Outcome Differences of Remnant- Preserving versus Non-Preserving Methods in Arthroscopic Anterior Cruciate Ligament Reconstruction: A Meta-analysis with Subgroup analysis

Anterior Cruciate Ligament Hybrid Remnant Preservation Reconstruction Demonstrates Equivalent Patient-Reported Outcomes and Complications as Traditional Anterior Cruciate Ligament Reconstruction After 1 Year

Purpose

To compare the outcomes of anterior cruciate ligament (ACL) Hybrid Remnant Preservation Reconstruction (HRPR) with traditional anterior cruciate ligament reconstruction (ACLR) and determine differences in patient-reported outcomes, range of motion (ROM), and complications after 12 months.

Methods

A retrospective cohort study of patients undergoing ACLR by a single surgeon from December 2020 to January 2022 was conducted. Patients undergoing ACL-HRPR were compared with control patients undergoing traditional ACLR with bone-patellar tendon-bone autograft. Preoperative and postoperative Patient-Reported Outcome Measurement Information System scores, International Knee Documentation Committee, and patient acceptable symptom state were recorded over 12 months. Any complications occurring 12 months postoperatively were collected.

Results

The final analysis included 104 patients, with 39 undergoing ACL-HRPR compared with 65 ACLR controls. Patients who received HRPR were on average 19.46 ± 5.01 years old, with 51.28% being female, whereas control patients were, on average, 21.92 ± 7.71 years old with 50.77% being female. Total ROM was equivalent between groups, with complete terminal extension at 12 months. No significant differences were found for patient acceptable symptom state; Patient-Reported Outcome Measurement Information System-Physical Function, -Pain Interference, or -Depression; or International Knee Documentation Committee at 6 months and 12 months postoperatively. Total ROM was similar between the HRPR and control groups. No differences were found for timed 6-meter hop test, hop for distance, or KT-1000 side-to-side differences. Over the 12-month period, complication rates were similar between groups (10% vs 12% P = .75) were similar.

Conclusions

ACL HRPR is associated with equivalent patient-reported outcomes, full ROM, and no differences in complications rates after 1 year compared with control patients in the present retrospective study.

Level of Evidence

Level III, retrospective cohort study.

Comparative efficacy and safety of different surgical approaches for the treatment of anterior cruciate ligament injury: a Bayesian network meta-analysis protocol

INTRODUCTION

Anterior cruciate ligament (ACL) rupture can be treated surgically or non-surgically, with several surgical interventions available at present. However, the comparatively effective surgical intervention with relatively fewer side effects remains unknown. This study aims to fill in this gap by conducting a Bayesian network meta-analysis (NMA) and provide a theoretical basis for the clinical application.

METHOD AND ANALYSIS

We will perform a Bayesian NMA and will include randomised controlled trials (RCTs) published in English or Chinese that compare surgical intervention (ie, standard ACL reconstruction, ACL remnant-preserving reconstruction and ACL repair with suture augmentation to conservative therapy or studies that compare one surgical intervention to another for the symptom relief and function recovery of patients with ACL rupture. Primary outcome will be the proportion of patients with symptomatic and functional improvement measured by the Knee Injury and Osteoarthritis Outcome Score before and 6 months after treatment, with scores ranging from 0 (worst) to 100 (best). Secondary outcomes will be knee-specific quality of life (ACL QoL), return to activity and level of sport participation (Tegner or modified Tegner score), health-related QoL (EuroQol Group 5-Dimension 5-Level, EQ-5D-5L), resource use, intervention-related complications and patient satisfaction. We have developed search strategies for PubMed, Embase, the Cochrane Library and Web of Science, retrieving RCTs that meet the inclusion criteria from database inception to 1 December 2023. The methodological quality of the included RCTs will be assessed based on the Cochrane risk of bias table. The relative ranking probability of the best intervention will be estimated using the surface under the cumulative ranking curve. The Bayesian NMA will be conducted by using WinBUGS V.1.4.3. The Grading of Recommendations Assessment, Development and Evaluation approach will be applied to determine our confidence in an overall treatment ranking from the NMA.

ETHICS AND DISSEMINATION

Ethical approval for this study is not required because no private or confidential patient data will be used in this study. Findings of this study would be disseminated through the publication in a peer-reviewed medical journal.

PROSPERO REGISTRATION NUMBER

CRD42023437115.

Remnant Preservation of the Primary Vertical Graft in Revision Anterior Cruciate Ligament Reconstruction

Background

The remnant preservation of a primary vertical graft in revision anterior cruciate ligament reconstruction (ACLR) can benefit anteroposterior stability. However, studies that address this concept are rare.

Purpose

To evaluate clinical outcomes of remnant preservation of primary vertical graft in revision ACLR.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 74 patients with revision ACLR were included in this retrospective study. Remnant preservation revision ACLR was performed only in patients with primary vertical grafts. The patients were divided into 2 groups according to whether the primary remnant vertical graft was preserved (remnant group; n = 48) or absent or sacrificed (no-remnant group; n = 26). The remnant group was further divided according to the degree of remnant tissue: sufficiently preserved subgroup (graft coverage, ≥50%; n = 25) and insufficiently preserved subgroup (graft coverage, <50%; n = 23). Clinical outcomes were evaluated using the International Knee Documentation Committee (IKDC) subjective form, Lysholm score, Tegner activity scale, manual laxity tests, and side-to-side difference in anterior tibial translation on Telos stress radiographs.

Results

The mean time to final follow-up was 40.7 ± 16.8 months. The remnant group showed more improved results in the postoperative Lachman test and Telos side-to-side difference than did the no-remnant group (P = .017 and .016, respectively). The post hoc test revealed that the side-to-side difference in laxity in the sufficiently preserved subgroup significantly outperformed that in the no-remnant group (P = .001), although no significant difference existed between the insufficiently preserved and no-remnant subgroups (P = .850). The postoperative IKDC subjective form, Lysholm score, and Tegner activity scale did not show significant differences between the 2 groups (P = .480, .277, and .883, respectively).

Conclusion

The remnant preservation of the primary vertical graft in revision ACLR may result in better anteroposterior stability. However, subjective outcomes in the remnant group did not exceed that of the no-remnant group. The subgroup analysis revealed that only sufficiently preserved remnants demonstrated better anteroposterior stability.

The Clinical Application of Machine Learning Models for Risk Analysis of Ramp Lesions in Anterior Cruciate Ligament Injuries

BACKGROUND

Peripheral tears of the posterior horn of the medial meniscus, known as "ramp lesions," are commonly found in anterior cruciate ligament (ACL)-deficient knees but are frequently missed on routine evaluation.

PURPOSE

To predict the presence of ramp lesions in ACL-deficient knees using machine learning methods with associated risk factors.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 2.

METHODS

This study included 362 patients who underwent ACL reconstruction between June 2010 and March 2019. The exclusion criteria were combined fractures and multiple ligament injuries, except for medial collateral ligament injuries. Patients were grouped according to the presence of ramp lesions on arthroscopic surgery. Binary logistic regression was used to analyze risk factors including age, sex, body mass index, time from injury to surgery (≥3 or <3 months), mechanism of injury (contact or noncontact), side-to-side laxity, pivot-shift grade, medial and lateral tibial/meniscal slope, location of bone contusion, mechanical axis angle, and lateral femoral condyle (LFC) ratio. The receiver operating characteristic curve and area under the curve were also evaluated.

RESULTS

Ramp lesions were identified in 112 patients (30.9%). The risk for ramp lesions increased with steeper medial tibial and meniscal slopes, higher knee laxity, and an increased LFC ratio. Comparing the final performance of all models, the random forest model yielded the best performance (area under the curve: 0.944), although there were no significant differences among the models (P > .05). The cut-off values for the presence of ramp lesions on receiver operating characteristic analysis were as follows: medial tibial slope >5.5° (P < .001), medial meniscal slope >5.0° (P < .001), and LFC ratio >71.3% (P = .033).

CONCLUSION

Steep medial tibial and meniscal slopes, an increased LFC ratio, and higher knee rotatory laxity were observed risk factors for ramp lesions in patients with an ACL injury. The prediction model of this study could be used as a supplementary diagnostic tool for ramp lesions in ACL-injured knees. In general, care should be taken in patients with ramp lesions and its risk factors during ACL reconstruction.

Occurrence Rate of Cyclops Lesion After Anatomic Double-Bundle ACL Reconstruction: Comparison Between Remnant Tissue Preservation and Resection Methods

Background

The occurrence rate of cyclops lesion after anatomic double-bundle anterior cruciate ligament (ACL) reconstruction with remnant tissue preservation remains unclear.

Hypothesis

The study hypotheses were as follows: (1) the occurrence rate of cyclops lesion will be comparable between the remnant-preserving and remnant-resecting ACL reconstruction methods, and (2) there will be no significant differences in clinical outcomes between the remnant-preserving and remnant-resecting procedures.

Methods

This retrospective comparative study involved 177 patients who underwent unilateral anatomic double-bundle ACL reconstruction using hamstring tendon autografts from 2014 to 2018 at our hospital. According to the Crain classification of ACL remnant tissue, 98 patients with remnant types I, II, or III underwent the remnant-preserving procedure (group A), and the remaining 79 patients with remnant type IV underwent the remnant-resecting procedure (group B). All patients underwent second-look arthroscopy. Patients were evaluated according to arthroscopic and clinical results at postoperative 15.2 ± 8.4 months (mean ± SD). Statistical comparisons between groups were made using the paired Student t test, chi-square test, and Fisher exact test.

Study Design

Cohort study; Level of evidence, 3.

Results

At second-look arthroscopy, the incidence of cyclops lesions was significantly higher in group B than in group A (29.1% vs 13.3%; P = .0139). Cyclops lesions were divided into 4 locations: femoral side (type 1), midsubstance (type 2), tibial side (type 3), and anterior (type 4) of the ACL graft. The ratio of the tibial-side cyclops lesion (type 3) was significantly higher in group B than in group A (P = .0354). There were no significant differences in the clinical evaluation scores between the procedures. Side-to-side anterior laxity was significantly less in group A than in group B (0.7 vs 1.6 mm; P = .0035). Concerning postoperative laceration and synovium coverage of the grafts, group A was significantly better than group B (P < .0001).

Conclusion

In this cohort of patients undergoing double-bundle ACL reconstruction, resection of the ACL remnant was associated with a significantly higher rate of cyclops lesion formation when compared with preservation of the remnant.

Effect of a new remnant-preserving technique with anatomical double-bundle anterior cruciate ligament reconstruction on MRI-based graft maturity: a comparison cohort study

PURPOSE

To investigate the effects of a new remnant-preserving double-bundle anterior cruciate ligament reconstruction (ACLR) technique, focused on avoiding remnant damage and preserving continuity of remnants, on graft maturity using magnetic resonance imaging (MRI).

METHODS

A total of 169 patients were divided into three groups: 41 in the preservation group, 70 in the resection group, and 58 in the absent group. In the preservation group, rather than passing the graft through the remnant tissue, the graft was reconstructed such that the anteromedial and posterolateral bundles sandwiched the remnant to avoid damage to the remnant and maintain its continuity. Based on 1-year postoperative MRI, the grafts were divided into three regions: distal, middle, and proximal. The signal/noise quotient (SNQ) of each region of interest was calculated to evaluate the signal intensity of the graft and was compared among the three groups. Additionally, to identify factors influencing graft maturity, a multiple regression analysis was performed with SNQ as the dependent variable and patient demographics, bone morphology, and surgical factors as independent variables.

RESULTS

In a three-group comparison of mean SNQs, the distal region was 3.3 ± 3.4, 8.9 ± 8.3, and 9.0 ± 8.6 (p < 0.001), the middle region was 5.3 ± 3.7, 10.9 ± 11.1, and 11.3 ± 10.2 (p < 0.001), and the proximal region was 6.8 ± 4.5, 11.1 ± 8.8, and 11.7 ± 10.8 (p = 0.017), in order of the preservation, resection, and absent groups, respectively. That indicated that the remnant-preserving ACLR was more hypointense than ACLR with remnant resection or absent in all three regions. Multiple regression analysis showed that remnant preservation remained the relevant factor affecting SNQ of the graft at the distal and middle levels.

CONCLUSION

The new remnant-preserving anatomic double-bundle ACLR had significantly better graft maturity, measured by SNQ on MRI, than the remnant resection and absent groups. The remnant procedure was the relevant factor affecting graft maturity.

LEVEL OF EVIDENCE

Level III.

A new remnant preservation technique reduces bone tunnel enlargement after anatomic double-bundle anterior cruciate ligament reconstruction

PURPOSE

To investigate the effect of a new remnant preservation technique with a focus on remnant continuity on postoperative femoral and tibial tunnel enlargement after anatomical double-bundle anterior cruciate ligament reconstruction (ACLR).

METHODS

A total of 150 knees were divided into three groups: Preservation Group (Group P: 49 knees), wherein the remnant continuity remained after tunnel creation; Resection Group (Group R: 47 knees), wherein the remaining remnant was resected, and Absent Group (Group A: 54 knees), wherein the remnant had no femoral attachment before tunnel creation. In Group P, the remnant maintained continuity, and the anteromedial (AM) and posterolateral (PL) bundles were positioned anterior and posterior to the remnant, respectively. Computed tomographic scans were performed at 1 week and 1 year after surgery, and the cross-sectional area of each tunnel aperture was measured. Tunnel enlargement was compared among the three groups by one-way analysis of variance (ANOVA) and the Bonferroni test. Univariate and multivariate logistic analyses were performed to identify the risk factors for tunnel enlargement in demographic and radiographic data.

RESULT

For femoral AM tunnels, the tunnel enlargement of Group P was significantly smaller than Groups R and A (p < 0.001), femoral PL (p < 0.001 vs. R and A), tibial AM (p < 0.001 vs. R, 0.002 vs. A), and tibial PL (p < 0.001 vs. R, 0.002 vs. A). There was no significant difference between Groups R and A. Multivariate logistic analysis showed that remnant preservation was a significant factor in reducing tunnel enlargement in the femoral AM, femoral PL, tibial AM, and tibial PL.

CONCLUSION

The new remnant-preserving anatomical double-bundle ACLR, which preserves the continuity of the remnant, prevented all bone tunnel enlargement at 1 year postoperatively.

LEVEL OF EVIDENCE

Level III.

Remnant preserving ACL reconstruction with a functional remnant is related to improved laxity but not to improved clinical outcomes in comparison to a nonfunctional remnant

PURPOSE

The Anterior cruciate ligament (ACL) remnant has been pointed out as a ligamentization enhancer. Nonetheless, the remaining tissue can be functional if it still provides some stability or nonfunctional. This study intends to compare the clinical results and knee stability of functional vs. nonfunctional remnant preservation ACL reconstruction (ACLR).

METHODS

One hundred and seventy-five patients with ACL injuries were included and underwent remnant preservation ACLR. They were divided into two groups accordingly to remnant tissue functionality: functional (Group F) and nonfunctional (Group NF). Primary outcome was defined as patient reported outcomes measured with Lysholm, IKDC and Tegner continuous scales and improvements. Secondary outcomes comprised of Lachman test, anterior drawer test, pivot shift test, extension and flexion deficit, graft coverage by remnant preserved tissue and failure rate (persistent instability or new ACL lesion). Menisci lesions, cartilage lesions and time to surgery were also recorded for each group.

RESULTS

One hundred and forty-four patients were available at a mean of 30.2 ± 10.1 months: 69 Functional and 75 Nonfunctional. Lysholm, IKDC and Tegner functional outcomes demonstrated no difference between the groups, Functional compared to Nonfunctional: 88.4 ± 10.5 vs. 92.2 ± 4.9, n.s. and 83.2 ± 11.3 vs. 87 ± 5.3, n.s. and 6 (5-10) vs. 6 (5-9), n.s., respectively. Lysholm and IKDC functional outcomes improvements demonstrated differences between the groups: Functional compared to Nonfunctional (39.3 ± 9.4 vs. 42.3 ± 7.4, p = 0.014 and 37.7 ± 10 vs. 41.0 ± 6.6, p = 0.032); however, they were not clinically significant. Functional group showed more stability on physical examination pre- and post-operatively (p < 0.001, p < 0.001). There was no difference regarding extension deficit (n.s.); however, functional group had more flexion deficit (p = 0.02). Nonfunctional group had better graft coverage (p = 0.001). There was no difference regarding failure rate: 4% vs. 9%, (n.s.).

CONCLUSION

Both remnant preservation ACLR techniques were able to achieve satisfactory functional outcomes. A functional remnant was not related to improved functional outcomes in comparison to a nonfunctional remnant; however, it was related to less laxity pre and postoperatively and inferior graft coverage.

LEVEL OF EVIDENCE

II.

Remnant preservation may improve proprioception after anterior cruciate ligament reconstruction

Aim

Our aim was to evaluate the literature investigating proprioception improvement after anterior cruciate ligament reconstruction (ACLR) and test the hypothesis that ACL tibial remnant-preserving reconstruction (ACLR-R) is more beneficial than standard technique (ACLR-S) in terms of postoperative proprioceptive function with various reported tests, including joint position sense (JPS) and threshold to detect passive motion (TTDPM).

Methods

An online search was performed in Embase, MEDLINE/PubMed, Cochrane, SPORTDiscus, and Web of Science databases before 5 October 2020, on the basis of the guidelines of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Key terms [(‘ACLR’ or ‘ACL-R’ or ‘anterior cruciate ligament reconstruction’) AND (‘remnant’ or ‘stump’) AND (‘proprioception’ or ‘proprioceptive’)] were used. The Oxford Centre for Evidence-Based Medicine and The McMaster Critical Review Form for Quantitative Studies were used for quality assessment. In total, four articles comparing proprioceptive functions between ACLR-R and ACLR-S were included, two of which were randomized clinical trials rated as level of evidence II, and two were retrospective cohort studies rated as level of evidence III. The outcomes were then compared. Evaluation of proprioception involved joint position sense (JPS) [reproduction of active positioning (RAP) and reproduction of passive positioning (RPP)] and threshold to detect passive motion (TTDPM) tests.

Results

Only four studies were included, with a total of 234 patients (119 ACLR-R patients and 115 ACLR-S patients). High heterogeneity in characteristics and outcome measurements was observed among the studies. Three studies performed sparing technique, and one performed tensioning technique. One study tested RAP and reported better results at an average of 7 months follow-up in ACLR-R (P < 0.05). Three studies tested RPP, one of which measured RPP within 12 months after surgery and reported better results in ACLR-R than in ACLR-S (P < 0.05). The other two studies reported similar results; however, the findings of one study were statistically insignificant. TTDPM was tested in one study, with no statistically significant difference found.

Conclusion

The current literature, although limited, reported proprioception improvement after ACLR-R (compared with ACLR-S) in terms of JPS. However, owing to the heterogeneity of the relevant studies, further research is required to determine remnant preservation effect on knee proprioceptive restoration.

Level of evidence

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

Does remnant tissue preservation in anterior cruciate ligament reconstruction influence the creation of the rectangular femoral tunnel?

PURPOSE

We have previously described anterior cruciate ligament reconstruction with a rounded rectangular femoral tunnel created using a rounded rectangular dilator designed to enable a more anatomical and wider tendon-bone junction. However, the influence of remnant tissue preservation on the creation of the rounded rectangular femoral tunnel is not clear. This study aimed to evaluate the influence of remnant tissue preservation on the creation of the rounded rectangular femoral tunnel.

METHODS

A total of 198 patients who underwent primary anterior cruciate ligament reconstruction with a rounded rectangular femoral tunnel were evaluated retrospectively. Patients were categorized into a remnant preservation group (group P) and a non-preservation group (group N). Computed tomography images taken 1 week postoperatively were analyzed. The location of the rounded rectangular femoral tunnel evaluated using the quadrant method, its rotation angle, and the graft bending angle were compared between the two groups. The differences and the variance in femoral tunnel assessment were compared using the two-sample t-test and Levene's test.

RESULTS

Although there was no significant difference in the location of femoral tunnel for the deep/shallow direction along the Blumensaat's line (difference, p = .326; variances, p = .970), the tunnel was significantly lower in group P than in group N, with no variances (difference, p = .001; variances, p = .326). There were no significant differences and no variances in the tunnel rotation angle and the graft bending angle (difference, p = .727 and 0.514, respectively; variances, p = .827 and .445, respectively). Blow out of the posterior wall of the medial aspect of the femoral lateral condyle was an intraoperative complication that occurred in one case in group N.

CONCLUSION

The remnant preservation approach creates a lower femoral tunnel compared to the non-preservation technique. However, a rounded rectangular femoral tunnel can be created safely and is reproducible with remnant tissue preservation.

Proprioceptive and Clinical Outcomes after Remnant Preserved Anterior Cruciate Ligament Reconstruction: Assessment with Minimal Confounding Factors

Objective

To evaluate the proprioceptive and clinical function of the knee joint after anterior cruciate ligament reconstruction (ACLR) with various amounts of remnant preserved with as few confounding factors as possible.

Methods

This retrospective study included 46 patients who underwent ACLR with remnant preservation between March 2013 and February 2019. These patients had less than 6 months injury‐to‐surgery interval and no concomitant injuries. The researchers divided these subjects into two groups based on the length of the remnant preserved after ACLR, with group A defined as having more than 1/3 of the original length preserved and group B defined as less than 1/3 of the original length preserved. Clinical scores were obtained using the Lysholm knee scoring scale and the Tegner activity scale. The Lysholm score was calculated preoperatively, at 3, 6, and 12 months postoperatively, and at the last follow up. The Tegner score was calculated preoperatively, at 12 months postoperatively and at the last follow up. Anterior laxity was measured using the KT2000 arthrometer preoperatively and at 12 months postoperatively. Proprioceptive function was evaluated through reproduction of passive positioning (RPP) and threshold to detection of passive motion (TDPM). Both RPP and TDPM were measured at the angle of 15° at 3, 6, and 12 months postoperatively. Unpaired t‐tests were performed to investigate the difference in each parameters between the two groups.

Results

In the present study, 20 patients were classified into group A and 26 into group B. All patients were followed up for an average of 34.70 ± 12.79 months. All 46 patients were satisfied with the outcome of the surgery and no complications were reported at the end of the study. No significant differences were found between the two groups in terms of the Lysholm score and anterior laxity by KT2000 at all time points. The Tegner score was significantly higher in group A at 12 months postoperatively and at the final follow‐up. In addition, group A's RPP was significantly better than that of group B's when tested at the angles of 15° and 30° at 3 months postoperatively, and at the angle of 15° at 6 months postoperatively. Group A's TDPM was also significantly better than that of group B's at all three tested angles at 3 months postoperatively, and at the angle of 15° at 6 months postoperatively.

Conclusion

Patients with ACLR with more than 1/3 of the original length preserved demonstrated a higher activity level 12 months postoperatively and better proprioceptive function at 15° of extension at 3 and 6 months postoperatively.

Comparable clinical and radiological outcomes between anatomical and high femoral tunnels in posterior cruciate ligament reconstruction

PURPOSE

To compare clinical and radiological outcomes and failure rates between anatomical and high femoral tunnels in remnant-preserving single-bundle posterior cruciate ligament (PCL) reconstruction.

METHODS

63 patients who underwent remnant-preserving single-bundle PCL reconstruction between 2011 and 2018 with a minimum 2-year follow-up were retrospectively reviewed. Patients were divided into two groups according to the femoral tunnel position: group A (33 patients with anatomical femoral tunnel) and group H (30 patients with high femoral tunnels). The femoral tunnel was positioned at the center (group A) or upper margin (group H) of the remnant anterolateral bundle. The position of the femoral tunnel was evaluated using the grid method on three-dimensional computed tomography. Clinical and radiological outcomes and failure rates were compared between the groups at the 2-year follow-up.

RESULTS

The position of the femoral tunnel was significantly high in group H than in group A (87.4% ± 4.2% versus 76.1% ± 3.7%, p < 0.001). Clinical outcomes were not significantly different between the two groups in terms of the clinical scores (International Knee Documentation Committee subjective, Lysholm, and Tegner activity scores), range of motion, and posterior drawer test. Radiological outcomes also showed no intergroup differences in the side-to-side differences of posterior tibial translation and osteoarthritis progression. Side-to-side difference on the Telos stress radiograph was 5.2 ± 2.9 mm in group A and 5.2 ± 2.7 mm in group H (n.s.). There were four failures in group A (12.1%) and one in group H (3.3%). The differences between the groups were not statistically significant.

CONCLUSION

The clinical and radiological outcomes and failure rates of the high femoral tunnels were comparable with those of the anatomical femoral tunnels at the 2-year follow-up after remnant-preserving single-bundle PCL reconstruction. The findings of this study suggest that high femoral tunnels can be considered an alternative in remnant-preserving single-bundle PCL reconstruction.

LEVEL OF EVIDENCE

III.

A technique for repairing rotator cuff transtendinous tears with a remnant attached to the footprint

BACKGROUND

Some unusual rotator cuff (RC) tears are located in more proximal tendinous portions, with substantial remnant tissue attached to the footprint. The two options for surgical repair are sacrificing or preserving the remnant tissue. We introduce a surgical repair technique that preserves as much of the remnant footprint as possible.

SURGICAL TECHNIQUE

A double-loaded suture anchor is inserted into the subchondral bone at the medial portion of the RC footprint; the lateral remnant tissue is preserved. Each strand is shuttled and repassed through the medial portion of the tendon in a mattress fashion using a suture hook device. Then, multiple no. 1 PDS sutures are passed through the medial and lateral stumps and left untied. Strands from the suture anchor are first tied in a double mattress fashion. Then, the repair is completed by tying the remaining no. 1 PDS sutures.

CONCLUSIONS

We propose a remnant-preserving RC repair technique for transtendinous RC tears with sufficient tissue remaining within the RC footprint. This technique appears advantageous in terms of re-establishing an environment that promotes tendon healing after repair.

Predictive factors for failure of anterior cruciate ligament reconstruction via the trans-tibial technique

INTRODUCTION

Factors for graft failure after trans-tibial (TT) ACL reconstruction, including anterolateral ligament (ALL) injury and degree of synovialization, remain unclear. This study is to evaluate the risk factors for graft failures after TT ACL reconstruction including ALL injury and synovialization.

MATERIALS AND METHODS

A total 391 patients who underwent primary TT ACL reconstruction were included. Failure was defined as greater than grade 2 laxity on the Lachman or pivot shift tests or 5 mm of anterior translation on stress radiograph. After applying inclusion/exclusion criteria, 31 patients with failure were categorized as group 1 and 89 patients without failure were categorized as group 2. Chi-square test and Cox proportional hazard analyses were performed.

RESULTS

Preoperatively, 64 patients had ALL injuries (53.3%), 58 had medial meniscal (MM) tears (48.3%), and 62 had lateral meniscal (LM) tears (51.6%). Ninety-three patients (77.5%) had acute injuries and 27 had chronic injuries as per 6-weeks duration. Significant risk factors for failure were LM tear (hazard ratio [HR], 4.018; 95% confidence interval [CI] 1.677-9.629; p = 0.002), chronicity (HR, 6.812; 95% CI 2.758-16.824; p = 0.000), presence of ALL injury (HR, 3.655; 95% CI 1.442-9.265; p = 0.006), and poor synovialization (HR, 3.134; 95% CI 1.298-7.566; p = 0.011) in Cox proportional hazard analysis. If combined MM and LM tears were found, an increased risk of failure was also identified (combined tears: HR, 3.951; 95% CI 1.754-8.901; p = 0.001/preoperative high-grade laxity: HR, 4.546; 95% CI 1.875-11.02; p = 0.001).

CONCLUSION

Chronic ACL injuries, meniscus tear, preoperative ALL injuries, preoperative high-grade laxity and poor synovialization are significant risk factors. Therefore, these factors should be carefully assessed and properly treated in TT ACL reconstruction.

LEVEL OF EVIDENCE

IV, retrospective cohort study.