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

The effectiveness of quadrupled semitendinosus graft technique in anterior cruciate ligament reconstruction: A network meta-analysis assessing various graft preparation techniques

PURPOSE

This study aims to perform a network meta-analysis of hamstring graft preparation techniques to enhance anterior cruciate ligament (ACL) reconstruction guidelines and inform clinical decision-making in patients with primary ACL rupture.

METHODS

A review of the literature, from 1 January 1990, to 31 August 2023, was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, focusing on the clinical outcomes of various hamstring graft preparation techniques. Forty-six studies (over 4800 knees) were analysed. Eight graft compositions: doubled hamstring (ST/G)-1978 grafts, doubled hamstring with augmentation (ST/G+A)-586 grafts, tripled semitendinosus (3ST)-124 grafts, quadrupled semitendinosus (4ST)-1273 grafts, five-strand tripled semitendinosus + doubled gracilis (3ST/2GR-839 grafts, six-strand tripled semitendinosus + tripled gracilis (3ST/3GR)-335 grafts, seven-strand quadrupled semitendinosus + tripled gracilis (4ST/3GR)-11 grafts and ≥eight strands-24 grafts were compared, considering graft sizes, laxity, muscle strength, range-of-motion, patient-reported outcome measures (PROMs), return to sport (RTS) and adverse events.

RESULTS

The 4ST grafts fared better than the ST/G grafts in the International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS) Sport, KOOS Q and RTS (mean difference [MD], -1.69; p = 0.0159; MD, -1.55; p = 0.0325; MD, -1.93; p = 0.001; odds ratio: 3.13; p < 0.0001). The IKDC differed significantly between the 4ST and ST/G+A groups (MD, 1.88; p = 0.046). The ST/G+A resulted in the lowest knee laxity, surpassing the ST/G, 3ST and 4ST. The ST/G had the smallest diameter (ST/G vs. ST/G+A: MD, 1.26; 95% confidence interval [CI]: 0.67-1.86, p < 0.0001). Reduced failure rates were noted with the 3ST/2GR (3ST/2GR vs. ST/G: MD, 6.93; p = 0.009) and 3ST/3GR (3ST/3GR vs. ST/G: MD, 53.64; p = 0.006).

CONCLUSION

The ideal hamstring graft for ACLR should be individualized. A 4ST graft is likely to yield good PROMs. For high stability and rapid RTS, adding augmentation to the graft is advisable. The ST/G is the thinnest graft possible.

LEVEL OF EVIDENCE

Network meta-analysis of level I-III studies.

Bridge-Enhanced Anterior Cruciate Ligament Restoration: 6-Year Results From the First-in-Human Cohort Study

Background

Bridge-enhanced anterior cruciate ligament restoration (BEAR) combines suture repair of the anterior cruciate ligament (ACL) with an extracellular matrix implant plus autologous blood to facilitate native ACL healing.

Purpose/Hypothesis

The purpose of this study was to compare the 6-year follow-up outcomes of patients who underwent the BEAR procedure with those of a nonrandomized concurrent control group receiving autograft ACL reconstruction (ACLR) in the first-in-human safety study of the BEAR implant (BEAR I trial). Based on the 2-year results, it was hypothesized that isometric hamstring strength after the BEAR procedure would be greater than that after ACLR and that there would be no other differences in outcomes at 6 years.

Study Design

Cohort study, Level of evidence, 2.

Methods

Ten patients underwent BEAR and 10 received ACLR with a 4-stranded hamstring autograft. Outcomes assessed included the record of subsequent surgeries, the International Knee Documentation Committee (IKDC) Subjective Knee Score, IKDC physical examination grade, the Knee injury and Osteoarthritis Outcome Score, instrumented knee laxity, functional outcomes (ie, muscle strength assessments and hop testing), and qualitative magnetic resonance imaging assessment. Comparisons between treatments were based on computations of the mean differences and the associated 95% CIs.

Results

One patient in the BEAR group and 3 patients in the ACLR group were lost to follow-up. In the period between 2 and 6 years, 1 patient in each group underwent revision surgery. There were no differences between groups at the 6-year follow-up in any of the outcome measures except for isometric hamstring strength, which was approximately equal to that of the contralateral knee in the BEAR group and <44% of that in the contralateral knee in the ACLR group (P < .01).

Conclusion

This preliminary study suggests that the outcomes of BEAR and ACLR with a hamstring tendon graft may be similar at the 6-year follow-up and warrants investigation of the BEAR procedure in a larger cohort of patients.

Risk factors for anteroposterior laxity increase over time in double-bundle anterior cruciate ligament reconstruction using hamstring autografts

PURPOSE

An anteroposterior (AP) laxity can increase over time after anterior cruciate ligament reconstruction (ACLR) using hamstring tendons; however, the associated risk factors remain unclear. This study aimed to investigate the risk factors of this phenomenon.

METHODS

Overall, 151 patients who underwent ACLR using hamstring autografts were recruited. AP laxity was evaluated using Knee Lax 3 arthrometer at 5 months, 1 and 2 years postsurgery. Patients were categorised into groups I (>1 mm increase) and C (<1 mm increase) based on whether they experienced an irreversible increase in AP laxity after 1 or 2 years compared with 5 months. Patient demographics and Knee injury and Osteoarthritis Outcome Score (KOOS) at 2 years postsurgery were compared between groups.

RESULTS

Group I (n = 33, 21%) showed a side-to-side difference of 4.6 (3.0-7.2) mm in AP laxity preoperatively and 0.3 (-0.7 to 1.3), 1.1 (0.2-1.9) and 2.4 (1.7-3.2) mm at 5 months, 1 and 2 years postoperatively, while group C (n = 119, 79%) showed 4.3 (2.8-5.7) mm preoperatively and 1.3 (0-1.9), 0.9 (0.1-1.8) and 0.6 (-0.3 to 1.5) mm, respectively. No significant differences were observed in the overall KOOS at 2 years (n.s.). However, group I was older (36 [22-46] vs. 28 [19-39] years; p = 0.044), had longer surgical waiting periods (122 [69-341] vs. 81 [52-136] days; p = 0.041) and lower preoperative Tegner activity scale scores (6 [5-7] vs. 7 [6,7]; p = 0.002).

CONCLUSION

While 33 patients (21%) experienced AP laxity increase over time, they had comparable clinical outcomes with group C.

LEVEL OF EVIDENCE

Level III.

Multicomponent supervised tele-rehabilitation versus home-based self-rehabilitation management after anterior cruciate ligament reconstruction: a study protocol for a randomized controlled trial

INTRODUCTION

Our study aims to assess the effectiveness of multicomponent supervised tele-rehabilitation compared to home-based self-rehabilitation management in patients following anterior cruciate ligament reconstruction (ACLR).

METHODS

The current study is designed as a single-center, single-blinded, randomized controlled, two-arm trial. Participants will be randomized and allocated at a 1:1 ratio into either a multicomponent supervised tele-rehabilitation group or a home-based self-rehabilitation group. All participants receive uniform preoperative education through the HJT software. Participants in the intervention group undergo multicomponent supervised tele-rehabilitation, while those in the control group follow a home-based self-rehabilitation program. All the participants were assessed and measured for the included outcomes at the outpatient clinic before the procedure, and in 2, 4, 8, 12, and 24 weeks after ACLR by two assessors. The primary outcome was the percentage of patients who achieve a satisfactory active ROM at the 12 weeks following the ACLR. The satisfactory active ROM was also collected at 2, 4, 8, and 24 weeks after ACLR. The secondary outcomes were active and passive range of motion (ROM), pain, muscle strength, and function results.

REGISTRATION DETAILS

Ethical approval has been obtained from the West China Hospital Ethics Committee (approval number 2023-1929, December 2023). The trial has been registered on ClinicalTrials.gov (registration number NCT06232824, January 2024).

Outcomes from different aspects indicate the all-inside technique may serve as an ideal option for anterior cruciate ligament reconstruction

PURPOSE

To evaluate the postoperative outcomes of the all-inside technique in arthroscopic anterior cruciate ligament reconstruction (ACLR).

METHODS

Patients who underwent ACLR using the all-inside technique between 2018 and 2021 were retrospectively assessed. All patients were followed up for at least 2 years. Functional recovery and pain relief were assessed using the International Knee Documentation Committee (IKDC) score, Lysholm score, Knee Injury and Osteoarthritis Outcome Score (KOOS) and visual analogue scale (VAS). Instrumented laxity was assessed via side-to-side difference using the Kneelax3 arthrometer. Graft maturity was estimated using the signal-to-noise quotient value based on magnetic resonance imaging (MRI). Adverse events during and after the surgery were recorded.

RESULTS

A total of 78 patients were included in this study, with a mean age of 28.1 ± 7.6 years. The IKDC (p < 0.001), Lysholm (p < 0.001) and KOOS (p < 0.001 for all subgroups) scores at the final follow-up were significantly higher than those before the surgery. The VAS scores (p < 0.05) were significantly lower than those before surgery. The side-to-side difference results indicated that 50 patients had a difference of less than 3 mm, indicating a tight graft, whereas only 1 patient had a difference of >5 mm, indicating a loose graft. The median signal-to-noise quotient of the graft on MRI was 1.4 (P25, P75: 1.0, 2.0). No intraoperative adverse events were observed. Postoperative adverse events included three cases of infection, three cases of graft rerupture, two cases of cyclops lesion and one case of surgical intervention for a meniscal tear.

CONCLUSION

ACLR using the all-inside technique offers promising results in patients with ACL rupture.

LEVEL OF EVIDENCE

Level IV.