Long-term follow-up after anterior cruciate ligament reconstruction using a press-fit quadriceps tendon-patellar bone autograft

Seven percent of primary anterior crucial ligament reconstruction patients have arthroscopic resection of cyclops lesions within 2 years: A cohort study of 2556 patients

PURPOSE

After anterior cruciate ligament reconstruction (ACL-R), a localised scar tissue called cyclops lesion may develop anterior to the graft causing knee extension deficits, pain, oedema, clicking and reduced knee function. This study determined the incidence of arthroscopic resection of a cyclops lesion within 2 years after ACL-R and investigated the associations of patient characteristics and surgical techniques with the need for arthroscopic resection of a cyclops lesion.

METHODS

This study included patients who underwent primary ACL-R with adult surgical technique from 2005 to 2019 at Aarhus University Hospital, Denmark. The cohort was identified in a national registry. To identify patients who had resected a cyclops lesion within the first 2 years after ACL-R, patients' surgical records were reviewed.

RESULTS

In 2005-2019, 2556 patients underwent primary ACL-R; 176 developed cyclops lesions that were resected within 2 years, equivalent to an incidence of 6.9% (95% confidence interval [CI]: 5.9-7.9). When stratified by the femoral drilling technique used, this incidence was 8.9% (95% CI: 7.7-10.3) with the anteromedial technique and 1.9% (95% CI: 1.0-3.1) with the transtibial technique. The incidence was 8.5% (95% CI: 6.8-10.3) in women and 5.7% (95% CI: 4.6-7.1) in men. Age, graft choice and the presence of cartilage or meniscal lesions did not affect the incidence.

CONCLUSION

The overall incidence of a cyclops lesion removal within 2 years post-ACL-R was 6.9%. This was five times higher with the anteromedial femoral drilling technique than with the transtibial technique. Women had a 47% higher incidence of cyclops lesion removal than men. This is relevant for the surgeon when planning an ACL-R.

LEVEL OF EVIDENCE

Level II.

Press-Fit-Hybrid Technique for Anterior Cruciate Ligament Reconstruction With Autologous Hamstring Tendons

Arthroscopic-assisted anterior cruciate ligament reconstruction follows standardized protocols. Multiple fixation techniques are known. Discussion has been raised about osseus fixation and integration. To improve a biological osseous fixation of the anterior cruciate ligament transplant, a Press-Fit-Hybrid technique has been developed. The basic principle is to recycle bony cylinders obtained from the femoral and tibial tunnel to fix the transplant in the femoral and tibial tunnel. In addition to the biological advantage, there are additional economic benefits, such as no extra fixation material is necessary compared with common fixation techniques, and the overall surgical procedure requires minimal effort.

Tape-Reinforced Graft Suturing and Retensioning of Adjustable-Loop Cortical Buttons Improve Quadriceps Tendon Autograft Biomechanics in Anterior Cruciate Ligament Reconstruction: A Cadaveric Study

PURPOSE

To investigate the biomechanical effects of tape-reinforced graft suturing and graft retensioning for all-soft tissue quadriceps tendon (ASTQT) anterior cruciate ligament reconstruction (ACLR) in a full-construct human cadaveric model.

METHODS

Harvested cadaveric ASTQT grafts were assigned to either (1) double-suspensory adjustable-loop cortical button device (ALD) fixation in which both graft ends were fixed with a suspensory fixation device with (n = 5) or without (n = 5) tape-reinforced suturing or (2) single-suspensory distal tendon fixation in which only the patellar end was fixed with an ALD (n = 5) or fixed-loop cortical button device (FLD) (n = 5). All specimens were prepared using a No. 2 whipstitch technique, and tape-reinforced specimens had an integrated braided tape implant. Graft preparation time was recorded for double-suspensory constructs. Samples were tested on an electromechanical testing machine using a previously published protocol simulating rehabilitative kinematics and loading.

RESULTS

Tape-reinforced graft suturing resulted in greater graft load retention after cycling (11.9% difference, P = .021), less total elongation (mean [95% confidence interval (CI)], 5.57 mm [3.50-7.65 mm] vs 32.14 mm [25.38-38.90 mm]; P < .001), greater ultimate failure stiffness (mean [95% CI], 171.9 N/mm [158.8-185.0 N/mm] vs 119.4 N/mm [108.7-130.0 N/mm]; P < .001), and less graft preparation time (36.4% difference, P < .001) when compared with unreinforced specimens. Retensioned ALD constructs had less cyclic elongation compared with FLD constructs (mean total elongation [95% CI], 7.04 mm [5.47-8.61 mm] vs 12.96 mm [8.67-17.26 mm]; P = .004).

CONCLUSIONS

Tape-reinforced graft suturing improves time-zero ASTQT ACLR construct biomechanics in a cadaveric model with 83% less total elongation, 44% greater stiffness, and reduced preparation time compared with a whipstitched graft without tape reinforcement. ALD fixation improves construct mechanics when compared with FLD fixation as evidenced by 46% less total elongation.

CLINICAL RELEVANCE

Tape-reinforced implants and graft retensioning using ALDs improve time-zero ACLR graft construct biomechanics in a time-zero biomechanical model. Clinical studies will be necessary to determine whether these implants improve clinical outcomes including knee laxity and the incidence of graft rupture.

Combined All-Inside Anterior Cruciate Ligament Reconstruction With Semitendinosus Plus Anterolateral Ligament Reconstruction With Intact Gracilis Tibial Insertion and Transtibial Passage

The indications for combining anterior cruciate ligament reconstruction with anterolateral ligament reconstruction have increased considerably in recent years since several anatomical, clinical, and biomechanical studies have proven the importance of the anterolateral periphery in knee rotational stability. Much is still being discussed on how to combine these techniques in terms of which grafts and fixation options to use, as well as avoiding tunnel convergence. This study aims to describe anterior cruciate ligament reconstruction with a triple-bundle semitendinosus tendon graft all-inside technique combined with an anterolateral ligament reconstruction maintaining the gracilis tendon insertion on the tibia, using independent anatomical tunnels. With this, we were able to reconstruct both using only hamstring autografts, reducing morbidity in other possible donor areas, in addition to allowing stable fixation of both grafts without tunnel convergence.

Less than 1% risk of donor-site quadriceps tendon rupture post-ACL reconstruction with quadriceps tendon autograft: a systematic review

PURPOSE

The purpose of this study is to develop a comprehensive complications profile for quadriceps tendon-autograft anterior cruciate ligament reconstruction (QT ACL-R).

METHODS

A traditional and grey literature search was conducted in accordance with PRISMA and R-AMSTAR guidelines. PubMed, EMBASE, MEDLINE, CINAHL, Cochrane, Web of Science, and many grey literature sources were searched from inception to May 29, 2022. All studies were searched and screened in duplicate with included studies being of all levels of evidence, reporting complications, and with patients of all ages undergoing primary ACL reconstruction with quadriceps tendon autograft in the last 15 years. Studies were excluded if they had cadaveric or animal subjects or were reviews. Risk of bias assessment was conducted using MINORS criteria for non-randomised studies and Cochrane's RoB 2.0 for randomised studies. Data were summarised with weighted event rates generated under a random-effects model.

RESULTS

A total of 55 studies (5315 reconstructions) were included: 32 used quadriceps tendon with bone block (B-QT), 19 used all-soft tissue quadriceps tendon (S-QT), and four did not report the QT graft subtype used. Included patients had an age range of 6.2-58 years and an average reported follow-up time of 28.1 months (range, 6-90 months) for non-randomised studies and 34.3 months (range, 0.233-120 months) for randomised studies. Pooled incidence rates for clinically relevant major complications included contralateral ACL injury at 6.0%, postoperative meniscal issues at 5.4%, cyclops lesions at 4.8%, graft failure at 4.1%, patellar fracture at 2.2%, hardware removal at 1.7%, infection at 1.5%, and donor-site quadriceps tendon rupture at 0.7%. Pooled incidence rates for clinically relevant minor complications included anterior knee pain at 9.7%, kneeling pain at 9.5%, sensation deficits at 4.4%, loss of extension at 4.2%, donor-site tendinopathy at 3.9%, cosmetic issues at 1.8%, and hematoma at 1.5%.

CONCLUSIONS

QT ACL-R resembles other graft types in its rates and types of postoperative complications. In this exploratory systematic review, no complications of QT ACL-R were found to be disproportionately represented in the literature. This graft type should remain an option with comparable complication rates to other graft choices.

LEVEL OF EVIDENCE

Level IV.

REGISTRATION

This study was preregistered under PROSPERO with preregistration code CRD42022302078.

Re-rupture rate and the post-surgical meniscal injury after anterior cruciate ligament reconstruction with the Press-Fit-Hybrid®-technique in comparison to the interference screw technique: a retrospective analysis of 200 patients with at least 3 years follow-up

BACKGROUND

There is currently no consensus regarding the preferred surgical procedure for the reconstruction of anterior cruciate ligament (ACL). The interference screw technique is widely used, but has been associated with a risk of graft damage. The Press-Fit-Hybrid®-technique is one of the alternatives for biological ACL-reconstruction with minimal implant requirements. The hypothesis of this retrospective analysis is, that the Press-Fit-Hybrid®-technique leads to better results with respect to re-rupture rate and secondary meniscal lesion than the interference-screw-technique.

METHODS

To compare the re-rupture rate of the interference-screw-technique (IF) used until 2015 with the currently used Press-Fit-Hybrid®-technique (PFH), the last 100 patients of the IF-group and the first 100 patients of the PFH-group were retrospectively analyzed. Primary outcomes were re-rupture rate, complications and secondary meniscal injury. Additionally, laxity, Lachman and Pivot-shift and range of motion were evaluated.

RESULTS

A mean follow-up of 4.2 and 5.3 years revealed 4% and 9% re-rupture rates and 1% and 2% complication rates in the PFH- and IF-group, respectively. In the PFH-group there were no re-ruptures in patients older than 23 years. Secondary meniscal injury post-surgery was 6% and 9% for the PFH and IF-group, respectively. Knee stability was similar in both groups. Range of motion was significantly better in the PFH-group, with 136° of flexion, 6 months after surgery.

CONCLUSION

For ACL-reconstruction the Press-Fit-Hybrid®-technique is an alternative new method. Low level of secondary meniscal lesions after surgery and high stability, is known to prevent later arthrosis of the knee. The encouraging observed trend of the reduction of the re-rupture rate in revision surgery and in young patients using the Press-Fit-Hybrid®-technique in comparison to the interference-screw-technique must be confirmed with further studies.

LEVEL OF EVIDENCE

Therapeutic Level III, retrospective cohort study.

Bone-patellar tendon-bone autograft and female sex are associated with the presence of cyclops lesions and syndrome after anterior cruciate ligament reconstruction

PURPOSE

Associated risk factors for the development of cyclops lesions have been little. Investigated, because most previous studies have limited their research to cases with symptomatic cyclops lesions (cyclops syndrome). The purpose of this study was to evaluate the presence of cyclops lesions using magnetic resonance image (MRI) at 6 and 12 months after anterior cruciate ligament reconstruction (ACL-R), and to investigate the associated risk factors of cyclops lesions and syndrome.

METHODS

A retrospective analysis of patients who underwent ACL-R using bone-patellar tendon-bone (BTPB) or hamstring tendon autograft from 2008 to 2017 was conducted. Predictor variables (age, sex, body mass index [BMI], time from injury to ACL-R, preinjury Tegner activity score, graft, meniscal and cartilage injury, and notch width index on MRI for the presence of cyclops lesions and syndrome were analyzed with multivariate logistic regression.

RESULTS

Four hundred and fifty-five patients (225 males and 230 females) were enrolled. One hundred and four patients (22.9%) had cyclops lesions, and all cyclops lesions were detected on MRI at 6 months post-operatively. In addition, 20 patients (4.4%) had cyclops syndrome which means that these were symptomatic cases. The risk factors for presence of cyclops lesions were BPTB autograft (OR = 2.85; 95% CI 1.75-4.63; P < 0.001) and female sex (OR = 2.03; 95% CI 1.27-3.25; P = 0.003). The presence of cyclops syndrome increased with graft (BPTB) (OR = 18.0; 95% CI 3.67-88.3; Powered by Editorial Manager^® and ProduXion Manager^® from Aries Systems Corporation P < 0.001), female sex (OR = 3.27; 95% CI 1.07-10.0; P = 0.038), and increased BMI (OR = 1.21; 95% CI 1.05-1.39; P = 0.008).

CONCLUSIONS

All cyclops lesions were detected 6 months after ACL-R, and the majority of them were asymptomatic. BPTB autograft and female sex were the significant risk factors for the presence of cyclops lesions and syndrome. In addition, increased BMI was associated with a higher risk of developing cyclops syndrome. When BPTB autograft is used for a female patient, full active knee extension should be encouraged in the early period after ACL-R to prevent cyclops lesion formation.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Delayed Surgery, Low Presurgery Activity, and Poor Preoperative IKDC Scores Are Correlated with Lower Rates of Return to Sports after ACL Reconstruction in an Asian Population

There is limited literature regarding the early postsurgical outcomes of anterior cruciate ligament (ACL) reconstruction in Asian populations, particularly in the rates of return to sports. We aimed to quantify early clinical outcomes for ACL reconstruction, determine the predictive value of surgeon- and patient-reported outcomes on the rate of return to sports in the early postoperative period, and identify factors predictive of return to sports. We analyzed the data of 55 patients who underwent ACL reconstruction at our tertiary medical center from 2015 to 2016. All patients underwent transportal ACL reconstruction and a standardized post-ACL reconstruction rehabilitation protocol. Patients with concurrent meniscal injury and repair were included. Patients were evaluated at the 3-month, 6-month, 1-year, and 2-year postoperative periods. Surgeon- and patient-reported outcome scores were collected at each follow-up through a systematic questionnaire designed to determine the patient's level of return to sport and reasons for not returning. Surgeon- and patient-reported outcome measures improved significantly over the 2-year postoperative period (p < 0.001). Overall rate of return to sports was 58.2%. The International Knee Documentation Committee (IKDC) subjective (p = 0.02), symptomatic (p = 0.001), composite (p = 0.005), Tegner (p < 0.001) and Lysholm (p = 0.049) scores at 2-year follow-up were significantly worse in patients who failed to return to sports. Earliest difference in scores manifested at 3-month postsurgery (p = 0.011). IKDC grade-D patients were 18.1 times less likely to return to sports (p = 0.035). Delayed surgery (p = 0.01) and presurgery inactivity (p = 0.023) were negatively predictive of return to sports. The rate of return to sport is consistent with the literature analyzing other ethnic populations. Both surgeon- and patient-reported outcome scores at 2-year postsurgery exhibited significant differences between those who did and did not return to sports. Patients should be advised to seek surgical treatment as soon as possible and stay active preoperatively to maximize return to sports.

In vivo knee rotational stability 2 years after the ACL reconstruction using a quadriceps tendon graft with bone block and bone-patellar tendon-bone graft

INTRODUCTION

The aim of this prospective randomised study was to evaluate clinical results and rotational stability at least 2 years after single-bundle anatomic anterior cruciate ligament reconstruction using a quadriceps tendon graft with bone block (BT) and bone-patellar tendon-bone graft (BTB).

MATERIALS AND METHODS

In both groups (BT and BTB), 40 patients selected prospectively at random were evaluated. The mean follow-up after the surgery was 28 months (range 24-33 months). A navigation system was used to measure rotational stability of the knee joint. Cincinnati, Lysholm, and IKDC scores and visual analog score (VAS) were used to evaluate clinical results and the non-parametric Wilcoxon test was used for the statistical analysis.

RESULTS

After the BT reconstruction, the mean internal rotation of the tibia (IR) was 9.5°. In the contralateral healthy knee joint, IR was 8.6° at average. After the BTB reconstruction, the mean IR was 9.9°. In the contralateral healthy knee joint, IR was 8.7° at average. We did not find any statistically significant difference in IR stability between BT and BTB reconstruction. In terms of clinical results, regarding the VAS, patients perceive significantly more pain after the BTB reconstruction (p < 0.05). Kneeling was reported more difficult and painful after BTB reconstruction.

CONCLUSIONS

The BT reconstruction of the ACL provides similar clinical results, less pain, better flexion and the same rotational stability of the knee in comparison with the BTB reconstruction.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

IV, systematic review of Level I-IV studies.

Effect of Geometry on the Fixation Strength of Anterior Cruciate Ligament Reconstruction Using BASHTI Technique

The goal of this study is to investigate the effects of tendon and cannulated drill bit diameter on the strength of the bone and site hold tendon inside (BASHTI) fixation technique for an anterior cruciate ligament (ACL) reconstruction. Bovine digital tendons and Sawbones blocks were used to mimic the ACL reconstruction. Mechanical strength of the specimens was measured using a cyclic loading continued by a single cycle pullout load until failure to simulate the real postsurgical loading conditions. Finally, failure modes of specimens and ultimate failure load were recorded. The maximum possible tendon surface strain (i.e., tendon compression [TC]) for tendon diameters of 6, 7, 8, and 9 mm were 0.73, 0.8, 0.7, and 0.65, respectively. Eighty per cent of the specimens with tendon diameter of 6 mm and 20% of specimens with tendon diameter of 7 mm failed on the torn tendon. All samples with larger tendon diameters (i.e., 8 and 9 mm) failed on the fixation slippage. The maximum fixation strength according to the most suitable core bones for 6, 7, 8, and 9 mm tendons were 148 ± 47 N (core 9.5 mm), 258 ± 66 N (core 9.5 mm), 386 ± 128 N (core 8.5 mm), and 348 ± 146 N (core 8.5 mm), respectively. The mode of tendon failure was significantly influenced by the tendon diameter. Also, an increase in TC raised the fixation strength for all tendon diameters; however, tendon over compression decreased the fixation strength for the 8 mm tendon group. Finally, an empirical equation was proposed to predict BASHTI fixation strength.

Graft Choice for Anterior Cruciate Ligament Reconstruction in Women Aged 25 Years and Younger: A Systematic Review

CONTEXT

Although anterior cruciate ligament (ACL) tears are relatively common in athletic populations, few studies have systematically reviewed graft choice in young women.

OBJECTIVE

To quantitatively and qualitatively examine reported outcomes for graft choice in women aged 25 years and younger undergoing primary ACL reconstruction.

DATA SOURCE

A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. An electronic search in the PubMed (includes MEDLINE) and EMBASE databases was completed using a combination of key terms.

STUDY SELECTION

Studies were included if they reported graft choice outcomes in women aged 25 years and younger.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

The following information was extracted: title, author, year of publication, number of female patients and age, graft type, follow-up, and patient-reported outcome measures. The following outcome scores were identified as being reported or not reported by each study: graft failure, contralateral ACL (CACL) rupture, IKDC (International Knee Documentation Committee), graft survival (Kaplan-Meier), Lysholm, Tegner, KT-1000, kneeling pain, return to sport, and Lachman.

RESULTS

Of 1170 identified articles, 16 met inclusion criteria, reporting on 1385 female patients aged 25 years and younger. Comparison of 655 bone-patellar tendon-bone (BPTB) versus 525 hamstring tendon (HT) autografts showed significant differences in mean failure rate between BPTB autografts (6.13% ± 2.58%) and HT autografts (17.35% ± 8.19%), P = 0.001. No statistically significant differences in CACL failure rates were found between BPTB autografts and HT autografts (P = 0.25). Pooled results for IKDC were possible in 3 of the HT autograft studies, showing a mean score of 88.31 (95% CI 83.53-93.08). Pooled Lysholm score results were possible in 2 of the HT autograft studies, showing a mean score of 93.46 (95% CI 91.90-95.01).

CONCLUSION

In female patients aged 25 years and younger, BPTB autografts showed significantly less graft failure compared with HT autografts. However, BPTB autografts had comparable patient-reported outcomes compared with HT autografts with the available data. The overall state of evidence for graft choice in female patients aged 25 years and younger is low. Future studies should report statistics by age and sex to allow for further analysis of graft choice for this specific population that is known to be more vulnerable to ACL injury.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

III, comparative therapeutic trial.

Bone fixation techniques for managing joint disorders and injuries: A review study

The majority of surgical procedures treating joint disorders require a technique to realize a firm implant-to-tissue and/or a tissue-to-tissue fixation. Fixation methods have direct effects on survival, performance and integration of orthopedic implants This review paper gives an overview of novel fixation techniques that have been evaluated and optimized for orthopaedic joint implants and could be alternatives for traditional implant fixation techniques or inspirations for future design of joint implantation procedures.

METHOD

The articles were selected using the Scopus search engine. Key words referring to traditional fixation methods have been excluded to find potential innovative fixation techniques. In order to review the recent anchorage systems, only articles that been published during the period of 2010-2020 have been included.

RESULTS

A total of 57 studies were analyzed. The result revealed that three main fixation principles are being employed: using mechanical interlockings, employing adhesives, and performing tissue-bonding strategies.

CONCLUSION

The development of fixation techniques demonstrates a transformation from the general anchoring tools like K-wires toward application-specific designs. Several new methods have been designed and evaluated, which highlight encouraging results as described in this review. It seems that mechanical fixations provide the strongest anchorage. Employing (bio)-adhesives as fixation tool could revolutionize the field of orthopedic surgery. However, the adhesives must be improved and optimized to meet the requirements of an anchorage system. Long-term fixation might be formed by tissue ingrowth approaches which showed promising results. In most cases further clinical studies are required to explore their outputs in clinical applications.

Tendão quadricipital: Opção na reconstrução ligamentar do joelho

Although it is a versatile tendon, only 1% of surgeons choose to use the quadricipital tendon as a graft in anterior cruciate ligament (ACL) reconstruction. The present article aims to describe a quadricipital graft removal technique in which its deepest part is maintained. The technique consists of an approach in which the first incision is made in the medial part of the quadricipital tendon to prevent it from getting too short. This is due to its triangular design. The technique also addresses the depth and identification of the three layers of the quadricipital tendon so that it is possible to preserve its deepest part. This approach aims to preserve the extensor apparatus and to not communicate it with the joint environment, avoiding fluid extravasation both in the trans and postoperative periods.

Long-term Outcomes of Anterior Cruciate Ligament Reconstruction Using Quadriceps Tendon-Patellar Bone Autograft

Background:

To date, there have been few studies on the outcomes of anterior cruciate ligament reconstruction (ACLR) using quadriceps tendon–patellar bone (QTPB) autograft.

Purpose:

To evaluate the long-term clinical outcomes of ACLR using QTPB autograft.

Study Design:

Case series; Level of evidence, 4.

Methods:

We retrospectively reviewed 139 patients who underwent primary ACLR with QTPB autografts and had at least 7 years of postoperative follow-up data. Instability, clinical scores, donor-site morbidity, radiographic progression of osteoarthritis, and any associated complications were assessed.

Results:

The proportion of knees classified as grade >1 on the anterior drawer, Lachman, and pivot-shift tests decreased significantly postsurgically (from 47.4% to 5.0%, 48.9% to 4.3%, and 53.3% to 5.0%, respectively; P < .001 for all). The mean clinical scores at the final follow-up were 89.8, 81.0, and 4.4 for the Lysholm, International Knee Documentation Committee, and Tegner Activity Scale, respectively. The results of the Cybex II dynamometer isokinetic test showed decreases in flexion and extension strength at both 60° and 180° per second, which persisted until the final follow-up visit. About one-fifth (19.4%) of the patients had osteoarthritis (Kellgren-Lawrence grade ≥1) before surgery, which increased to 33.8% at the final follow-up. The overall complication rate was 23.2%, and about one-third of the patients who experienced complications underwent revision surgery as a result of graft rupture and residual instability.

Conclusion:

In the current study, ACLR using QTPB autograft provided satisfactory long-term clinical results, with acceptable rates of complication and donor-site morbidity.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

IV, systematic review of level I-IV studies.

Quadriceps tendon vs. patellar tendon autograft for ACL reconstruction using a hardware-free press-fit fixation technique: comparable stability, function and return-to-sport level but less donor site morbidity in athletes after 10 years

INTRODUCTION

The use of quadriceps tendon-patellar bone (QTB) autograft for anterior cruciate ligament (ACL) reconstruction is gaining momentum. Yet, long-term results that compare this procedure with established methods are lacking. The aim of this study was to report and compare long-term results of ACL reconstruction using QTB autografts versus bone-patellar tendon-bone (BPTB) autografts, both anchored using a hardware-free press-fit fixation technique.

MATERIALS AND METHODS

60 athletes (Tegner score ≥6) with primary ACL rupture were prospectively randomized into two groups. 56 patients were evaluated after a mean duration of 12.2 ± 1.9 months (range 10-14) and 43 patients after 10.3 ± 0.2 years (range 10-11).

RESULTS

On final follow-up, 90% of patients scored very good and good results in the functional Lysholm score (mean 99 ± 7.1, range 74-100 points). Normal or almost normal IKDC score was reported by 84% of the patients (mean 97 ± 9.5, range 60-100 points). The activity level decreased in the Tegner score from median of 7 before injury to 6 after 10 years. The KT-1000 arthrometer showed a difference in the anterior translation of less than 3 mm (mean 1.0 ± 1.2, range - 1 to 5 mm) in 91% of the patients. Significant degeneration was radiologically detected in one patient per group. No tunnel widening was seen in any patient. Up to 97% of all patients were satisfied with the operative procedure. No significant differences were found in the mentioned parameters between the two groups and also in comparison with the 1-year results. The only significant difference was in the donor site morbidity. Significantly more patients in the BPTB group had complaints during kneeling both at 1 (p < 0.001) and 10 years (p = 0.019). Squatting was also subjectively more problematic in the BPTB group than in the QTB group both after 1 (p = 0.003) and 10 years (p = 0.046).

CONCLUSIONS

This study shows equally good functional, clinical and radiological long-term results for both hardware-free methods of ACL reconstruction. These results clinically confirm the safety of press-fit anchoring after 10 years. The failure rate in this study was very low, with only one re-rupture in 10 years. The increased donor site morbidity when using the BPTB autograft compared to the QTB autograft supports already reported data. It was also seen in this study for the implant-free press-fit techniques.

STUDY DESIGN

Prospective and randomized, level of evidence 2.

Revision ACL reconstruction using quadriceps or hamstring autografts leads to similar results after 4 years: good objective stability but low rate of return to pre-injury sport level

PURPOSE

Due to the increased importance of revision ACL reconstruction, this study aims to evaluate the outcome 4 years after the surgery, compare two revision strategies and identify factors that influence the results.

METHODS

Seventy-nine patients who received a revision ACL reconstruction were retrospectively evaluated. All patients were assessed with an average follow-up of 4.4 years (range 3.3-5.5 years). The results of patients treated with a quadriceps autograft were compared with those treated with a hamstring autograft.

RESULTS

Ninety-seven percent of patients had a KT-1000 side-to-side difference of ≤ 5 mm (mean 1.7 ± 2.0 mm). Pivot-shift test was absent or minor in 95%. In the SLTH-test, 70% of patients reached 90% of the contralateral side. The mean Lysholm score on follow-up was 83 ± 12 (56% excellent/good). The mean IKDC 2000 subjective evaluation score was 81 ± 14 (58% normal/almost normal). The median Tegner activity score was 6 (range 3-10), a median of 2 levels worse than before the first injury. Return to sport rate was 89% but only 34% of patients reached their pre-injury sport level. Most common cause for this reduction was fear of another injury. Three patients suffered a re-rupture. Patients with a hamstring autograft performed pivoting sports more often, but had worse pivot-shift results compared to those with a quadriceps autograft. No significant influence was seen for other parameters. Young, male patients with a high activity level and no chondral damage had the best results.

CONCLUSION

Through revision ACL reconstruction, the goal of stabilizing the knee can be achieved in the majority of patients. However, a good function and a high activity level are significantly less common in these patients. The main reason for this is fear of a renewed ACL-injury. Both quadriceps and hamstring autografts were able to achieve a good outcome. Young, male, patients with a normal BMI, a high activity level and without cartilage damage seem to benefit the most from revision ACL surgery. The discrepancy between the good laxity restoration and the lower activity rate should therefore be a main point in clinical counseling when deciding for or against revision ACL-Reconstruction.

LEVEL OF EVIDENCE

III.

Multivariable analysis of anatomic risk factors for anterior cruciate ligament injury in active individuals

OBJECTIVE

The aim of the present study was to compare the morphometric differences between patients with or without anterior cruciate ligament (ACL) injury, and identify the anatomic risk factors associated with ACL injury in active individuals.

METHODS

The knee joint magnetic resonance images (MRI) of 100 subjects were included in this study. Data from the ACL-injured group (50 patients) and matched controls (50 subjects) were obtained from the same hospital. These data were analyzed by univariable analysis or multivariable conditional logistic regression analysis to examine the effects of the following variables on the risk of suffering ACL injury for the first time: TT-TG distance, medial and lateral tibial slope, intercondylar notch width and depth, femur condylar width, lateral femoral condylar depth, notch width index (NWI), notch shape index (NSI), notch depth index (NDI), and cross-sectional area (CSA).

RESULTS

In the univariable analysis, the ACL-injured group had a larger TT-TG distance, increased medial and lateral tibial slope, narrower intercondylar notch width, deeper lateral femoral condylar depth, lesser NWI and NSI, and CSA when compared with the control group (P < 0.05). However, there were no significant between-group differences in intercondylar notch depth (P = 0.174), femur condylar width (P = 0.797), and NDI (P = 0.436). The multivariable analysis revealed that TT-TG distance [odds ratio (OR) = 1.37, 95% CI = 1.04-1.81, P = 0.028], medial tibial slope (OR = 1.30, 95% CI = 1.02-1.66, P = 0.036) and NWI (OR = 0.46, 95% CI = 0.24-0.91, P = 0.025) had significant multivariable associations with the sole independent risk of ACL injury.

CONCLUSION

Larger TT-TG distance, increased MTS, and lesser NWI are independent anatomic risk factors for active individuals with ACL injury.

LEVEL OF EVIDENCE

Case-control study; Level of Evidence, III.

Safety and feasibility of using calcium phosphate hybridization method for quadriceps tendon-bone graft in anterior cruciate ligament reconstruction

Background

To improve tendon-to-bone healing in anterior cruciate ligament (ACL) reconstruction, a novel technique via the calcium phosphate (CaP) hybridization method for tendon graft using an alternate soaking process was developed. The use of the CaP hybridization method for quadriceps tendon-bone (QTB) graft in ACL reconstruction has not been reported in previous studies. Thus, this clinical trial aimed to clarify the safety and feasibility of using CaP hybridization method for quadriceps tendon-bone (QTB) graft in ACL reconstruction.

Methods

Eight patients (average age, 41.6 ± 10.6 years; 2 men and 6 women) with unilateral ACL injury were included in this study. They underwent ACL reconstruction using QTB graft that hybridized CaP. The follow-up period was from 2 months to 4 years (average, 2.4 ± 1.5 years). Cases of adverse events, including tumor formation, infection, fracture, contracture, severe pain, and re-rupture, were recorded. Moreover, clinical results (KT-1000 arthrometry, pivot-shift test, International Knee Documentation Committee grade, Lysholm scale, and sports activity level), and images of graft and bone tunnel (magnetic resonance imaging, arthroscopic appearance, and computed tomography) were also evaluated.

Results

No adverse events were observed in the follow-up periods. Postoperative clinical results showed improvement compared with the preoperative findings. The sports activity level after the surgery became equivalent to that before injury. There was no progression of bone tunnel enlargement.

Conclusions

Using the CaP hybridization method for QTB graft in ACL reconstruction was safe and feasible in the clinical trial. Moreover, this method may improve clinical outcomes. In the future, it is necessary to verify the effect of the CaP hybridization method for QTB graft in ACL reconstruction.

ACL reconstruction with quadriceps tendon graft and press-fit fixation versus quadruple hamstring graft and interference screw fixation - a matched pair analysis after one year follow up

Background

The objective of the study was to compare the results of a primary anterior cruciate ligament reconstruction (ACLR) using the press-fit fixation technique for a quadriceps tendon (QT) graft to a standard quadrupled hamstring (HT) graft with interference screw fixation.

Methods

A retrospective cohort study with a 12-month follow up provided data for 92 patients. Exclusion criteria were accompanying ligament injuries and contralateral ACL injury. Patients who suffered a graft failure, which was defined as a side-to-side difference of > 3 mm, or infection were rated ‘D’ according to the IKDC and excluded from further evaluation. Forty-six patients underwent primary ACLR using the press-fit fixation technique for autologous bone QT graft. These patients were matched in terms of age, gender, accompanying meniscus tear and cartilage injury to 46 patients who underwent standard HT graft with interference screw fixation. Patients were evaluated according to the Lachman test, Pivot-Shift test, IKDC score, Tegner score, Rolimeter measurements, one-leg hop test, thigh circumference and donor side morbidity.

Results

No significant differences in Tegner score (p = 0.9), subjective or objective IKDC score (p = 0.9;p = 0.6), knee stability (Lachman Test p = 0.6; Pivot-Shift Test p = 0.4; Side-to-Side Difference p = 0.4), functioning testing (One-Leg Hop Test p = 0.6; Thigh Circumference p = 0.4) or donor side morbidity (p = 0.4) were observed at the follow up. The Lachman test was negative for 85% of the QT group and 83% of the HT group. The Pivot Shift Test was negative for 80% of the QT group and 85% of the HT group. The mean side-to-side difference was 1.6 ± 0 .2mm in both groups. The one-leg hop test revealed a collateral-side jumping distance of 96.2 ± 8.5% for the QT group and 95.5 ± 8.5% for the HT group. The thigh circumference of the injured leg was 98.3 ± 3.0% on the uninjured side in the QT group and 99.7 ± 3.0% in the HT group. A knee walking test resulted in no discomfort for 90% of the QT group and 85% of the HT group. The graft failure rate was 7.3% in the QT group and 9.8% in the HT group.

Conclusion

QT grafts fixated using the press-fit technique are a reliable alternative for primary ACL surgery.