteotomy may be considered for at-risk populations. The purpose of this review is to explore causes of ACLR failure, clinical indications and appropriate patient evaluation, and technical considerations when performing revision ACLR.

Eighteen-year outcome of anterior cruciate ligament reconstruction with patellar tendon or hamstring autograft

PURPOSE

To evaluate patient reported outcomes and radiographic arthritic changes of transtibial anterior cruciate ligament reconstruction (ACLR) with either bone-patellar tendon-bone (BPTB) or hamstrings (HS) auto-grafts at a minimum of 15-year follow-up.

METHODS

Ninety-four patients (51 of the HS group, 43 of BPTB group) who were operated between the years 2000 to 2005 in two tertiary referral hospitals were contacted and invited to a retrospective evaluation. The interview included subjective outcomes using the Lysholm knee scoring questionnaire, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Tegner activity level scale, Visual Analogue Scale (VAS) for pain and patients' satisfaction scale. Knee examination included measurements of motion and stability. Knee radiographs were evaluated for osteoarthritic changes according to the Kellgren-Lawrence (KL) score.

RESULTS

The average evaluation time from surgery was 18.6 years. Subjectively, there was no significant difference between groups except for a better post-operative level of activity and satisfaction in the HS group. Objectively, there was no significant difference between groups in knee stability and range of motion. Most patients had grade KL ≤ 1 radiographic osteoarthritits changes and there was no significant difference between groups. Recurrent complete tear of the reconstructed graft occurred in 3 patients of each group. In both groups 84% had no further surgery while the indications for further surgery were mostly a meniscal tear or tibial hardware removal.

CONCLUSIONS

Very long-term outcomes and clinical stability of transtibial HS or BPTB graft ACL reconstruction are good with low rate of graft failure and radiographic osteoarthritis.

Primary Anterior Cruciate Ligament Reconstruction with Suture Tape Augmentation: A Case Series of 252 Patients

Anterior cruciate ligament reconstruction (ACLR) using suture tape augmentation to internally brace is a relatively new technique. The primary goal of this study was to prospectively collect patient-reported outcomes (PROs) and surgical history from patients who underwent primary ACLR with internal bracing to determine if internal bracing resulted in a low graft failure rate while maintaining acceptable PROs. A total of 252 patients with a mean age of 23.6 years (95% confidence interval [CI]: 22.1-25.1) and a mean follow-up of 37.9 months (95% CI: 35.8-40.0) were included in this study. Patients who underwent primary ACLR with internal brace augmentation between July 12, 2016 and July 31, 2021 were eligible. A total of 222 patients were contacted via telephone and administered the visual analog scale (VAS), the single assessment numeric evaluation (SANE), the Lysholm knee score scale, and, if applicable, the short version ACL return to sport after injury (SV-ACL-RSI) survey. Additionally, patients were asked to give an updated orthopaedic history. Thirty additional patients were included from either our institution's registry or by completing their surveys in-office or by e-mail. The minimal clinically important difference (MCID) and patient-acceptable symptom states (PASS) were calculated based on our patient population and applied to each individual patient. The patients' electronic health record (EHR) was searched for pre- and postoperative clinical data including KT-1000 arthrometer measurements. Two patients (0.8%) had subsequent graft failures and one patient (0.4%) required a revision surgery. MCID was achieved in 242 patients (96.0%) for the Lysholm, 227 patients (90.1%) for the SANE, and 146 patients (57.9%) for the VAS. PASS was achieved in 214 patients (84.9%) for the Lysholm, 198 patients (78.6%) for the SANE, and 199 (80.0%) patients for the VAS, postoperatively. Of note, 65 patients (25.8%) exceeded the PASS threshold for the VAS preoperatively. A total of 127 patients (84.4%) met the cutoff of ≥60/100 for the SV-ACL-RSI survey postoperatively. Postoperative KT-1000 measurements showed near-identical side-to-side differences at both the 13.6-kg pull and manual maximum pull. When stratifying patients based on age at the time of surgery, it was noted that patients younger than 25 years had significantly higher SANE scores (91.6 [95% CI: 90.2-92.9] vs. 82.6 [95% CI: 79.0-86.2]; p < 0.0001) and lower VAS pain scores (0.7 [95% CI: 0.5-0.8] vs. 1.2 [95% CI: 0.8-1.5]; p = 0.004). Primary ACLR with internal bracing led to acceptable patient outcomes and a graft failure rate of less than 1%. LEVEL OF EVIDENCE:: case series, IV.

Risk of Revision and Reoperation After Quadriceps Tendon Autograft ACL Reconstruction Compared With Patellar Tendon and Hamstring Autografts in a US Cohort of 21,973 Patients

BACKGROUND

The use of quadriceps tendon (QT) autografts has increased in the past 10 years. However, there remains a dearth of large studies examining the effects of graft selection on anterior cruciate ligament reconstruction (ACLR) that includes QT grafts.

PURPOSE

To evaluate the risk of subsequent surgical outcomes, including revision and reoperation, for a large cohort of patients with primary ACLR according to autograft selection.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Data from a US health care system ACLR registry were used to conduct a cohort study. Primary isolated autograft ACLRs were identified (2012-2021). The exposure of interest was autograft type: QT, bone-patellar tendon-bone (BPTB), and hamstring tendon (HT). Multivariable Cox regression models were used to evaluate the risk of aseptic revision (defined as a subsequent surgery where removal and replacement of the original graft for noninfectious reasons was required) and risk of aseptic reoperation (defined as any subsequent surgery for noninfectious reasons where the graft was left intact) according to autograft selection.

RESULTS

The study sample comprised 21,973 ACLRs performed by 290 surgeons at 53 hospitals. QT, BPTB, and HT autografts were used in 1103 (5.0%), 9519 (43.3%), and 11,351 (51.7%) ACLRs, respectively. In adjusted models, no significant differences were observed in revision risk (hazard ratio [HR], 1.06; 95% CI, 0.60-1.89; P = .837) or reoperation risk (HR, 1.00; 95% CI, 0.70-1.43; P = .993) within 4 years of follow-up when comparing QT ACLR with BPTB ACLR. Additionally, no differences in 4-year revision (HR, 0.62; 95% CI, 0.34-1.12; P = .111) or reoperation (HR, 1.24; 95% CI, 0.85-1.80; P = .262) risks were observed when comparing QT ACLR with HT ACLR. HT ACLRs were noted to have a higher risk of revision (HR, 1.52; 95% CI, 1.25-1.84; P < .001) compared with BPTB ACLRs but a lower risk of reoperation (HR, 0.86; 95% CI, 0.75-0.98; P = .024).

CONCLUSION

In this large multicenter study using data from an ACLR registry, the authors found no difference in the risk of revision or reoperation when QT was compared with BPTB or HT autograft with the numbers available, but they did find a 1.5 times higher risk of revision when HT autograft was compared with BPTB autograft. Surgeons may use this information when choosing the appropriate graft for ACLR in their patients.

Randomized Controlled Trials Comparing Bone-Patellar Tendon-Bone Versus Hamstring Tendon Autografts in Anterior Cruciate Ligament Reconstruction Surgery Are Statistically Fragile: A Systematic Review

PURPOSE

To assess the statistical fragility of recently published randomized controlled trials (RCTs) comparing the use of hamstring tendon autograft with bone-patellar tendon-bone autograft for anterior cruciate ligament (ACL) reconstruction.

METHODS

The PubMed, Embase, and MEDLINE databases were queried for RCTs published since 2010 comparing autograft type (bone-patellar tendon-bone vs hamstring tendon) in ACL reconstruction surgery. The fragility index (FI) and reverse FI (rFI) were determined for significant and nonsignificant outcomes, respectively, as the number of outcome reversals required to change statistical significance. The fragility quotient (FQ) and reverse FQ, representing fragility as a proportion of the study population, were calculated by dividing the FI and rFI, respectively, by the sample size.

RESULTS

We identified 19 RCTs reporting 55 total dichotomous outcomes. The median FI of the 55 total outcomes was 5 (interquartile range [IQR], 4-7), meaning a median of 5 outcome event reversals would alter the outcomes' significance. Five outcomes were reported as statistically significant with a median FI of 4 (IQR, 2-6), meaning a median of 4 outcome event reversals would change outcomes to be nonsignificant. Fifty outcomes were reported as nonsignificant with a median rFI of 5 (IQR, 4-7), meaning a median of 5 outcome event reversals would change outcomes to be significant. The FQ and reverse FQ for significant and nonsignificant outcomes were 0.025 (IQR, 0.018-0.045) and 0.082 (IQR, 0.041-0.106), respectively. For 61.8% of outcomes, patients lost to follow-up exceeded the corresponding FI or rFI.

CONCLUSIONS

There is substantial statistical fragility in recent RCTs on autograft choice in ACL reconstruction surgery given that altering a few outcome events is sufficient to reverse study findings. For over half of outcomes, maintaining patients lost to follow-up may have been sufficient to reverse study conclusions.

CLINICAL RELEVANCE

We recommend co-reporting FIs and P values to provide a more comprehensive representation of a study's conclusions when conducting an RCT.

Higher Eccentric Hamstring Muscle Fatigue After Participation in a Soccer Match in Young Female Athletes

BACKGROUND

Hamstring (HS) strength deficits and imbalances have been identified as risk factors for sustaining anterior cruciate ligament (ACL) injuries and muscular strains, with HS injuries being the most prevalent muscle injuries in soccer athletes. The aim of this study was to investigate HS eccentric strength before and after a soccer match in both male and female soccer athletes.

HYPOTHESIS

Soccer athletes have changes in eccentric HS strength after a soccer game.

STUDY DESIGN

Cohort observational study.

LEVEL OF EVIDENCE

Level 3.

METHODS

HS eccentric strength (mean and absolute peak torque and total work) was measured in 64 healthy male and female competitive football athletes (14-25 years) with an automatic device during the execution of the Nordic hamstring exercise (NHE) test before and after a 90-minute soccer match. The anterior-knee laxity (AKL) was quantified with an arthrometer.

RESULTS

Mean and absolute eccentric HS peak torque decreased by 24.5 N.m (-12.34%; P < 0.01) and 21.9 N.m (-10.08%; P < 0.01) in female athletes, whereas their male peers improved by 19.9 N.m (+9.01%; P = 0.01) and by 20.9 N.m (+8.51%; P = 0.02), respectively. HS total work in female athletes decreased by 831.1 J (P < 0.01) compared with the male athlete reduction of 235.3 J. Both the pre- versus postmatch intersex mean and absolute eccentric HS peak torque changes were significant (P < 0.01), as were the changes in HS total work (P < 0.01). The pre- versus postmatch AKL difference and the dominant versus nondominant limb comparison of the strength parameters were not significantly different. Younger female athletes (14-19 years old) presented a greater decrease in mean and absolute peak HS eccentric strength compared with those in older female athletes and men.

CONCLUSION

HS eccentric strength and work differ based on athlete sex, as measured by the NHE test. Mean peak, absolute peak, and total work showed greater reductions in female athletes than those in their male peers. The subgroup of 14- to 19-year-old female athletes experienced the highest reduction in strength parameters.

Using 3D MRI Bone Shape to Predict Pre-Osteoarthritis of the Knee 2 Years After Anterior Cruciate Ligament Reconstruction

BACKGROUND

Anterior cruciate ligament (ACL) injury increases risks for osteoarthritis (OA), a poorly modifiable and disabling condition. Joint changes of potentially reversible pre-OA have been described just 2 years after ACL reconstruction (ACLR) when early bone shape changes have also been reported.

PURPOSE

This study evaluates relationships between interlimb differences in tibiofemoral bone shape derived from statistical shape modeling (SSM) of magnetic resonance imaging (MRI) and participant factors on patient-reported outcomes 2 years after unilateral ACLR.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

SSM-derived tibiofemoral bone shape and subchondral bone area were assessed from bilateral knee MRI scans of 72 participants with unilateral ACLR (mean age, 34 ± 11 years; 32 women) and compared with a reference cohort of 398 older individuals without OA (mean age, 50 ± 3 years; 213 women). Multivariable logistic regression models examined relationships between participant and surgical factors with interlimb differences in bone shapes or subchondral bone areas. Relationships between patient-reported outcomes and the interlimb differences in bone shape and subchondral area were examined using similar models.

RESULTS

Bone shape scores and subchondral bone areas were greater (more OA-like) in ACLR knees than uninjured contralateral knees in every bone metric tested (P≤ .001). Interlimb differences in femur shape scores of participants with ACLR were 65% greater (P < .001) than those of the significantly older reference cohort. Taller height, medial meniscal tears, and decreasing age were associated with larger interlimb differences in shape scores and subchondral areas (P < .05). Bone-patellar tendon-bone (BPTB) autograft recipients demonstrated greater interlimb subchondral area differences compared with allograft recipients (P < .05). Interlimb differences for hamstring autograft recipients did not differ from those with BPTB or allograft. Greater interlimb differences in medial femur subchondral areas were associated with worse patient-reported Knee injury and Osteoarthritis Outcome Score Symptoms (R = 0.27; P = .040).

CONCLUSION

Even in the absence of radiographic OA, just 2 years after unilateral ACLR patients showed greater bone shape scores and subchondral areas consistent with pre-OA in their ACLR knees. Furthermore, greater medial femur bone areas were weakly associated with worse symptoms. Patients who are younger, are taller, have meniscal tears, or have BPTB grafts may be at increased risk for bony asymmetries 2 years after ACLR.

Contralateral hamstring autografts do not provide benefit compared to ipsilateral hamstring autografts in primary or revision anterior cruciate ligament reconstruction: a systematic review

PURPOSE

To evaluate the clinical outcomes of primary or revision ACL reconstruction (ACLR) after contralateral hamstring autografts versus ipsilateral hamstring autograft harvest.

METHODS

Three databases (MEDLINE, PubMed and EMBASE) were searched from inception to April 27th, 2023 for studies investigating contralateral hamstring autografts in primary or revision ACLR. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, strength measures, patient-reported outcome measures (PROMs), and rates of positive Lachman test, positive pivot-shift test and graft rupture were extracted. PROMs included Lysholm, International Knee Documentation Committee (IKDC) and Tegner scores.

RESULTS

Nine studies comprising 371 patients were included in this review. In primary ACLR, there were no significant differences between contralateral and ipsilateral groups in isokinetic hamstring torque in the non-ACLR limb or isokinetic quadriceps torque in both limbs when tested at 60, 90, 120 or 180 degrees/second. Isokinetic hamstring torque in the non-ACLR limb was significantly weaker in the contralateral group at six months for primary ACLR; however, these deficits did not persist. There were no significant differences in postoperative median Tegner scores and Lysholm scores between contralateral and ipsilateral groups in primary ACLR. There were no significant differences in postoperative median Tegner, mean Lysholm and IKDC scores between groups in revision ACLR. There were no significant differences in positive Lachman, positive pivot-shift and rupture rates in primary ACLR between groups. Rates of positive Lachman and pivot-shift were slightly higher in the contralateral than ipsilateral group for revision ACLR.

CONCLUSION

Contralateral hamstring autografts results in comparable muscle strength to ipsilateral hamstring autografts, with the exception of weaker hamstring strengths in the early postoperative period. Patient-reported outcome measures were similar between the two groups across both primary and revision ACLR, with rates of instability and failure being similar between groups for primary ACLR. Contralateral hamstring grafts do not provide additional benefit when compared to ipsilateral options for either primary or revision ACLR, and should be used only in select circumstances including insufficient ipsilateral hamstring grafts or situations where quadriceps or patella autografts are not optimal.

LEVEL OF EVIDENCE

Level IV.

Various Definitions of Failure Are Used in Studies of Patients Who Underwent Anterior Cruciate Ligament Reconstruction

Purpose

To conduct a literature review to assess the definitions of anterior cruciate ligament reconstruction (ACLR) failure used throughout the orthopaedic literature.

Methods

A systematic search of Embase, Ovid Medline, SPORTDiscus, and Web of Science was conducted by a university librarian to identity level I-IV clinical studies on ACLR failure. Inclusion criteria consisted of patients who underwent ACLR and included a definition of failure of ACLR. Patients who underwent anterior cruciate ligament (ACL) repairs, animal/cadaver studies, review studies, non-English language articles, and non-full text articles were excluded. Failure data were extracted from each study and categorized. Other data that were extracted included follow-up time after ACLR, failure reoperation rate, and failure reoperation procedure. Descriptive statistics was used to analyze the data.

Results

Out of 2,775 studies, 104 (3.75%) met inclusion criteria and were analyzed in this review. The most common definition of ACLR failure included the use of a physical examination, specifically Lachman's test (21/104 [20.2%]), anterior laxity assessment, or a Pivot-Shift test (24/104 [35.2%]) or undergoing or requiring revision ACLR (39/104 [37.5%]). Although some studies used quantitative tests or imaging to help define "failure," others simply defined it as graft rerupture that was otherwise not defined (22/104 [22.5%]). Other common definitions included: the use of imaging (magnetic resonance imaging/radiographs) to confirm graft re-rupture (37/104 [35.6%]), patient-reported outcomes (recurrent instability)/patient reported outcomes measures (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Tegner) (18/104 [17.3%]), and the use of an arthrometer (KT-1000/2000, Rollimeter, or Kneelax) (17/104 [16.3%]). The least common definitions included graft failure or rerupture confirmed by arthroscopy (13/104 [12.5%]) and nonrevision surgery (2/104 [1.0%]). The failure rate of this procedure ranged from 0% to 100% depending on the definition of "failure."

Conclusion

In this study, we found that a variety of definitions of failure are used among studies published in the orthopaedic literature. The most common criteria for failure of ACLR were the results of physical examination tests (35%), the need for undergoing a revision ACLR (36%), and the use of imaging to diagnose the failure (34%). About 17% of studies included in this review used patient-reported outcomes, specifically recurrent instability, or PROMs (IKDC, KOOS, Tegner) in their assessment of failure of ACLR. The least used definitions of "failure" of ACLR included nonrevision ACLR surgery (2%). Although some studies used similar tests or categories in their definition of failure, there were a variety of score and grade cutoff points between them.

Level of Evidence

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

Prevalence of post-traumatic osteoarthritis after anterior cruciate ligament injury remains high despite advances in surgical techniques

Aims

The aim of this study was to report the pooled prevalence of post-traumatic osteoarthritis (PTOA) and examine whether the risk of developing PTOA after anterior cruciate ligament (ACL) injury has decreased in recent decades.

Methods

The PubMed and Web of Science databases were searched from 1 January 1980 to 11 May 2022. Patient series, observational studies, and clinical trials having reported the prevalence of radiologically confirmed PTOA after ACL injury, with at least a ten-year follow-up, were included. All studies were analyzed simultaneously, and separate analyses of the operative and nonoperative knees were performed. The prevalence of PTOA was calculated separately for each study, and pooled prevalence was reported with 95% confidence intervals (CIs) using either a fixed or random effects model. To examine the effect of the year of injury on the prevalence, a logit transformed meta-regression analysis was used with a maximum-likelihood estimator. Results from meta-regression analyses were reported with the unstandardized coefficient (β).

Results

The pooled prevalence of PTOA was 37.9% (95% CI 32.1 to 44) for operatively treated ACL injuries with a median follow-up of 14.6 years (interquartile range (IQR) 10.6 to 16.7). For nonoperatively treated ACL injuries, the prevalence was 40.5% (95% CI 28.9 to 53.3), with a median of follow-up of 15 years (IQR 11.7 to 20.0). The association between the year of operation and the prevalence of PTOA was weak and imprecise and not related to the choice of treatment (operative β -0.038 (95% CI -0.076 to 0.000) and nonoperative β -0.011 (95% CI -0.101 to 0.079)).

Conclusion

The initial injury, irrespective of management, has, by the balance of probability, resulted in PTOA within 20 years. In addition, the prevalence of PTOA has only slightly decreased during past decades. Therefore, further research is warranted to develop strategies to prevent the development of PTOA after ACL injuries.

Comparison of Knee Pain and Difficulty With Kneeling Between Patellar Tendon and Hamstring Tendon Autografts After Anterior Cruciate Ligament Reconstruction: A Study From the New Zealand ACL Registry

BACKGROUND

The bone-patellar tendon-bone (BTB) autograft is associated with difficulty with kneeling after anterior cruciate ligament (ACL) reconstruction; however, it is unclear whether it results in a more painful or symptomatic knee compared with the hamstring tendon autograft.

PURPOSE

To identify the rate and risk factors for knee pain and difficulty with kneeling after ACL reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Primary ACL reconstruction procedures prospectively recorded in the New Zealand ACL Registry from April 2014 to May 2021 were analyzed. The Knee injury and Osteoarthritis Outcome Score (KOOS) was used to identify patients reporting consequential knee pain (CKP), defined as a KOOS Pain subscore of ≤72 points, and severe kneeling difficulty (SKD), defined as a self-report of "severe" or "extreme" difficulty with kneeling. Absolute values of the KOOS Pain and Symptoms subscales were also compared.

RESULTS

A total of 10,999 patients were analyzed. At 2-year follow-up, 9.3% (420/4492) reported CKP, and 12.0% (537/4471) reported SKD. The most important predictor of CKP at 2-year follow-up was having significant pain before surgery (adjusted odds ratio, 4.10; P < .001). The most important predictor of SKD at 2-year follow-up was the use of a BTB autograft rather than a hamstring tendon autograft (21.3% vs 9.4%, respectively; adjusted odds ratio, 3.12; P < .001). There was no difference between the BTB and hamstring tendon grafts in terms of CKP (9.9% vs 9.2%, respectively; P = .494) or in absolute values of the KOOS Pain (mean, 88.7 vs 89.0, respectively; P = .37) and KOOS Symptoms (mean, 82.5 vs 82.1, respectively; P = .49) subscales.

CONCLUSION

At 2-year follow-up after primary ACL reconstruction, 9.3% of patients reported CKP, and 12.0% reported SKD. The BTB autograft was associated with difficulty with kneeling, but it did not result in a more painful or symptomatic knee compared with the hamstring tendon autograft.

Risk Factors for Revision or Rerupture After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

The rerupture or need for revision after anterior cruciate ligament reconstruction (ACLR) is a serious complication. Preventive strategies that target the early identification of risk factors are important to reduce the incidence of additional surgery.

PURPOSE

To perform a systematic review and meta-analysis to investigate risk factors for revision or rerupture after ACLR.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

Literature searches were performed in PubMed, Embase, and Web of Science from database inception to November 2021 and updated in January 2022. Quantitative, original studies reporting potential adjusted risk factors were included. Odds ratios (ORs) were calculated for potential risk factors.

RESULTS

A total of 71 studies across 13 countries with a total sample size of 629,120 met the inclusion criteria. Fifteen factors were associated with an increase in the risk of revision or rerupture after ACLR: male sex (OR, 1.27; 95% CI, 1.14-1.41), younger age (OR, 1.07; 95% CI, 1.05-1.08), lower body mass index (BMI) (OR, 1.03; 95% CI, 1.00-1.06), family history (OR, 2.47; 95% CI, 1.50-4.08), White race (OR, 1.32; 95% CI, 1.08-1.60), higher posterolateral tibial slope (OR, 1.15; 95% CI, 1.05-1.26), preoperative high-grade anterior knee laxity (OR, 2.30; 95% CI, 1.46-3.64), higher baseline Marx activity level (OR, 1.07; 95% CI, 1.02-1.13), return to a high activity level/sport (OR, 2.03; 95% CI, 1.15-3.57), an ACLR within less than a year after injury (OR, 2.05; 95% CI, 1.81-2.32), a concomitant medial collateral ligament (MCL) injury (OR, 1.62; 95% CI, 1.31-2.00), an anteromedial portal or transportal technique (OR, 1.36; 95% CI, 1.22-1.51), hamstring tendon (HT) autografts (vs bone-patellar tendon-bone [BPTB] autografts) (OR, 1.60; 95% CI, 1.40-1.82), allografts (OR, 2.63; 95% CI, 1.65-4.19), and smaller graft diameter (OR, 1.21; 95% CI, 1.05-1.38). The other factors failed to show an association with an increased risk of revision or rerupture after ACLR.

CONCLUSION

Male sex, younger age, lower BMI, family history, White race, higher posterolateral tibial slope, preoperative high-grade anterior knee laxity, higher baseline Marx activity level, return to a high activity level/sport, an ACLR within less than a year from injury, a concomitant MCL injury, an anteromedial portal or transportal technique, HT autografts (vs BPTB autografts), allografts, and smaller graft diameter may increase the risk of revision or rerupture after ACLR. Raising awareness and implementing effective preventions/interventions for risk factors are priorities for clinical practitioners to reduce the incidence of revision or rerupture after ACLR.

Long-term results after anterior cruciate ligament reconstruction using patellar tendon versus hamstring tendon autograft with a minimum follow-up of 10 years-a systematic review

INTRODUCTION

A lot of research addresses superiority of the two commonly used autografts bone-patellar tendon-bone (BPTB) and hamstring tendon for anterior cruciate ligament (ACL) reconstruction, without getting to consensus. While there are numerous studies and reviews on short- to mid-term follow-up, not much literature is available on long-term follow-up. As patients suffering ACL injuries are often of young age and high athletic activity, it is crucial to have the best evidence possible for graft choice to minimize consequences, like osteoarthritis later on.

MATERIALS AND METHODS

A search of the online databases, PubMed and Embase, was carried out last on 31st March 2022 for studies comparing BPTB and hamstring tendon (HT) autografts for ACL reconstruction in human patients with a minimum follow-up of 10 years. The methodological quality of each study has been evaluated using the modified Coleman Methodology Score. Results on the three variables patient-oriented outcomes, clinical testing and measurements and radiographic outcomes were gathered and are presented in this review.

RESULTS

Of 1299 records found, nine studies with a total of 1833 patients were identified and included in this systematic review. The methodological quality of the studies ranged from a Coleman Score of 63-88. Many studies reported no or only few statistically significant differences. Significant results in favour of BPTB were found for activity levels and for instrumented laxity testing with the KT-1000 arthrometer. Better outcomes for HT were found in IKDC-SKF, the KOOS, donor site morbidity, pivot shift test, radiographic osteoarthritis (IKDC C or D) and contralateral ACL rupture. No studies presented significant differences in terms of Lysholm Score or Tegner Activity Score, Lachman test, single-legged hop test, deficits in range of motion, osteoarthritis using the Kellgren and Lawrence classification or graft rupture.

CONCLUSION

We cannot recommend one graft to be superior, since both grafts show disadvantages in the long-term follow-up. Considering the limitation of our systematic review of no quantitative analysis, we cannot draw further conclusions from the many insignificant results presented by individual studies.

LEVEL OF EVIDENCE

IV.

Long-term Quality of Life in Patients After ACL Reconstruction With Concomitant Meniscal Injury Treatment: Patient-Reported Outcomes at Minimum 10-Year Follow-up

Background

Long-term studies of patients after anterior cruciate ligament (ACL) reconstruction with or without concomitant meniscal tear treatment are limited.

Purposes

To (1) report postoperative outcomes after anatomic ACL reconstruction with a hamstring autograft, (2) investigate how concomitant treatment of meniscal injury could affect these outcomes, and (3) evaluate the association between quality of life and activity levels at a minimum 10-year follow-up.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients treated with a unilateral, anatomic ACL reconstruction between 2005 and 2011 were investigated. The following patient-reported outcome measures (PROMs) were reported for the overall sample as well as a subsample of patients with meniscal injury: International Knee Documentation Committee Subjective Knee Form (IKDC-SKF), Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm knee score, Tegner activity scale, 5-level EQ-5D (EQ-5D-5L), and patient satisfaction. Sex, age, body mass index (BMI), and meniscal injury treatment (meniscectomy vs meniscal repair) were examined as patient-specific risk factors regarding long-term activity and quality of life.

Results

Overall, 106 patients, 90 men (85%) and 16 women (15%), were enrolled in the study, with a mean follow-up of 13.2 years. The ACL retear rate was 2.8%. The mean scores were 80.6 ± 16.7 (IKDC-SKF), 87.4 ± 15.0 (KOOS), 90.5 ± 11.5 (Lysholm), 5.6 ± 1.9 (Tegner), and 91.8 ± 14.5 (EQ-5D-5L). The majority (90.6%) of patients considered their knee state satisfactory during follow-up. When compared with patients who underwent meniscal repair, patients who underwent meniscectomy had statistically significantly lower scores on all PROMs except for the Tegner and EQ-5D-5L (P < .05 for all). The mean difference between the 2 groups was ≥7 points on all PROM scores. Patient sex, age, and BMI did not affect PROM scores. There was a statistically significant, strong positive correlation between quality of life and activity.

Conclusion

Patients had few or no symptoms and considered their knee state satisfactory 13.2 years after anatomic ACL reconstruction. Patients with concomitant meniscal tears having undergone meniscal repair had improved PROMs compared with those treated with meniscectomy. Finally, participation in activities of daily living and sports was interrelated with quality of life and was not affected by patient age, sex, or BMI.

Bone-patellar tendon-bone versus two- and four-strand hamstring tendon autografts for ACL reconstruction in young adults: a Bayesian network meta-analysis

Bone-patellar tendon-bone (BPTB), two- and four-strand hamstring tendon (4SHT and 2SHT, respectively) are the most common autografts used for anterior cruciate ligament (ACL) reconstruction. The present study compared BPTB, 2SHT, and 4SHT for ACL reconstruction in terms of joint laxity, patient reported outcome measures (PROMs), rate of failure and anterior knee pain (AKP). The time to return to sport and the peak torque between the autografts were also compared. Finally, prognostic factors leading to worse outcomes were also investigated. It was hypothesized that all grafts yield similar proprieties in terms of joint laxity, patient reported outcome measures (PROMs) and rate of failure, but that the BPTB autograft causes a greater rate of anterior knee pain (AKP). The literature search was conducted. All clinical trials comparing BTPB and/or 2SHT, and/or 4SHT were accessed. Grafts other than BTPB and/or 4SHT and/or 2SHT were not considered. Articles reporting outcomes of allografts or synthetic grafts were not eligible, nor were those concerning revision settings. Articles reporting ACL reconstruction in patients with multi-ligament damage were also not eligible. Data from 95,575 procedures were retrieved. The median length of follow-up was 36 months. The median age of the patients was 27.5 years. With regard to joint laxity, similarity was found in terms of Lachman and Pivot shift tests between all three autografts. The BPTB demonstrated the greatest stability in terms of instrumental laxity. BPTB demonstrated the greatest PROMs. BPTB demonstrated the greatest rate of AKP, while AKP in 2SHT and 4SHT was similar. Concerning failure, statistically significant inconsistency was found (P = 0.008). The 4SHT demonstrated the quickest return to sport, followed by BPTB, and 2SHT. There was evidence of a negative association between the time span between injury to surgery, Lysholm score (P = 0.04), and Tegner scale (P = 0.04). Furthermore, there was evidence of a weak positive association between the time span between injury to surgery and return to sport (P = 0.01). BPTB may result in lower joint laxity, greater PROMs, and greater peak flexion torque compared to 2SHT and 4SHT autografts. On the other hand, BPTB reported the lowest peak extension torque and the greatest rate of AKP. Finally, a longer time span between injury and surgery negatively influences outcome.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level I.

Current trends in graft choice for primary anterior cruciate ligament reconstruction - part II: In-vivo kinematics, patient reported outcomes, re-rupture rates, strength recovery, return to sports and complications

Postoperative patient satisfaction after anterior cruciate ligament reconstruction (ACL-R) is influenced mainly by the degree of pain, the need for reoperation, and functional performance in daily activities and sports. Graft choice has shown to have an influence on postoperative outcomes after ACL-R. While patient reported outcomes measurements do not differ between graft options, evidence shows that normal knee kinematics is not fully restored after ACL-R with an increase in postoperative anterior tibial translation (ATT). Postoperative graft rupture rates seem to favor bone-patella-tendon-bone (BPTB) and quadriceps tendon (QT) autografts over HT or allografts. While return to sports rates seem comparable between different graft types, postoperative extensor strength is reduced in patients with BPTB and QT whereas flexion strength is weakened in patients with HT. Postoperative donor site morbidity is highest in BPTB but comparable between HT and QT. With all graft options having advantages and drawbacks, graft choice must be individualized and chosen in accordance with the patient.

Lower donor site morbidity with hamstring and quadriceps tendon autograft compared with bone-patellar tendon-bone autograft after anterior cruciate ligament reconstruction: a systematic review and network meta-analysis of randomized controlled trials

PURPOSE

To perform a meta-analysis of RCTs evaluating donor site morbidity after bone-patellar tendon-bone (BTB), hamstring tendon (HT) and quadriceps tendon (QT) autograft harvest for anterior cruciate ligament reconstruction (ACLR).

METHODS

PubMed, OVID/Medline and Cochrane databases were queried in July 2022. All level one articles reporting the frequency of specific donor-site morbidity were included. Frequentist model network meta-analyses with P-scores were conducted to compare the prevalence of donor-site morbidity, complications, all-cause reoperations and revision ACLR among the three treatment groups.

RESULTS

Twenty-one RCTs comprising the outcomes of 1726 patients were included. The overall pooled rate of donor-site morbidity (defined as anterior knee pain, difficulty/impossibility kneeling, or combination) was 47.3% (range, 3.8-86.7%). A 69% (95% confidence interval [95% CI]: 0.18-0.56) and 88% (95% CI: 0.04-0.33) lower odds of incurring donor-site morbidity was observed with HT and QT autografts, respectively (p < 0.0001, both), when compared to BTB autograft. QT autograft was associated with a non-statistically significant reduction in donor-site morbidity compared with HT autograft (OR: 0.37, 95% CI: 0.14-1.03, n.s.). Treatment rankings (ordered from best-to-worst autograft choice with respect to donor-site morbidity) were as follows: (1) QT (P-score = 0.99), (2) HT (P-score = 0.51) and (3) BTB (P-score = 0.00). No statistically significant associations were observed between autograft and complications (n.s.), reoperations (n.s.) or revision ACLR (n.s.).

CONCLUSION

ACLR using HT and QT autograft tissue was associated with a significant reduction in donor-site morbidity compared to BTB autograft. Autograft selection was not associated with complications, all-cause reoperations, or revision ACLR. Based on the current data, there is sufficient evidence to recommend that autograft selection should be personalized through considering differential rates of donor-site morbidity in the context of patient expectations and activity level without concern for a clinically important change in the rate of adverse events.

LEVEL OF EVIDENCE

Level I.

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.

Comparison of Anterior Cruciate Ligament Reconstruction With Versus Without Anterolateral Augmentation: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background

It is clear that the anterolateral ligament has an important role in rotational knee stability. However, whether patients undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) can benefit from anterolateral augmentation (ALA) is still controversial.

Purpose

To compare the effects of isolated ACLR versus ACLR combined with ALA (ACLR+ALA) on clinical outcomes and knee stability.

Study Design

Systematic review; Level of evidence, 1.

Methods

The methodology followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search of the PubMed, Embase, and Cochrane Library Central Register of Controlled Trials databases was undertaken to identify all randomized controlled trials (RCTs) comparing isolated ACLR with ACLR+ALA for the treatment of ACL injuries in the last 15 years. The Cochrane Collaboration risk-of-bias tool and the revised Jadad scale were utilized by 2 independent reviewers to determine the quality of RCTs. Relevant data were extracted and compared between procedures, and heterogeneity across the RCTs was assessed using the I ² statistic.

Results

The initial search yielded 849 articles. A total of 14 studies (1850 patients; 941 ACLR and 909 ACLR+ALA) satisfied the eligibility criteria for the meta-analysis. There were no significant differences between the procedures in terms of patient-reported outcomes (International Knee Documentation Committee score, Tegner score, Knee injury and Osteoarthritis Outcome Score) or return-to-sport rates. However, patients who underwent ACLR+ALA had better knee stability based on the pivot-shift test (risk ratio [RR], 1.06 [95% CI, 1.02 to 1.10]; P = .0008), Lachman test (RR, 1.03 [95% CI, 1.00 to 1.07]; P = .04), and side-to-side difference in anterior laxity (standardized mean difference, -0.55 [95% CI, -0.98 to -0.12]; P = .01) as well as a lower incidence of graft failure (RR, 0.30 [95% CI, 0.19 to 0.45]; P < .01) compared with patients who underwent isolated ACLR.

Conclusion

ALA can be considered as a reinforcement of ACLR to improve anteroposterior and anterolateral rotational stability of the knee and reduce the risk of failure. The patient-reported outcomes of isolated ACLR were similar to those of ACLR+ALA, and both procedures provided improved knee function.

Clinical Outcomes After Anterior Cruciate Ligament Reconstruction in Patients With a Concomitant Segond Fracture: A Systematic Review

BACKGROUND

The Segond fracture can be observed in patients with an anterior cruciate ligament (ACL) tear. It is unclear whether the Segond fracture affects clinical outcomes after ACL reconstruction.

PURPOSE

To investigate whether the presence of a concomitant Segond fracture affects clinical outcomes after ACL reconstruction and to compare clinical outcomes when a Segond fracture is repaired surgically or left unrepaired.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Three databases (PubMed, Embase, Cochrane Library) were searched in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on July 27, 2020. Relevant studies regarding ACL injury with concomitant Segond fracture treated by primary ACL reconstruction were screened in duplicate. Data regarding patient characteristics and clinical outcomes were extracted. Descriptive data are presented, and a random-effects model was used to pool amenable data.

RESULTS

A total of 5 studies examining 2418 patients (987 female; 40.8%), mean age 25.4 years, were included in this study. There were 304 patients with a Segond fracture (mean age, 28.1 years; 35.9% female) and 2114 patients without a Segond fracture (mean age, 25.1 years; 41.5% female). Four studies directly compared outcomes between patients with an unrepaired Segond fracture and no Segond fracture. One study reported 12 patients who underwent ACL reconstruction and repair of a Segond fracture. Among 4 studies, 11 of 292 (3.8%) graft failures/revision surgeries were reported in the groups that had Segond fracture, whereas 145 of 2114 (6.9%) graft failures/revision surgeries were reported in groups that did not have Segond fracture. No significant difference was observed in the risk of graft failure between the 2 groups, with a pooled risk ratio of 0.59 (95% CI, 0.32-1.07; P = .08; I2 = 0%). No clinically significant differences were observed with regard to International Knee Document Committee score, Lysholm score, Tegner activity scale, and postoperative knee laxity between the group with Segond fracture and those without.

CONCLUSION

An unrepaired Segond fracture does not appear to have any significant negative effect on postoperative stability or risk of graft failure or revision surgery after ACL reconstruction. Future prospective studies may be warranted to confirm the finding that patients with combined ACL injury and Segond fracture may have outcomes comparable with those of ACL-injured patients without a Segond fracture when isolated ACL reconstruction is performed.

Knee Laxity in the Menstrual Cycle after Anterior Cruciate Ligament Reconstruction: A Case Series

The aim of this study was to compare anterior knee laxity (AKL), genu recurvatum (GR), and muscle stiffness between reconstructed and contralateral sides in females who underwent anterior cruciate ligament (ACL) reconstruction during early follicular and ovulatory phases. AKL was measured as an anterior displacement of the tibia using a KS measure. GR was measured as the range of motion of knee hyperextension using a hyperextension apparatus. Muscle stiffness was measured for semitendinosus (ST) and biceps femoris long head (BF) using a MyotonPRO. The study investigated eighteen knees in nine females (Age, 20.4 ± 1.5 years; BMI, 21.5 ± 1.5) with normal menstrual cycles at least 1 year after reconstruction using hamstring autograft. E2 (Estradiol) concentration did not differ between the two phases, but AKL on the reconstructed side was lower during the ovulatory phase (8.3 [5.9-9.3] mm) than during the early follicular phase (9.4 [7.3-9.7] mm) (p = 0.044, r = 0.756), whereas there was no significant difference between the two phases on the contralateral side. AKL side-to-side difference, GR, and muscle stiffness (ST and BF) on both sides did not differ in either phase. These results indicate that AKL may behave differently on the reconstructed and contralateral sides during the menstrual cycle.

The Bone Bridge for Tibial ACL Graft Fixation: A Biomechanical Analysis of Different Tibial Fixation Methods for ACL Reconstruction

Background

The tibial fixation site is considered the weak link in anterior cruciate ligament (ACL) reconstruction, and conflicting results regarding the biomechanical properties of various fixation methods have been reported.

Purpose

To examine knots tied over a bone bridge and its biomechanical properties as a suitable tibial fixation method in ACL reconstruction.

Study Design

Controlled laboratory study.

Methods

We divided 40 fresh-frozen porcine tibiae into 4 equal groups to evaluate flexor tendon grafts set with standard tibial fixation techniques: (1) bone bridge (BB group), (2) suspension button (SB group), (3) combined interference screw and bone bridge (IFS/BB group), and (4) combined interference screw and suspension button (IFS/SB group). Each construct was subjected to cyclic loading (1500 cycles, 50-250 N, 1 Hz) with a servohydraulic materials testing machine to measure elongation; load-to-failure testing (displacement rate: 25 mm/s) was then performed. Load to failure, stiffness, and yield load were compared between constructs using 1-way analysis of variance.

Results

The hybrid fixation constructs (IFS/BB and IFS/SB groups) showed significantly better biomechanical properties than the isolated extracortical fixation constructs (BB and SB groups) (P < .05 for all). There were no differences between the isolated extracortical fixation constructs or between the hybrid fixation constructs in elongation or load to failure; however, stiffness of the IFS/BB group was significantly higher than that of the IFS/SB group (175.3 ± 16.6 vs 144.9 ± 20.1 N/mm, respectively; P < .05). Stiffness between the SB and BB groups was not significantly different.

Conclusion

Hybrid fixation had superior biomechanical performance compared with isolated extracortical fixation. However, tibial graft fixation using a bone bridge either as isolated extracortical fixation or combined with an interference screw for hybrid fixation showed equivalent biomechanical properties compared with suspension button-based graft fixation.

Clinical Relevance

The clinical use of a bone bridge for tibial graft fixation could reduce the cost for ACL reconstruction and lower the rate of implant-associated issues.

Qualitative and Quantitative Assessment of the Medial Patellar Retinaculum Anatomy: the Anteromedial Side of the Knee Revisited

BACKGROUND

In the current literature, studies on the anatomy of the anteromedial region of the knee are scarce. However, the anteromedial structures, especially the longitudinal medial patellar retinaculum (MPR), may play an important role in restraining external tibial rotation.

PURPOSE

To conduct a layer-by-layer dissection of the anteromedial side of the knee and describe qualitatively and quantitatively the MPR anatomy pertaining to surgically relevant landmarks.

STUDY DESIGN

Descriptive laboratory study.

METHODS

A total of 10 fresh-frozen human cadaveric knees (mean age 81 ± 16.3 years) without history of previous ligament injury were used in this study. A layer-by-layer dissection was performed, and measurements were obtained using a tactile 3-dimensional (3-D) measuring arm to define the anatomy of the MPR in relation to surgically relevant landmarks, such as the superficial medial collateral ligament (sMCL) and medial patellofemoral ligament (MPFL). The 3-D datasets were used for multiplanar reconstruction.

RESULTS

The tibial and femoral attachment of the MPR were identified in 100% of cases. Layer-by-layer dissection confirmed its close topography to the sMCL. The mean length of the MPR was 84.9 ± 9.1 mm. The average width of the tibial and femoral attachment was 23.8 ± 3.1 mm and 69.2 ± 8.2 mm, respectively. The distance from the midpoint of the MPR tibial attachment to the midpoint of the distal tibial attachment of the sMCL was 27.2 ± 5.8 mm. Femorally, the MPR attached at the anterior border of the MPFL over a mean distance of 52.3 ± 9.4 mm.

CONCLUSION

The MPR is a distinct tibiofemoral structure with well-defined tibial and femoral attachments, which could be consistently identified. Layer-by-layer dissection confirmed its close topography to the sMCL and MPFL.

CLINICAL RELEVANCE

As injuries to the anteromedial side of the knee may contribute to anteromedial rotational rotatory instability (AMRI), precise knowledge of the underlying anatomy of the MPR may be necessary to perform an anatomic reconstruction of the anteromedial side of the knee.

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

OBJECTIVE

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

DESIGN

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

DATA SOURCES

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

ELIGIBILITY

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

RESULTS

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

CONCLUSION

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

Combined Assessments of Patellar Tendon and Hamstring Tendon Parameters on Preoperative Magnetic Resonance Imaging Can Improve Predictability of Hamstring Tendon Autograft Diameter in the Setting of Anterior Cruciate Ligament Reconstruction

Purpose

To evaluate whether preoperative magnetic resonance imaging (MRI) measurements of multiple tendon autograft sources could be used to improve estimates of intraoperative hamstring tendon autograft (HTA) diameter.

Methods

Patients who underwent anterior cruciate ligament reconstruction with HTA at our institution were identified through electronic health records. Preoperative MRI tendon measurements of the patellar tendon (PT) length, PT width, PT thickness, quadriceps tendon thickness, semitendinosus tendon (ST) cross-sectional area (CSA), and gracilis tendon (GT) CSA were conducted by 2 independent evaluators using digital imaging measurement tools.

Results

A total of 53 patients met the inclusion criteria, with a mean HTA diameter of 7.98 ± 0.7 mm. Height greater than 1.63 m, weight greater than 63.4 kg, PT length greater than 4.2 cm, PT thickness greater than 0.33 cm, ST CSA greater than 10.8 mm², and GT CSA greater than 6.3 mm² were associated with an HTA of 8 mm or greater (P < .005). Female sex was associated with an HTA of less than 8 mm (P < .05). PT length, PT thickness, and GT CSA were the strongest predictors of an HTA of 8 mm or greater and were combined into an additive logistic regression model: Score = -23.24 + (1.68 × PT length) + (20.104 × PT thickness) + (1.48 × GT CSA). If the score was greater than 0.237, the HTA graft diameter was predicted to be 8 mm or greater with 83% specificity, 91% sensitivity, and 87% accuracy.

Conclusions

By combining PT length and PT thickness measurements with GT CSA measurements in a logit function model, we were able to show improved overall specificity, sensitivity, and accuracy of estimated HTA diameters in our data set when compared with assessments of anthropometric, ST CSA, GT CSA, or combined ST-GT CSA measurements in isolation.

Clinical Relevance

Preoperative MRI measurements may be used to screen whether a patient is likely to have an 8-mm graft in the setting of anterior cruciate ligament reconstruction with HTA and thus may help guide graft choice.

Risk factors for knee osteoarthritis after traumatic knee injury: a systematic review and meta-analysis of randomised controlled trials and cohort studies for the OPTIKNEE Consensus

Objective

To identify and quantify potential risk factors for osteoarthritis (OA) following traumatic knee injury.

Design

Systematic review and meta-analyses that estimated the odds of OA for individual risk factors assessed in more than four studies using random-effects models. Remaining risk factors underwent semiquantitative synthesis. The modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for prognostic factors guided the assessment.

Data sources

MEDLINE, EMBASE, CENTRAL, SPORTDiscus, CINAHL searched from inception to 2009–2021.

Eligibility

Randomised controlled trials and cohort studies assessing risk factors for symptomatic or structural OA in persons with a traumatic knee injury, mean injury age ≤30 years and minimum 2-year follow-up.

Results

Across 66 included studies, 81 unique potential risk factors were identified. High risk of bias due to attrition or confounding was present in 64% and 49% of studies, respectively. Ten risk factors for structural OA underwent meta-analysis (sex, rehabilitation for anterior cruciate ligament (ACL) tear, ACL reconstruction (ACLR), ACLR age, ACLR body mass index, ACLR graft source, ACLR graft augmentation, ACLR+cartilage injury, ACLR+partial meniscectomy, ACLR+total medial meniscectomy). Very-low certainty evidence suggests increased odds of structural OA related to ACLR+cartilage injury (OR=2.31; 95% CI 1.35 to 3.94), ACLR+partial meniscectomy (OR=1.87; 1.45 to 2.42) and ACLR+total medial meniscectomy (OR=3.14; 2.20 to 4.48). Semiquantitative syntheses identified moderate-certainty evidence that cruciate ligament, collateral ligament, meniscal, chondral, patellar/tibiofemoral dislocation, fracture and multistructure injuries increase the odds of symptomatic OA.

Conclusion

Moderate-certainty evidence suggests that various single and multistructure knee injuries (beyond ACL tears) increase the odds of symptomatic OA. Risk factor heterogeneity, high risk of bias, and inconsistency in risk factors and OA definition make identifying treatment targets for preventing post-traumatic knee OA challenging.

Anterior cruciate ligament (ACL) repair using cortical or anchor fixation with suture tape augmentation vs ACL reconstruction: A comparative biomechanical analysis

BACKGROUND

The purpose was to compare knee kinematics in a cadaveric model of anterior cruciate ligament (ACL) repair using an adjustable-loop femoral cortical suspensory (AL-CSF) or independent bundle suture anchor fixation (IB-SAF) with suture tape augmentation to a bone-patellar tendon-bone (BPTB) ACL reconstruction.

METHODS

Twenty-seven cadaveric knees were randomly assigned to one of three surgical techniques: (1) ACL repair using the AL-CSF technique with suture tape augmentation, (2) ACL repair using the IB-SAF technique with suture tape augmentation, (3) ACL reconstruction using a BPTB autograft. Each specimen underwent three conditions according to the state of the ACL (native, proximal transection, repair/reconstruction) with each condition tested at four different angles of knee flexion (0°, 30°, 60°, 90°). Anterior tibial translation (ATT) and internal tibial rotation (ITR) were evaluated using 3-dimensional motion tracking software.

RESULTS

ACL transection resulted in a significant increase in ATT and ITR when compared to the native state (P < 0.001, respectively). ACL repair with the AL-CSF or IB-SAF technique as well as BPTB reconstruction restored native ATT and ITR at all tested angles of knee flexion, while showing significantly less ATT at 0°, 30°, 60°, and 90° as well as significantly less ITR at 30°, 60°, and 90° of knee flexion when compared to the ACL-deficient state. There were no significant differences in ATT and ITR between the three techniques utilized.

CONCLUSION

ACL repair using the AL-CSF or IB-SAF technique with suture tape augmentation as well as BPTB ACL reconstruction each restored native anteroposterior and rotational laxity, without significant differences in knee kinematics between the three techniques utilized.

LEVEL OF EVIDENCE

Controlled Laboratory Study.

Minimal graft site morbidity using autogenous semitendinosus graft from the uninjured leg: a randomised controlled trial

PURPOSE

To quantify the effect on strength of semitendinosus (ST) graft harvest by comparing isokinetic and isometric muscle strength.

METHODS

A cohort of 140 patients underwent anterior cruciate ligament (ACL) reconstruction (ACLR) and were randomized to ipsilateral or contralateral ST graft harvest. Isokinetic and isometric muscle strength testing using a dynamometer were collected for the operated and non-operated leg. Patients were assessed pre-surgery and at 6, 12 and 24 months after reconstruction.

RESULTS

ST graft harvest reduced isokinetic flexion muscle strength for 6 months. At 12 months follow up there was no significant difference between the two groups and they were all stronger than pre-injury. No other significant differences were found in any primary or secondary outcome measurements.

CONCLUSION

Solitary ST graft harvest does not appear to result in a permanent reduced isometric or isokinetic quadriceps muscle strength on the side where the graft is harvested. A reduction in hamstring muscle strength of less than 10% can be seen at short-term follow-up with full recovery by 12 months. Most patients report little or no donor site pain. Given these findings, ST autograft is an alternative graft choice that could be used for various reconstructions in terms of donor site morbidity.

LEVEL OF EVIDENCE

Level II.

High Return to Play and Low Reinjury Rates in National Collegiate Athletic Association Division I Football Players Following Anterior Cruciate Ligament Reconstruction Using Quadrupled Hamstring Autograft

PURPOSE

The purpose of this study was to examine the outcomes of anterior cruciate ligament (ACL) reconstruction using quadrupled hamstring (QH) autograft in a cohort of National Collegiate Athletic Association (NCAA) Division I football players.

METHODS

A retrospective analysis was performed on NCAA Division I football players at a single institution who had transtibial ACL reconstruction using QH autograft between 2001 and 2016. Primary outcomes were ACL reinjury and return to play (RTP). Secondary outcomes were position, percent of eligibility used after surgery, graft diameter, Tegner-Lysholm scores, concomitant injuries/surgeries, and postcollegiate professional play.

RESULTS

Between 2001 and 2016, 34 players had QH autograft ACL reconstruction, and 29 players achieved RTP. Of the 29, 2 (6.9%) sustained ACL reinjuries. The average RTP was 318 days (range 115-628) after surgery. Players used 79.5% of their remaining collegiate eligibility after surgery. Nine players sustained multiligamentous knee injuries. This did not have a significant effect on RTP (P = 0.709; mean 306±24 days for isolated ACL, mean of 353±51 for 2 ligaments, mean of 324±114 for 3 + ligaments) and none sustained reinjury. Associated meniscal injuries were sustained by 28, and 8 sustained chondral injuries. The mean postoperative Tegner-Lysholm score was 90.7 of 100, with mean follow-up of 102 months. Of these players, 18 went on to play professionally, with 17 joining National Football League rosters and 1 an arena team roster.

CONCLUSION

QH demonstrated an ACL reinjury and RTP rates similar to those in previously published, predominantly bone-patella tendon-bone ACL reinjury data in elite athletes. This study demonstrates that QH autograft may be a viable option in elite athletes.

LEVEL OF EVIDENCE

IV, case series.

Application and Surgical Technique of ACL Reconstruction Using Worldwide Registry Datasets: What Can We Extract?

Anterior cruciate ligament (ACL) injuries are among the most common knee injuries. The purpose of this study was to compare surgical reconstruction of the ACL between different countries and regions in order to describe differences regarding epidemiological data, reconstruction frequency, and graft choice. A systematic literature search was performed using the ACL study group website in order to identify the relevant knee ligament registers. Four national registries were included, comprising those from Sweden, the UK, New Zealand, and Norway. A large variation was found concerning the total number of primary ACL reconstructions with a reported range from 4.1 to 51.3 per 100,000 inhabitants. The country-specific delay between injury and reconstruction varied between an average of 6.0 months and 17.6 months. The leading sports activities resulting in ACL injury included soccer, alpine skiing, handball, rugby, and netball. Moreover, a strong variability in graft choice for primary reconstruction was found. The comparison of ACL registers revealed large differences, indicating different clinical implications regarding conservative or surgical therapy and choice of the preferable graft. ACL registers offer a real-world clinical perspective with the aim to improve quality and patient safety by investigating factors associated with subsequent surgical outcomes.

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.

ACL Study Group survey reveals the evolution of anterior cruciate ligament reconstruction graft choice over the past three decades

PURPOSE

Anterior cruciate ligament reconstruction (ACLR) aims to restore knee function and stability, allowing patients to return to the activities they enjoy and minimize further injury to the meniscus and cartilage and their ultimate progression to osteoarthritis. This study aims to present the evolution of graft choice over the last three decades according to members of the ACL Study Group (SG).

METHODS

Prior to the January 2020 ACL SG biannual meeting, a survey was administered consisting of 87 questions and 16 categories, including ACLR graft choice. A similar questionnaire has been administered prior to each meeting and survey results from the past 14 meetings (1992 through 2020, excluding 1994) are included in this work. Survey responses are reported as frequencies in percentages to quantify changes in practice over the surgery period.

RESULTS

In 1992, the most frequent graft choice for primary ACLR was bone-patellar tendon-bone (BTB) autograft, at nearly 90%. Hamstring tendon (HT) autografts have increased in popularity, currently over 50%, followed by just under 40% BTB autograft. Recently, quadriceps tendon (QT) autograft has increased in popularity since 2014.

CONCLUSION

Autograft (HT, BTB, QT) is an overwhelming favorite for primary ACLR over allograft. The preference for HT autograft increased over the study period relative to BTB autograft, with QT autograft gaining in popularity in recent years. Graft selection should be individualized for each patient and understanding the global trends in graft choice can help orthopaedic surgeons discuss graft options with their patients and determine the appropriate graft for each case.

LEVEL OF EVIDENCE

Level V, Expert Opinion.

Anterior Cruciate Ligament Reconstruction with Hybrid Graft versus Autograft: A Systematic Review and Meta-Analysis

Background

The standard surgical treatment for ACL tear is ACL reconstruction. There is a debate of a choice between autograft or hybrid graft for treating ACL reconstruction. The purpose of this paper is to compare both case scenarios.

Methods

A lot of libraries were searched like PubMed, Cochrane, and EMBASE Library for clinical trials which were then compared and analyzed via meta-analysis. The systematic review and meta-analysis were performed as per PRISMA guidelines, and RevMan software was used to perform the meta-analysis.

Results

We analyzed 6 studies where patients of both autograft and hybrid graft were studied. The study outcomes, graft failures, graft diameters, reoperations, and so on were compared via forest plot and funnel plot. No significant difference was noted in both cases.

Conclusions

In this meta-analysis, the performance of both autograft and hybrid graft was similar. Though the diameters were larger in hybrid, other factors also had an influence like graft failures, reoperations, and age at reconstruction which must be further investigated in detail.

Biomechanical Comparison of a Novel Tibial Fixation Technique Versus Interference Screw Fixation for ACL Reconstruction Using Soft Tissue Grafts

Background:

Controversy remains regarding the optimal technique for tibial fixation of soft tissue grafts in anterior cruciate ligament (ACL) reconstruction.

Purpose/Hypothesis:

To compare the biomechanical outcomes of a novel transtibial tubercle fixation technique with those of a commonly utilized interference screw fixation at the tibial site. Our hypothesis was that transtibial tubercle fixation achieves higher ultimate failure loads than interference screw fixation.

Study Design:

Controlled laboratory study.

Methods:

We used 24 matched porcine tibias and digital extensor tendons, from which 12 grafts and tibial tunnels were prepared using the novel transtibial tubercle fixation technique and 12 were prepared using the interference screw fixation technique. The specimens underwent a cyclic loading test (50-250 N applied for 1000 cycles at a frequency of 1 Hz), followed by a load-to-failure test. The slippage, stiffness, and ultimate failure loads were compared between the techniques.

Results:

No differences in slippage were found during the cyclic loading test, and no graft fixation or tibial complex failures occurred during cyclic testing in either group. The transtibial tubercle fixation technique had higher ultimate failure loads (mean ± SD, 756.28 ± 123.43 N) as compared with interference screw fixation (602.15 ± 81.62 N; P < .05). The grafts in the transtibial tubercle fixation group were less stiff than those in the interference screw fixation group (84.43 vs 101.23 N/mm; P < .05).

Conclusion:

Transtibial tubercle fixation achieved higher ultimate failure loads than interference screw fixation in the load-to-failure test.

Clinical Relevance:

The novel transtibial tubercle fixation technique compared favorably with interference screw fixation during ACL reconstruction. This technique does not require hardware, has a low cost, theoretically eliminates the risk of complications associated with hardware implantation (eg, graft damage and pain attributed to retained hardware requiring removal), and is relatively easy to perform.

The Statistical Fragility of Hamstring Versus Patellar Tendon Autografts for Anterior Cruciate Ligament Reconstruction: A Systematic Review of Comparative Studies

BACKGROUND

Evidence-based medicine utilizes data to inform clinical decision making, despite the ability of a small number of outcome reversals to change statistical significance. P values are common measurements of statistical significance that possess inherent flaws. The inclusion of the fragility index (FI) and fragility quotient (FQ) may provide a clearer conveyance of statistical strength.

PURPOSE/HYPOTHESIS

The purpose was to examine the statistical stability of studies comparing hamstring tendon and bone-patellar tendon-bone autografts in primary single-bundle anterior cruciate ligament reconstruction with independent tunnel drilling. We hypothesized that the findings of these studies are vulnerable to a small number of outcome event reversals, often fewer than the number of patients lost to follow-up.

STUDY DESIGN

Systematic review.

METHODS

Comparative studies and randomized controlled trials (RCTs) published in 10 leading orthopaedic journals between 2000 and 2020 were analyzed. Statistical significance was defined as a P value ≤.05. FI for each outcome was determined by the number of event reversals necessary to alter significance. FQ was calculated by dividing the FI by the respective sample size.

RESULTS

Of the 1803 studies screened, 643 met initial search criteria, with 18 comparative studies ultimately included for analysis, 8 of which were RCTs. A total of 114 outcomes were examined. Overall, the mean (interquartile range) FI and FQ were 3.77 (2-4) and 0.040 (0.016-0.055), respectively. The FI was less than the number of patients lost to follow-up for 76.3% of outcomes.

CONCLUSION

Studies examining graft choice for anterior cruciate ligament reconstruction may not be as statistically stable as previously thought. Comparative studies and RCTs are at substantial risk for statistical fragility, with few event reversals required to alter significance. The reversal of <4 outcome events in a treatment group can alter the statistical significance of a given result; this is commonly fewer than the number of patients lost to follow-up. Future comparative study analyses might consider including FI and FQ with P values in their statistical analysis.

A Systematic Review of Randomized Controlled Trials in Anterior Cruciate Ligament Reconstruction: Standard Techniques Are Comparable (299 Trials With 25,816 Patients)

PURPOSE

To provide an overview of all published randomized controlled trials (RCTs) in anterior cruciate ligament reconstruction (ACLR) summarizing the available evidence.

METHODS

Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched the Cochrane FIGCentral Register of Controlled Trials, Ovid MEDLINE, and Embase for RCTs of ACLR from their inception to August 26, 2020. Outcome measure was whether RCTs reported statistically significant findings. RCTs were then classified according to their intervention groups in a narrative synthesis of the evidence.

RESULTS

In total, 299 RCTs met the inclusion criteria and were included with a total number of 25,186 patients. Only 30 RCTs (10%) reported significant differences between the intervention and the control groups. These included 101 RCTs on grafts, 20 RCTs on tunnel placements, 48 RCTs on graft fixation, 42 RCTs on single-bundle compared with double-bundle reconstructions, 11 RCTs on additional procedures, 11 RCTs on graft tensioning, 5 RCTs on timing of surgery, 25 RCTs on technical variations from standard techniques, 6 RCTs on ACL repair, 5 RCTs on navigation, 16 RCTs on perioperative management, and 9 RCTs on other aspects of ACLR. Only 14 RCTs (4.7%) reported outcomes beyond 10 years with greater allograft failures compared with autografts, high incidence of osteoarthritic changes in reconstructed knees (22%-100%), with no significant differences in outcomes between bioabsorbable or metal screws for graft fixation, patellar versus hamstrings or single- versus double-bundle reconstructions.

CONCLUSIONS

The evidence indicates that a standard arthroscopic single- or double-bundle ACLR with hamstrings/patella autografts, transportal technique, and fixation techniques familiar to the surgeon leads to comparable results. This evidence offers surgeons the flexibility to use standard and cost-effective techniques and achieve comparable outcomes.

LEVEL OF EVIDENCE

Level II; systematic review of Level I-II randomized controlled trials.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Evaluation of Graft Tensioning Effects in Anterior Cruciate Ligament Reconstruction between Hamstring and Bone-Patellar Tendon Bone Autografts

This article investigates the clinical, functional, and radiographic outcomes in anterior cruciate ligament (ACL) reconstruction patients over 7 years to determine the effects of initial graft tension on outcomes when using patellar tendon (bone-tendon-bone [BTB]) and hamstring tendon (HS) autografts. Ninety patients, reconstructed with BTB or HS, were randomized using two initial graft tension protocols: (1) normal anteroposterior (AP) laxity ("low-tension"; n = 46) and (2) AP laxity overconstrained by 2 mm ("high-tension"; n = 44). Seventy-two patients had data available at 7 years, with 9 excluded for graft failure. Outcomes included the Knee Injury and Osteoarthritis Outcome Score, Short-Form-36 (SF-36), and Tegner activity scale. Clinical outcomes included KT-1000S and International Knee Documentation Committee examination score; and functional outcomes included 1-leg hop distance and peak knee extensor torque. Imaging outcomes included medial joint space width, Osteoarthritis Research Society International radiographic score, and Whole-Organ Magnetic Resonance Score. There were significantly improved outcomes in the high-tension compared with the low-tension HS group for SF-36 subset scores for bodily pain (p = 0.012), social functioning (p = 0.004), and mental health (p = 0.014) 84 months postsurgery. No significant differences in any outcome were found within the BTB groups. Tegner activity scores were also significantly higher for the high-tension HS group compared with the low-tension (6.0 vs. 3.8, p = 0.016). Patients with HS autografts placed in high tension had better outcomes relative to low tension for Tegner activity score and SF-36 subset scores for bodily pain, social functioning, and mental health. For this reason, we recommend that graft fixation be performed with the knee at 30-degree flexion ("high-tension" condition) when reconstructing the ACL with HS autograft.

Comparing the Efficacy of Kneeling Stress Radiographs and Weighted Gravity Stress Radiographs to Assess Posterior Cruciate Ligament Insufficiency

BACKGROUND

Kneeling posterior cruciate ligament (PCL) stress radiographs are commonly used to evaluate PCL laxity. Patients, however, report significant pain, and the method's reproducibility may be challenged due to its dependence on patient body weight distribution to produce posterior tibial displacement. Weighted gravity stress radiography may offer better reproducibility and comfort than the kneeling technique, but its efficacy has not been studied.

HYPOTHESIS

Weighted gravity PCL stress radiographs will be more comfortable and produce similar measurements of side-to-side difference in posterior tibial displacement when compared with the kneeling technique.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

A total of 40 patients with nonoperatively or >6 months postoperatively treated PCL injuries (isolated or multiligamentous) underwent bilateral stress radiographs. Weighted gravity and kneeling stress radiographs were acquired, in random order, for each patient, as well as side-to-side difference in posterior tibial displacement between each knee, patient-reported visual analog scale knee pain (100 mm), time to acquire the images, and patient preference for technique. Paired t tests were used to compare the side-to-side difference, pain score, and time to complete the radiographs.

RESULTS

There was no difference between the 2 radiographic methods in the mean side-to-side difference (gravity: 6.45 ± 4.61 mm, kneeling: 6.82 ± 4.60 mm; P = .72), time required to acquire radiographs (kneeling: 307.3 ± 140.5 seconds, gravity: 318.7 ± 151.1 seconds; P = .073), or number of radiographs taken to obtain acceptable images (kneeling: 3.6 ± 1.6, gravity: 3.7 ± 1.7; P = .73). Patients reported significantly less knee pain during the weighted gravity views (kneeling: 31.8 ± 26.6, gravity: 4.0 ± 12.0; P < .0001). Of the patients, 88% preferred the weighted gravity method.

CONCLUSION

Weighted gravity stress radiographs produce similar side-to-side differences in posterior tibial translation compared with the kneeling stress technique, but do not rely on patient weightbearing and provide significantly better patient comfort. Clinicians should therefore consider the use of weighted gravity stress radiographs in clinical practice to minimize the pain associated with stress radiography while allowing for accurate decision making.

The long-term outcomes of different grafts in anterior cruciate ligament reconstruction: a network meta-analysis

OBJECTIVES

To compare the long-term prognosis of patients with different types of grafts used in anterior cruciate ligament reconstruction (ACLR).

METHODS

PubMed, Ovid (MEDLINE and Embase) and the Cochrane library were searched up to Feb 2020. Eligible studies about different grafts in ACLR were searched for identifying the evidence comparing the long-term (mean or median follow-up time or the general description of the follow-up time≥2 years) knee outcomes of different grafts for ACLR. The final included articles and evaluation criteria were confirmed by the authors and senior clinicians to ensure the validity of the included articles. Lysholm score, the results of pivot shift test, Lachman test and International Knee Documentation Committee (IKDC) evaluation were selected as prognostic indicators. A Bayesian network meta-analysis was conducted.

RESULTS

A total of 30 articles were included in our network meta-analysis. Finally, we found that artificial graft or augmentation can provide the not bad Lysholm score but the worse result of IKDC evaluation for patients with ACLR compared with other types of grafts. Double-bundle hamstring autograft can provide a good Lysholm score as well as lower positive rate of pivot shift test and Lachman test. Patellar tendon autograft can provide the better result of IKDC evaluation. The patients with allogeneic tendon graft may get the higher positive rate of pivot shift test and Lachman test. Patients with single-bundle hamstring autograft may get the ordinary result of IKDC evaluation and Lysholm score.

CONCLUSIONS

Double-bundle hamstring autograft may be a better choice because of more items of good prognosis for the patients with ACLR. Patellar tendon autograft is a right choice which only shows the disadvantage on the Lysholm score. The prognosis of patients with single-bundle hamstring autograft is ordinary. The effect of artificial graft or augmentation needs more evidence to prove. Allogeneic tendon graft is not a better choice when compared with other grafts referred in our network meta-analysis.

TRANSLATIONAL POTENTIAL STATEMENT

In this study, we made a comprehensive comparison of the grafts commonly used in anterior cruciate ligament reconstruction. The evidence presented in this study provides a reference for clinicians to select a suitable anterior cruciate ligament graft.

Utilizing a contralateral hamstring autograft facilitates earlier isokinetic and isometric strength recovery after anterior cruciate ligament reconstruction: a randomised controlled trial

PURPOSE

To compare muscle strength and patient reported outcomes following ACLR using a semitendinosus (ST) graft from the ipsilateral (IL) leg compared to a graft from the contralateral (CL) leg.

METHODS

One-hundred and forty patients with an ACL injury were randomized to IL or CL ACLR. Patients were assessed at 6, 12 and 24 months with isokinetic and isometric muscle strength measured using Biodex. Patient-reported outcomes and manual stability measurements were also recorded.

RESULTS

Patient-related outcomes improved over time for both groups with no significant differences between groups at any time point. No differences between groups in objective knee assessment scores or rerupture rates were found. The IL group was significantly weaker in knee flexion strength at all time points compared to the CL group, additionally the IL group did not recover flexor strength within 2 years.

CONCLUSION

This study demonstrated that utilizing an ST graft harvested from the uninjured limb for ACLR facilitates early isokinetic and isometric strength recovery, with no significant adverse outcomes demonstrated in other measurements and therefore be performed to reduce the risk of long-term strength deficits in the injured leg LEVEL OF EVIDENCE: II.

Clinical and radiological outcome after anterior cruciate ligament reconstruction using the T-lock Osteotrans resorbable tendon anchor: early experience and midterm follow-up

PURPOSE

Reconstruction of the Anterior cruciate ligament (ACL) using tendon grafting is an established method for restoring knee function and stability. Multiple methods are established for graft fixation. Several involve anchoring the autograft distant to the joint with hardware that remains implanted. This study reports the first early to midterm results in patients who received ACL reconstruction (ACLR) using the T-Lock Osteotrans femoral near joint fixation method with a tibial fixation using the BioactIF Osteotrans interference screw.

METHODS

This consecutive prospective series included 20 Patients (14 Male, 6 Female) with a primary ACL rupture. All patients were treated with an ACLR using a semitendinosus autograft fixated with the T-Lock Osteotrans and were followed-up postoperatively. The following parameters were assessed: Side-to-side difference of the posterior-anterior translation measured using the KT-1000 arthrometer, Tegner activity score, Lysholm score, IKDC subjective knee evaluation form. Magnetic resonance imaging (MRI) was done to assess tunnel enlargement and integrity of the anchoring device.

RESULTS

The average follow-up duration was 2 years (range 1-4.2 years). One patient was lost to follow-up. Two Patients suffered a traumatic ACL re-rupture 2 years postoperatively and received a 2-stage revision ACLR. Difference in the posterior-anterior translation was 1.8 mm (range 0-5). The median Tegner score was 6 (range 4-10) and 9 patients (45%) returned to their preinjury level of activity. The mean IKDC subjective knee evaluation form scored 91 points (range 77-100). The mean Lysholm score was 86 points (74-96). All mentioned scores were significantly better compared to preoperative values. No relevant tunnel enlargement was seen on MRI. The anchoring device was evaluated to be intact in all patients.

CONCLUSION

ACLR with the aforementioned procedure leads to good clinical and radiological outcome.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Early clinical and neuromuscular properties in patients with normal or sub-normal subjective knee function after anterior cruciate ligament reconstruction

PURPOSE

To determine clinical and neuromuscular properties in patients with normal or sub-normal subjective knee function after finalisation of 6 months' post-operative rehabilitation following anterior cruciate ligament reconstruction (ACLR).

METHODS

Sixty patients after primary anatomical single-bundle hamstring ACLR were prospectively enrolled. Demographics, subjective, clinical and functional status of the injured knee were recorded at baseline, 6 and 12 months post-operatively. Return to pre-injury activities time (months) was monitored. Tensiomyography and isokinetic dynamometry of thigh muscles were performed at 6 months, when standard ACLR rehabilitation is finalized. Based on their IKDC Subjective Knee Evaluation scores at 6 months, they were assigned into "Normal" or "Sub-normal" group. All the above measured parameters were then compared between the two groups.

RESULTS

At 6 months' timeline, 21 patients (35%) perceived their knee function as "Normal", while 39 (65%) were "Sub-normal". There were no differences in clinical status between both groups, but patients in Normal group achieved higher IKDC, Lysholm, Tegner scores as well as higher single-leg hop test. They were taller, had lower body mass index and more of them achieved their preinjury level of activity at 12 months (67% vs. 33%). Tensiomyography revealed higher biceps femoris as well as semitendinosus and semimembranosus radial displacement values on the operated leg in Normal group. Isokinetic dynamometry showed significantly higher normalised peak torque and average power of knee extensor muscles.

CONCLUSIONS

Patients who perceive their knee function as normal at 6 months following ACLR presented with better neuromuscular properties of the thigh muscles. Decreased hamstring stiffness seems to be the key to higher return-to-preinjury activity. Postoperative rehabilitation should be more focused on reducing hamstring stiffness in addition to improving knee extensor muscle strength. Level of evidence II (prospective cohort study).

Patellar Tendon Versus 4-Strand Semitendinosus and Gracilis Autografts for Anterior Cruciate Ligament Reconstruction: A Meta-analysis of Randomized Controlled Trials With Mid- to Long-Term Follow-Up

PURPOSE

To compare patellar tendon (PT) autografts with 4-strand semitendinosus and gracilis (STG) autografts concerning knee stability, functional outcomes, as well as complications after anterior cruciate ligament (ACL) reconstruction at minimal follow-up of 5 years.

METHODS

A systematic search of the literature was performed in PubMed, Embase, and the Cochrane Library to identify published prospective randomized controlled trials on clinical studies comparing PT autograft and 4-strand STG autografts for ACL reconstruction. The results of the eligible studies were analyzed in terms of knee stability (laxity measurements, Lachman test, and pivot-shift test), functional outcomes (Lysholm score, International Knee Documentation Committee score, Cincinnati score, Tegner score, single-legged hop test, and return to preinjury activity level), and complications (loss of range of motion [ROM], pain, graft re-rupture, revision, and osteoarthritis [OA]).

RESULTS

Nine clinical studies with 630 patients (313 PT and 317 STG autografts) met the inclusion criteria. No statistically significant differences were found between the PT and STG group in Lachman test, pivot-shift test, International Knee Documentation Committee score, Cincinnati score, loss of ROM, kneeling pain, graft re-rupture rate, revision rate, and OA rate. The STG group was found with less anterior knee pain (P = .003). There were no clinically significant differences for the outcomes of SSD, Lysholm score, and Tegner score.

CONCLUSIONS

Except for significantly greater risk of anterior knee pain, PT autograft had comparable results with 4-strand STG autograft in terms of knee stability and functional outcomes after ACL reconstruction with mid- to long-term follow-up. Besides, we found no statistically significant difference in loss of ROM, kneeling pain, graft re-rupture rate, revision rate, and OA change, but these results were underpowered.

LEVEL OF EVIDENCE

Level I, meta-analysis of Level I studies.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

III (Cohort Study).