Reconstruction of the anterior cruciate ligament: a historical view

Bone-patellar tendon-bone, hamstring, and quadriceps tendon autografts for anterior cruciate ligament reconstruction in skeletally immature patients: a systematic review

INTRODUCTION

Historically, anterior cruciate ligament (ACL) ruptures in the paediatric age group were managed conservatively with bracing, casting, activity modification, and physical therapy. However, most of these patients had to reduce their sports activities, and secondary damages to the affected knee were prevalent.

SOURCE OF DATA

Published scientific literature in Embase, Web of Science, PubMed, and Google Scholar databases.

AREAS OF AGREEMENT

ACL reconstruction in children with open physes patients is debated. Any damage to the physes around the knee could lead to growth abnormalities and axial deviation of the knee.

AREAS OF CONTROVERSY

Different grafts are available and suitable for ACL reconstruction in skeletally immature patients; however, which graft performs better remains unclear.

GROWING POINTS

This systematic review compared bone-patellar tendon-bone (BPTB), hamstring tendon (HT), and quadriceps tendon (QT) autografts for ACL reconstruction in skeletally immature patients. The joint laxity, Patient-reported outcome measures (PROMs), return to sport, and complications were compared.

AREAS TIMELY FOR DEVELOPING RESEARCH

In skeletally immature patients, HT, BPTB, and QT autografts for ACL reconstruction yielded good outcomes. Comparative studies are strongly required to establish the most suitable autograft.

A machine learning system for artificial ligaments with desired mechanical properties in ACL reconstruction applications

The anterior cruciate ligament is one of the important tissues to maintain the stability of the human knee joint, but it is difficult for this ligament to self-heal after injury. Consequently, transplantation of artificial ligaments (ALs) has gained widespread attention as an important alternative treatment method in recent years. However, accurately predicting the intricate mechanical properties of ALs remains a formidable challenge, particularly when employing theoretical frameworks such as braiding theory. This obstacle presents a significant impediment to achieving optimal AL design. Therefore, in this study, a high-precision machine learning model based on an artificial neural network was developed to rapidly and accurately predict the mechanical properties of ALs. The results showed that the proposed model achieved a reduction of 45.22% and 50.17% in the normalized root mean square error on the testing set when compared to traditional machine learning models (Random Forest and Support Vector Machine), demonstrating its higher accuracy. In addition, the design of ALs with desired mechanical properties was achieved by optimizing the braiding parameters, and its effectiveness was verified through experiments. The mechanical properties of the prepared ALs were able to fully meet the desired targets and were at least 2% higher. Finally, the influence weights of different braiding parameters on the mechanical properties of ALs were analyzed by feature importance.

A Comprehensive Review of Graft Choices and Surgical Techniques in Primary Anterior Cruciate Ligament Reconstruction: An Outcome Analysis

Anterior cruciate ligament (ACL) injuries are among the most prevalent knee injuries, particularly in athletes engaged in high-impact sports. ACL reconstruction is a widely performed surgical procedure to restore knee stability, prevent further knee damage, and enable patients to return to their previous physical activity levels. However, the success of ACL reconstruction is influenced by various factors, including the choice of graft and the surgical technique employed. This comprehensive review explores the outcomes of different graft options - autografts, allografts, and synthetic grafts - and various surgical techniques such as single-bundle versus double-bundle reconstruction and anatomic versus non-anatomic tunnel placement. The review analyzes the short- and long-term outcomes, including functional recovery, return to sports, complication rates, and the impact of patient-specific factors such as age, activity level, and comorbidities. Additionally, the review discusses the role of rehabilitation protocols in optimizing surgical outcomes. By synthesizing current evidence, this review aims to provide clinicians with insights into the most effective graft choices and surgical techniques for primary ACL reconstruction, ultimately guiding the optimization of patient outcomes and highlighting areas for future research.

The "Golden Age" of quadriceps tendon grafts for the anterior cruciate ligament: a bibliometric analysis

IMPORTANCE

Bibliometric research is a statistical analysis of publications to measure the scientific output in a specific field in order to highlight medical developments or knowledge gaps and to direct future scientific research. The quantity of orthopedic papers on the internet is astounding and is steadily growing as a result of recent advancements in technology and medicine. This is why choosing the right information is essential.

AIM

The purpose of this study was to analyze the current literature for trends in publications regarding quadriceps tendon (QT) grafting of the anterior cruciate ligament (ACL).

EVIDENCE REVIEW

PubMed was searched on August 28, 2023. References were collected from PubMed, and trends were analyzed using this information. This search retrieved 405 articles regarding human and animal studies. We analyzed the top 10 authors and journals in terms of publication numbers, citation numbers, and citations per year. The PubMed-by-year feature was used to compare the number of publications regarding ACL reconstruction by quadriceps grafting with all publications in PubMed.

FINDINGS

The number of yearly publications averaged 10 or less up to 2018, starting from 1982 when the first paper on the QT was published. However, the number of publications increased from 2018. While the total number of publications on this topic was 405, 260 were published from 2018 alone. The number of citations was 8262 in total overall years. It is expected that the last five years' publications, especially those for the last year, will be low in number, as it takes time for citations to accrue. The journal Arthroscopy published the most articles on this topic, with 57 papers and 1884 citations, followed by the American Journal of Sports Medicine, with 39 articles and 1576 citations. The top three journals on this topic were Arthroscopy, AmericanJournalofSportsMedicine, and KneeSurgery, SportsTraumatology, Arthroscopy. The most published author was Musahl V (with 24 articles), and the most cited author was Xerogeanes JW (with 570 citations).

CONCLUSIONS AND RELEVANCE

Global trend analysis suggests that research on anterior cruciate ligament reconstruction with the quadriceps has significantly increased in the last 5 years and that the number of papers on this topic is increasing steadily. We found that the publications and citations are exhibiting a rising trend, Arthroscopy is the most impactful journal, and Musahl V is the most impactful author on the topic. Xerogeanes JW is the author with the most citations on the topic. The promising clinical results of anterior cruciate ligament reconstruction with the QT have attracted the most research interest.

LEVEL OF EVIDENCE

Level IV.

Comparative effectiveness of peroneus longus tendon (PLT) autografts versus hamstring tendon (HT) autografts in anterior cruciate ligament reconstruction: a comprehensive systematic review and meta analysis

The hamstring tendon (HT) autograft is currently the most widely utilised autograft option for anterior cruciate ligament (ACL) reconstruction. However, recent studies endorse the peroneus longus tendon (PLT) autograft as a viable alternative. To evaluate this, we systematically reviewed randomised controlled trials (RCTs) to compare the efficacy of PLT against HT autografts. Our search encompassed Cochrane, Embase, OVID, PubMed, and Scopus databases for RCTs comparing outcomes of PLT and HT autografts in ACL reconstruction. Primary outcomes included Lysholm and International Knee Documentation Committee (IKDC) scores, while secondary outcomes involved American Orthopaedic Foot and Ankle Society (AOFAS) scores, graft diameters and donor-site complications. Statistical analysis was performed using Review Manager 5.4 (Cochrane Collaboration) and heterogeneity was assessed with I2 statistics. 683 patients from 6 RCTs were included, with 338 (49.5%) patients treated with PLT autografts. Follow-up ranged from 12 to 30 months. Despite lower preoperative Lysholm scores in the PLT group, no significant differences were observed at 6 and 12 months. Although preoperative and 6-month IKDC scores were lower in the PLT group, no significant differences were found at 12 and 24 months. AOFAS scores showed no significant preoperative difference, but slightly lower scores were noted in the PLT group at 12 or 24 months. There was no significant difference in graft diameter, while donor-site complications were fewer in the PLT group. In summary, the PLT autograft is a promising and non-inferior alternative to the HT autograft, demonstrating equivalent outcomes in patient-reported knee and ankle metrics, comparable graft diameters and fewer donor-site complications.

Italian research on anterior cruciate ligament: a bibliometric analysis

INTRODUCTION

This study analysed the trend of publications on anterior cruciate ligament (ACL) in Italy. It was hypothesised that publications on this topic have quickly increased in recent years due to increased knowledge of both clinical and radiological pathology.

METHODS

PubMed and Scopus were accessed on 29/11/2023. This retrieved 838 articles from PubMed and 1050 from Scopus. We analysed the top 10 authors, and journals in publication numbers, citation numbers, and citations per year. We have also looked at the top 10 institutions publishing on anterior cruciate ligament from Scopus as PubMed does not give this information in the output. Data mining was performed using the Orange software, Mac version 3.32.0 ( https://orangedatamining.com/ ) from the titles of all articles. A word cloud analysis of titles, authors, journals and universities was performed.

RESULTS

The peak of citations was in 2017 with 1529, whilst the peak of publications was in 2019 with 59 articles published. Analysing the number of publications and citations for the journal, the most impacted journal is Knee Surgery, Sports Traumatology, Arthroscopy with 5472 citations and 183 articles, followed by The American Journal of Sports Medicine, with 2722 citations and 56 articles and Arthroscopy with 1990 citations and 62 articles. Considering also international collaborations, the most cited author is Della Villa F. in 2020 with 43.67 citations per year. The Italian author with the major number of publications is Zaffagnini S. with 39 articles, whilst the author with the higher number of citations is Aglietti P. with 1612 citations.

CONCLUSIONS

ACL reconstruction has gained growing interest amongst the scientific community. Publications and citations presented a rising trend, the majority of the highly cited papers were contributed by few centres, and clinical trials were the most cited study designs. The long-term outcomes of ACL lesions have attracted interest. The authors hypothesised that shortly there will be an increase in articles analysing the results of ACL revisions, the use of lateral extra-articular tenodesis, and meniscus transplants.

LEVEL OF EVIDENCE IV

Cross-Sectional Study.

A review of Marcel Lemaire's original work on lateral extra-articular tenodesis

This classic discusses Marcel Lemaire's original publications in the context of modern surgical practice, including a description of his original lateral extra-articular tenodesis. Previously published in French, these translations shed light on his revelations regarding the anterior cruciate ligament's role in knee stability and his detailed insights into the ressaut rotatoire or the pivot shift phenomenon. We track the evolution of Lemaire's procedure since the publication of his original technique in 1967 which used a nylon cord superficial to the lateral collateral ligament followed by cast immobilisation for one month. We report his patient outcomes as he refines his methods through experiential learning. Lemaire's fundamental concepts in relation to anterior cruciate ligament deficiency remain relevant in contemporary clinical practice. Furthermore, the "modified Lemaire technique" has emerged as one of the preferred methods for lateral extra-articular tenodesis. We hope that disseminating his thoughts to a wider audience will help enlighten the ongoing debate regarding the management of rotatory instability. LEVEL OF EVIDENCE: V - Expert Opinion.

Over-the-Top Double-Bundle Revision Anterior Cruciate Ligament Reconstruction Technique With Hybrid Hamstring Tendon Autograft-Allograft and Associated Lateral Extra-articular Tenodesis

Revision anterior cruciate ligament (ACL) presents many technical challenges that are not commonly seen in primary ACL reconstruction. The purpose of this article is to describe an alternative technique consisting of over-the-top double-bundle ACL revision combined with lateral extra-articular tenodesis using hybrid hamstring tendon autograft-allograft. This technique provides a valid treatment option in ACL revision surgery.

A slight degree of osteoarthritis appears to be present after anterior cruciate ligament reconstruction compared with contralateral healthy knees at a minimum of 20 years: A systematic review of the literature

Purpose

The aim of the present systematic review was to quantitatively synthesize the best literature evidence regarding osteoarthritis developing after anterior cruciate ligament reconstruction (ACLR), including only studies with a follow-up duration of at least 20 years.

Material and Methods

A systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines on four electronic databases (PubMed, Scopus, EMBASE and Cochrane Library). The outcome measures extracted from the studies were failure rate, subsequent knee surgery on the same knee, radiographic development of osteoarthritis measured with Kellgren-Lawrence, International Knee Documentation Committee (IKDC) radiographic score and Ahlbäck classification. The health of both the ACLR knee and the contralateral knee was compared.

Results

A total of 1552 patients were included in the study, of which 1290 (83.11%) were operated on using a patellar tendon graft, 190 (12.24%) with hamstrings, 27 (1.73%) with an iliotibial band and 45 (2.89%) with patellar tendon plus a ligament augmentation device (LAD). The mean age at the time of surgery was 25.18 ± 1.91 years, and the mean follow-up time was 23.34 ± 2.56 years. Analysing IDKC Score at final follow-up, ACLR Group showed a higher degree of OA compared with contralateral healthy knee (p < 0.01), but only 33.2% (324/976) of the patients showed a moderate to severe degree (Grade C or D) of osteoarthritis, while for Kellgren-Lawrence, ACLR Group showed a higher degree of OA compared with contralateral healthy knee (p < 0.01), but only 28.9% (196/678) of the patients showed a moderate to severe degree (Grade III or IV) of osteoarthritis. In total, 1552 patients were registered, 155 reruptures (9.98%) and a total of 300 (19.3%) new surgeries, of which 228 meniscectomy (14.69%), 21 (1.35%) knee arthroplasty and 17 (1.09%) hardware removal were recorded.

Conclusions

ACL reconstruction appears to result in mild osteoarthritis in the long term in most of the patients and only less than 33.2% develop a moderate to severe degree of knee OA according to IKDC radiographic score. A slight degree of osteoarthritis appears to be present in ACLR knees compared with contralateral healthy knees.

Level of Evidence

Level IV.

The healing effect of the all inside technique is superior to the traditional technique in the reconstruction of the anterior cruciate ligament

Our main objective was to examine the curative effect of all inside technique and traditional technique in anterior cruciate ligament (ACL) reconstruction. In our retrospective study at the First People's Hospital of Jiashan County, we analyzed 88 participants with ACL injuries (50 males, 38 females, average age 27 years). They were randomly divided into two groups: traditional ACL reconstruction (42 participants) and all inside ACL reconstruction (46 participants). We measured and recorded the Visual Analog Scores (VAS), International Knee Documentation Committee (IKDC), Lysholm scores, operation time, graft diameter and length between the traditional technique group and all inside technique group. There were statistically significant differences in the Lysholm scores and IKDC scores between traditional and all inside technique groups. The all inside technique showed a higher efficacy and effective post-operative recovery with minimal pain and recurrent injuries. Our findings showed that the differences in gender, age, side of injury and operation time were not significant (p> 0.05). Follow-up was conducted at 6 months and 12 months post operations (mean, 7.5 ± 1.1 months). All inside technique minimizing tissue disruption, optimizing graft placement and facilitating early recovery have a significant impact on patient outcomes.