Soaking of autografts with vancomycin is highly effective on preventing postoperative septic arthritis in patients undergoing ACL reconstruction with hamstrings autografts.

PURPOSE: To evaluate the impact of local soaking of the autografts with vancomycin during anterior cruciate ligament (ACL) reconstruction on postoperative infection rates. METHODS: Between 2003 and 2014 (first study period), 1,242 patients underwent ACL reconstruction using autografts, without soaking them in vancomycin solution, while between 2014 and 2019 (second study period) all ACL autografts in 593 patients were soaked in a 5-mg/ml vancomycin solution, in a territory University Hospital. The same standard treatment of perioperative IV antibiotics was applied in both groups. RESULTS: Postoperative septic arthritis occurred in seven out of 1,242 patients (0.56%) during the first study period. Bone patellar tendon bone autograft was used in 311 (25%) patients, and hamstring tendon autograft was used in the rest 931 (75%) of the study population during this period. All infected cases were male and had a hamstrings graft implanted. There were no postoperative infections (0%) in 593 ACL reconstructions during the second study period. Bone patellar tendon bone autograft was used in 178 (30%) patients while hamstring tendon autograft was used in the rest 415 (70%) of the study population, during this period. Statistical analysis revealed a significantly reduced postoperative infection rate (p = 0.018) between the two reported periods, with the main impact referring to the use of hamstrings autograft (p = 0.031) for the first study period. CONCLUSIONS: Septic arthritis following ACL reconstruction can be significantly reduced (or even eliminated) by soaking ACL autografts in a 5 mg/ml vancomycin solution. Of note, this strategy seems to be more effective in the setting of hamstring tendon autograft use, since the risk of postoperative knee infection is significantly higher when this type of graft is used.

Low re-rupture rate with BPTB autograft and semitendinosus gracilis autograft with preserved insertions in ACL reconstruction surgery in sports persons.

PURPOSE: To compare the results of bone-patellar tendon-bone graft (BPTB), semitendinosus-gracilis graft with preserved insertions (STGPI) and semitendinosus-gracilis-free graft (STGF) in terms of graft failure, objective mechanical stability, functional outcome, and return to sports in elite and recreational sports persons. It was hypothesized that the STGPI graft provided superior outcome as compared to the other two grafts. METHODS: Two hundred and forty-nine elite and recreational players who underwent ACL reconstruction surgery, with BPTB graft (N = 80), STGPI graft (N = 85), and STGF graft (N = 84) with a minimum follow-up of 2 years, were assessed using clinical tests, knee arthrometer (KT 1000™), single-leg hop test, Lysholm knee score, Tegner's activity scale, and return to sports. Groups were matched in terms of age, gender, mode of injury, side involved, the level of sports, associated injuries, and mean follow-up. RESULTS: The median age of the patients was 24 years (range 16-46 years), with 227 males and 22 females, with a mean follow-up of 61.8 ± 25.9 months. At the final follow-up, the mean side-to-side difference by KT 1000™ was significantly superior in BPTB group (1.4 ± 2.1 mm) as compared to STGPI (1.9 ± 2.0 mm) and STGF group (2.5 ± 2.0 mm) (p = 0.002). The mean Lysholm knee score, Limb symmetry index (LSI) using single-leg hop test and the mean difference in pre-injury and post-surgery level of Tegner's activity scale were not significantly different. The rate of graft failure was significantly higher in STGF group (7.1%) as compared to BPTB (1.2%) and STGPI (1.2%) groups (p = 0.043). CONCLUSION: BPTB graft is a better graft in terms of mechanical stability than STGPI and STGF grafts. STGPI graft and BPTB graft are superior to STGF graft in terms of graft failure rate. However, there is no statistically significant difference amongst the three grafts in terms of return to sports and clinical tests of instability. STGPI graft is another option in the clinical setting with low graft failure rate like that of BPTB graft and with the added advantage of not having significant donor site morbidity. LEVEL OF EVIDENCE: III.

Perineural dexamethasone with subsartorial saphenous nerve blocks in ACL reconstruction.

PURPOSE: Subsartorial saphenous nerve blockade (SSNB) is an effective analgesic alternative to femoral nerve blockade after anterior cruciate ligament (ACL) reconstruction with bone-tendon-bone (BTB) autograft. It was hypothesized that dexamethasone in a SSNB will prolong analgesia, improve pain and satisfaction, and reduce postoperative opioid requirements and side effects. METHODS: One hundred ninety-five patients undergoing ACL reconstruction with BTB autograft (ages 16-65) were enrolled. Subjects received SSNB with 13 ml of 0.5 % bupivacaine (control group), 1 mg preservative-free dexamethasone +0.5 % bupivacaine (treatment group I), or 4 mg preservative-free dexamethasone +0.5 % bupivacaine (treatment group II). Subjects received identical perioperative management. On postoperative days 1 and 2, subjects reported perceived block duration, pain scores, satisfaction, opioid use, and side effects. Cox-proportional hazards modelling was used to compare block duration, adjusting for body mass index, age, sex, tourniquet time, American Society of Anesthesiologists classification, and intravenous dexamethasone dose. RESULTS: Patient-perceived block duration was significantly increased in treatment group I [hazard ratio (95 % confidence interval [CI]) 0.48 (0.31-0.75); P = 0.001] and treatment group II (hazard ratio (95 % CI): 0.52 (0.33-0.81); P = 0.004) compared to control. The block was extended from a median (95 % CI) of 33.1 (28.4-37.3) to 41.2 (32.4-50.9) and 46.5 (35.8-48.9) hours, respectively. Additionally, patients in treatment group II reported increased time that block provided pain relief, higher patient satisfaction, lower pain scores at rest, and decreased drowsiness and confusion. CONCLUSION: The addition of 1 and 4 mg of dexamethasone to the block injectate significantly increased SSNB duration by 8-13 h compared to control. LEVEL OF EVIDENCE: Therapeutic study, level 1.

[The Use of BTB Allograft in Revision Reconstruction of the Anterior Cruciate Ligament and Its Success Rate in Terms of Subjective Patient Satisfaction]. / Úspesnost kadaverózních náhrad predního zkrízeného vazu kolenního kloubu se zamerením na subjektivní spokojenost pacientu.

PURPOSE OF THE STUDY A retrospective evaluation of the success rate of revision ACL reconstruction performed using BTB allograft in terms of the life expectancy of the procedure up to and over five years from surgery. MATERIAL AND METHODS Over a ten-year period, from 2003 to 2013, we performed 47 revision ACL reconstruction surgeries. The majority of the primary ACL reconstructions using BTB autografts were not performed at our site. The group observed included 16 women (34%) and 31 men (66%). The women were aged between 25 and 48 years, the median age being 32.5, and the men were aged between 25 and 46 years with the median age of 35. We were able to make a full pre- and post-operative evaluation of 22 out of 47 patients who underwent secondary ACL reconstruction surgery using a cadaverous BTB graft. This evaluation included an objective clinical testing and a subjective evaluation of the function and stability of the knee joint using the Tegner activity score, Lysholm score, and a modified Cincinatti score. The set of 22 patients was split into two groups: up to five years from revision surgery and over five years from the procedure. RESULTS In the group of patients who were fully evaluated within five years of revision reconstruction there was an average improvement of 16.4 points on the Cincinatti score, 19.9 points on the Lysholm score, and an upward movement averaging 1.5 levels on the Tegner activity score. In the over five years from surgery category the average improvement was 15.5, 15.9, and 1.2 levels upward movement, respectively. We were unable to prove a significantly increased level of failure in BTB allografts after five and more years from revision ACL reconstruction. DISCUSSION The two strongest factors affecting the life expectancy of ACL replacements are the age of the patient and the type of the graft used, allograft or autograft. The most at risk, in terms of how long the graft will last, is the age group of 10 - 19 years old. With each ten-year increase in age the risk of rupture is reduced more-or-less by half. Patients with ACL allograft replacement show a fourfold increased risk of the graft rupturing. The younger and more active the patient requiring revision ACL reconstruction is, the greater the need for an autograft. If an allograft has been used in revision reconstruction on an athlete, a great emphasis must be placed on the necessity of delaying the return to previous sporting activities for at least nine months. CONCLUSIONS The mid-term results of revision ACL reconstruction show that, subject to reasonable levels of stress, a correctly performed procedure using cadaverous BTB grafts is a good option to restore the stability of the knee joint over a period of five years and more from surgery. An increased incidence of reruptures or greater insufficiency of the cadaverous graft were not evident in our group after five and more years. The risk of cadaverous grafts failure is just like in the autologous replacement directly linked to the return to sport interval, frequency and intensity of stress to which the graft is subjected over a long period of time. The risk of rerupture is always higher in allograft reconstructions that have already stood in need of restructuring for a longer period of time. For this reason, a delay in returning to sports activity must be emphasized. As a rule, we recommend a return to full athletic training only after nine months to a year after surgery. Key words: anterior cruciate ligament, revision ACL reconstruction, tendon graft insufficiency, BTB autograft insufficiency, BTB allograft of the ACL, cadaverous BTB graft, ACL graft rerupture.

Bone-Patellar Tendon-Bone Versus Soft-Tissue Allograft for Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: To describe the outcomes of bone-patellar tendon-bone (BPTB) and soft-tissue allografts in anterior cruciate ligament (ACL) reconstruction with respect to graft failure risk, physical examination findings, instrumented laxity, and patient-reported outcomes. METHODS: A search of the PubMed, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Complete, Cochrane Collaboration, and SPORTDiscus databases was performed. English-language studies with outcome data on primary ACL reconstruction with nonirradiated BPTB and soft-tissue allografts were identified. Outcome data included failure risk, physical examination findings, instrumented laxity measurements, and patient-reported outcome scores. RESULTS: Seventeen studies met the inclusion criteria. Of these studies, 11 reported on BPTB allografts exclusively, 5 reported on soft-tissue allografts exclusively, and 1 compared both types. The comparative study showed no difference in failure risk, Lachman grade, pivot-shift grade, instrumented laxity, or overall International Knee Documentation Committee score between the 2 allograft types. Data from all studies yielded a failure risk of 10.3% (95% confidence interval [CI], 4.5% to 18.1%) in the soft-tissue group and 15.2% (95% CI, 11.3% to 19.6%) in the BPTB group. The risk of a Lachman grade greater than 5 mm was 6.4% (95% CI, 1.7% to 13.7%) in the soft-tissue group and 8.6% (95% CI, 6.3% to 11.2%) in the BPTB group. The risk of a grade 2 or 3 pivot shift was 1.4% (95% CI, 0.3% to 3.3%) in the soft-tissue group and 4.1% (95% CI, 1.9% to 7.2%) in the BPTB group. CONCLUSIONS: One comparative study showed no difference in results after ACL reconstruction with nonirradiated BPTB and soft-tissue allografts. Inclusion of case series in the analysis showed qualitatively similar outcomes with the 2 graft types.

Patellar tendon autograft versus patellar tendon allograft in anterior cruciate ligament reconstruction: a systematic review and meta-analysis.

OBJECTIVE: This review aims to compare the clinical results of bone-patellar tendon-bone (BPTB) autograft and BPTB allograft in primary anterior cruciate ligament (ACL) reconstruction. METHODS: PubMed Medline, EMBASE, and the Cochrane Library were systematically searched for prospective or retrospective cohort studies that compared BPTB autograft with BPTB allograft in ACL reconstruction. The results of the eligible studies were independently extracted and analyzed according to the following: one-leg test, range of motion (ROM), overall International Knee Documentation Committee (IKDC), Lachman test, pivot shift test, Lysholm scores, Tegner scores, KT-1000 test, anterior knee pain, crepitus, and clinical failure. Random-effect and fixed-effect models were adopted to calculate the weight mean difference and the odds ratio for continuous and dichotomous variables with 95% confidence interval. RESULTS: Thirteen studies met the inclusion criteria, resulting in 1,046 (484 autografts and 562 allografts) patients available for the present study. A meta-analysis showed no significant differences between the two treatment groups in terms of the following: one-leg test (p = 0.21), ROM (p = 0.41), overall IKDC (p = 0.25), Lysholm scores (p = 0.25), Tegner scores (p = 0.09), KT-1000 (p = 0.69), Lachman test (p = 0.89), positive pivot shift test (p = 0.18), anterior knee pain (p = 0.93), and crepitus (p = 0.96). However, a significant difference in clinical failure (p = 0.01) in favor of autograft was observed. In the fresh-frozen subgroup, no difference in the evaluations, except for Tegner scores, were found between autograft and allograft. CONCLUSIONS: Therefore, BPTB autograft shows potential as an optimal choice for ACL reconstruction on the basis of earlier functional recovery and fewer graft failure.

Congenital absence of the anterior cruciate ligament in monozygotic twins.

Cases of congenital absence of the cruciate ligaments are seen rarely in the literature. When reported, they are almost exclusively associated with various additional lower extremity deformities. We report the cases of 15-year-old monozygotic twin brothers. Both brothers presented with right knee pain and instability and were found on magnetic resonance imaging (MRI) to have congenital absence of the right anterior cruciate ligament (ACL). Examination of full length leg radiographs and MRI of the knee showed no associated abnormalities. Twin B previously underwent partial medial meniscectomy performed by an outside orthopaedic surgeon at which time the absence of the ACL was noted but not repaired. After diagnosis at our practice, both twins underwent arthroscopically assisted ACL construction with bone-patella-bone-autograft. Following recovery from surgery, both twins returned to high level athletics. These cases are among few reports of isolated congenital absence of the ACL, and to our knowledge there are no other cases of isolated congenital absence of the ACL in monozygotic twins.

Autografts commonly used in anterior cruciate ligament reconstruction.

Anterior cruciate ligament reconstruction is among the most common orthopaedic procedures in the United States, with >200,000 performed annually. Much has been published regarding the use of autograft versus allograft. Bone-patellar tendon-bone is the most frequently used autograft, but hamstring and quadriceps tendon grafts are common alternatives. Each graft has distinct advantages and disadvantages, and selection is individualized. Fixation methods vary by graft type. Fixation resulting in a construct that is too rigid may restrict knee range of motion. Donor site morbidity must be considered, as well. Autograft harvest may result in anterior knee pain, kneeling pain, anterior knee numbness, muscle weakness, and patellar fracture. Appropriate graft selection is essential to optimize outcomes.

Open tibial inlay versus arthroscopic transtibial posterior cruciate ligament reconstructions.

PURPOSE: The optimal method of posterior cruciate ligament (PCL) reconstruction is not known. The purpose was to evaluate the biomechanical and clinical literature comparing open tibial inlay and arthroscopic transtibial PCL reconstructions and determine which method of reconstruction is superior. METHODS: A systematic review of the literature was performed on PubMed. Biomechanical and clinical studies comparing the outcomes of open tibial inlay and arthroscopic transtibial PCL reconstructions were selected and reviewed. RESULTS: Biomechanical studies evaluating posterior stability found no difference or increased stability with open inlay reconstruction. Graft degradation at the killer turn after arthroscopic transtibial reconstruction was described in some of the biomechanical studies. Biomechanical studies found no significant difference in graft forces after cyclic loading between the 2 groups. Biomechanical studies were influenced by methodologic limitations of graft fixation, power analysis, graft tensioning protocol, and magnitude of load applied for cyclic loading. Clinical studies with some methodologic limitations found no significant difference in maintaining posterior stability between the 2 reconstruction groups at short-term follow-up. CONCLUSIONS: The advantage of open inlay or arthroscopic transtibial PCL reconstruction techniques remains uncertain in the setting of conflicting biomechanical studies, with notable limitations in clinical studies. The arthroscopic tibial inlay technique may provide benefits of both open inlay and transtibial reconstruction techniques and comparable stability to the conventional PCL reconstruction methods according to several biomechanical studies. LEVEL OF EVIDENCE: Level IV, systematic review.

Anterior cruciate ligament reconstruction: a multicenter prospective cohort study evaluating 3 different grafts using same bone drilling method.

OBJECTIVE: To compare the clinical outcomes after anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone autograft (BPTBAu), BPTB allograft (BPTBAll), or hamstring (semitendinosus-gracilis) tendon autograft (HTAu), performing bone drilling with same methods in terms of transtibial drilling, orientation, positioning, and width of femoral and tibial tunnels. DESIGN: Multicenter prospective cohort study (level of evidence II). SETTING: Departments of Orthopedic Surgery of Centro Médico Teknon (Barcelona, Spain) Clínica Universitaria de Navarra (Navarra, Spain), and Clínica FREMAP (Gijón, Spain). PATIENTS: All patients with ACL tears attending 3 different institutions between January 2004 and June 2006 were approached for eligibility and those meeting inclusion criteria finally participated in this study. INTERVENTION: Each institution was assigned to perform a specific surgical technique. Patients were prospectively followed after undergoing ACL reconstruction with BPTBAu, BPTBAll, or HTAu, with a minimum follow-up of 24 months. MAIN OUTCOME MEASURES: Included knee laxity and International Knee Documentation Committee (IKDC) score. Knee laxity was assessed with the KT-1000 arthrometer (evaluated with neutral and external rotation positions) and both Lachman and pivot shift tests. Additional outcomes included main symptoms (anterior knee pain, swelling, crepitation, and instability), disturbance in knee sensation, visual analogue scale (VAS) for satisfaction with surgery, range of motion (ROM), and isokinetic knee strength. RESULTS: There were no significant differences among the 3 groups for any of the clinical outcomes, except for a slightly greater KT-1000-measured knee laxity in external rotation in the BPTBAu compared with the other groups. All patients demonstrated grade A or B of the IKDC. The mean VAS for satisfaction with surgery in all patients was 8.5. CONCLUSIONS: The selection of the surgical technique for ACL reconstruction may be based on the surgeon's preferences.

Anterior cruciate ligament graft placement recommendations and bone-patellar tendon-bone graft indications to restore knee stability.

The anterior cruciate ligament (ACL) resists the combined abnormal motions of anterior tibial translation and internal tibial rotation that occur in the pivot-shift phenomenon. The placement of a single ACL graft high and proximal at the femoral attachment and posterior at the tibial attachment results in a vertical graft orientation. This graft position has a limited ability to provide rotational stability. A more oblique ACL graft orientation in the sagittal and coronal planes achieved from a central anatomic femoral and tibial location provides an orientation that is better in resisting the pivot-shift phenomenon. Tibial and femoral tunnels are drilled independently; transtibial drilling of the femoral tunnel is not recommended. The meticulous surgical technique for ACL reconstruction includes identifying the appropriate landmarks to achieve correct graft placement. There are insufficient experimental and clinical data to recommend the more complex double-bundle ACL graft technique over a central anatomic single graft in terms of restoring knee rotational stability. Allografts are used only in select knees for which autograft tissue is not available. The postoperative rehabilitation program takes into account the condition of the menisci and articular cartilage and associated reconstructive procedures.

Technical aspects of anterior cruciate ligament reconstruction for the general orthopaedic surgeon.

Anterior cruciate ligament reconstruction is the sixth most common procedure performed by orthopaedic surgeons. The goals of the procedure are to restore knee stability and patient function. These goals are dependent on proper graft positioning and incorporation. Anterior cruciate ligament reconstruction involves a technically complicated series of steps, all of which affect graft healing and clinical outcome. A wide variety of graft choices and surgical techniques are currently available for use. It is important for orthopaedic surgeons performing anterior cruciate ligament reconstructions to be aware of the indications for graft selection, techniques for correct graft placement, and the biologic implications related to these factors.

Special considerations for ACL graft selection in the young, active military patient.

Anterior cruciate ligament (ACL) injury is an extremely common injury in the young, physically demanding active duty military population. The diagnosis of an ACL injury in active duty military personnel often requires special consideration in terms of return to function, reliability, and performance of the knee-often in life-threatening situations when one has to rely on a stable knee for survival. This article outlines the considerations of ACL surgical treatment in the active duty military population, with an emphasis on the young, physically competitive athlete to optimize outcomes. Numerous treatment options and controversies regarding ACL surgery will be reviewed to provide a framework for which to perform a reliable and effective ACL surgery in active duty military personnel.

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

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

The transtibial versus the anteromedial portal technique in the arthroscopic bone-patellar tendon-bone anterior cruciate ligament reconstruction.

The transtibial (TT) drilling of the femoral tunnel in the bone-patellar tendon-bone (BPTB) anterior cruciate ligament (ACL) reconstruction was found to place the tunnel non-anatomically. The use of the anteromedial portal (AMP) for the femoral drilling would provide the surgeon with more freedom to anatomically place the tunnel in the real femoral ACL footprint. The purpose of this study was to compare the clinical outcomes of BPTB ACL reconstruction using the AMP or the TT technique for the femoral tunnel drilling. A Medline search was not able to identify any study directly comparing the clinical outcomes of the AMP and the TT techniques. The literature search identified experimental and quasi-experimental studies published from 1966 to March 2009 where at least one group underwent arthroscopic autologous BPTB ACL reconstructions using either the AMP or the TT technique for the femoral tunnel drilling. Overall IKDC, Lysholm score, activity level, range of motion, single-leg hoop test, Lachman test, Pivot shift sign test, KT-1000 arthrometer measurements, and radiographic assessments were indirectly compared between the two groups (AMP versus TT). Twenty-one studies, involving a total of 859 patients (257 in the AMP and 602 in the TT group), were included in this analysis. The AMP group demonstrated significantly earlier return to run and significantly greater range of motion, Lachman test values, and KT-1000 arthrometer measurements in the 1-2-year follow-up, although no differences were found for both the 3-5 and the 6-10-year follow-ups for any of these parameters. In contrast, the TT group demonstrated significantly higher activity level for the 3-5 and 6-10-year follow-up. The use of the AMP elicited greater knee stability and range of motion values, and earlier return to run compared to the TT technique. These results may indicate a potential benefit of the AMP over the TT technique. However, as the benefits of the AMP were not obtained in the mid and long-term follow-ups, overall there is no definitive evidence at this point to conclude that one technique is superior to the other. Randomized controlled trials directly comparing the use of both techniques with long-term follow-ups will help clarify which one, if any, provides best clinical outcomes.

Patellar Bone-Tendon-Bone Autografts versus Quadriceps Tendon Allograft with Synthetic Augmentation in a Canine Model.

Patellar bone-tendon-bone (pBTB) autografts are often considered the "gold standard" for complete anterior cruciate ligament (ACL) reconstruction and are also associated with significant complications and early-onset knee osteoarthritis (OA). A novel quadriceps tendon allograft with synthetic augmentation, or "internal brace" (QTIB), has been reported to have potential advantages for ACL reconstruction based on animal model data. In this preclinical canine comparison study, we hypothesized that QTIB allograft compared with pBTB autograft would provide superior durability for knee stability, function, and prevention of OA. Under approval from our Institutional Animal Care and Use Committee, adult purpose-bred research hounds (n = 10) underwent arthroscopic complete transection of the ACL followed by either an arthroscopic-assisted all-inside ACL reconstruction using the QTIB allograft (n = 5) or pBTB autograft (n = 5). Contralateral knees were used as nonoperated controls (n = 10). Radiographic and arthroscopic assessments were performed at 2 and 6 months, respectively, after surgery. Anterior drawer, internal rotation, lameness, kinetics, pain, effusion, and comfortable range of knee motion were measured at 2, 3, and 6 months. Biomechanical and histologic assessments were performed at 6 months. All reconstructed knees were stable and had intact ACL grafts 6 months after surgery. At 6 months, QTIB reconstructed knees had significantly less lameness, lower pain, less effusion, and increased range of motion when compared with BTB knees (p < 0.05). BTB knees had significantly higher radiographic OA scores than QTIB knees at 6 months (p < 0.05). Superior outcomes associated with QTIB allograft may be due to the lack of donor site morbidity, the use of a robust tendon graft, and/or protection of the graft from the synthetic augmentation. Robust tendon grafts combined with a synthetic internal brace and platelet-rich plasma (PRP) may allow for more rapid and robust tendon-bone healing and graft "ligamentization," which protects the graft from early failure and rapid OA development that can plague commonly-used allografts.

Passive anterior tibia translation in anterior cruciate ligament-injured, anterior cruciate ligament-reconstructed and healthy knees: a systematic review.

Anterior tibia translation (ATT) is mainly prevented by the anterior cruciate ligament. Passive ATT tests are commonly used to diagnose an anterior cruciate ligament (ACL) injury, to select patients for an ACL reconstruction (ACLR), and as an outcome measure after an ACLR. The aim of this review was to present an overview of possible factors determining ATT. A second purpose was to give a summary of the ATT measured in the literature in healthy, ACL-injured and ACLR knees and a comparison between those groups. A literature search was conducted with PubMed. Inclusion criteria were full-text primary studies published in English between January 2006 and October 2016. Studies included reported ATT in explicit data in healthy as well as ACL-injured or ACLR knees or in ACL-injured as well as ACLR knees. Sixty-one articles met inclusion criteria. Two articles measured the ATT in healthy as well as ACL-injured knees, 51 in ACL-injured as well as in ACLR knees, three in ACLR as well as in healthy knees and three in healthy, ACL-injured and ACLR knees. A difference in ATT is found between healthy, contralateral, ACLR and ACL-injured knees and between chronic and acute ACL injury. Graft choices and intra-articular injuries are factors which could affect the ATT. The mean ATT was lowest to highest in ACLR knees using a bone-patella tendon-bone autograft, ACLR knees using a hamstring autograft, contralateral healthy knees, healthy knees, ACLR knees with an allograft and ACL-injured knees. Factors which could affect the ATT are graft choice, ACL injury or reconstruction, intra-articular injuries and whether an ACL injury is chronic or acute. Comparison of ATT between studies should be taken with caution as a high number of different measurement methods are used. To be able to compare studies, more consistency in measuring devices used should be introduced to measuring ATT. The clinical relevance is that an autograft ACLR might give better results than an allograft ACLR as knee laxity is greater when using an allograft tendon. LEVEL OF EVIDENCE: III.

Does the type of graft affect the outcome of revision anterior cruciate ligament reconstruction? a meta-analysis of 32 studies.

AIMS: Our aim was to perform a meta-analysis of the outcomes of revision anterior cruciate ligament (ACL) reconstruction, comparing the use of different types of graft. MATERIALS AND METHODS: A search was performed of Medline and Pubmed using the terms "Anterior Cruciate Ligament" and "ACL" combined with "revision", "re-operation" and "failure". Only studies that reported the outcome at a minimum follow-up of two years were included. Two authors reviewed the papers, and outcomes were subdivided into autograft and allograft. Autograft was subdivided into hamstring (HS) and bone-patellar tendon-bone (BPTB). Subjective and objective outcome measures were analysed and odds ratios with confidence intervals were calculated. RESULTS: A total of 32 studies met the inclusion criteria. Five studies used HS autografts, eight reported using BPTB autografts, two used quadriceps tendon autografts and eight used various types. Seven studies reported using allografts, while the two remaining used both BPTB autografts and allografts. Overall, 1192 patients with a mean age of 28.7 years (22.5 to 39) and a mean follow-up of 5.4 years (2.0 to 9.6) were treated with autografts, while 269 patients with a mean age of 28.4 years (25 to 34.6) and a mean follow-up of 4.0 years (2.3 to 6.0) were treated with allografts. Regarding allografts, irradiation with 2.5 mrad was used in two studies while the graft was not irradiated in the seven remaining studies. Reconstructions following the use of autografts had better outcomes than those using allograft with respect to laxity, measured by KT-1000/2000 (MEDmetric Corporation) and the rates of complications and re-operations. Those following the use of allografts had better mean Lysholm and Tegner activity scores compared with autografts. If irradiated allografts were excluded from the analysis, outcomes no longer differed between the use of autografts and allografts. Comparing the types of autograft, all outcomes were similar except for HS grafts which had better International Knee Documentation Committee scores compared with BPTB grafts. CONCLUSION: Autografts had better outcomes than allografts in revision ACL reconstruction, with lower post-operative laxity and rates of complications and re-operations. However, after excluding irradiated allografts, outcomes were similar between autografts and allografts. Overall, the choice of graft at revision ACL reconstruction should be on an individual basis considering, for instance, the preferred technique of the surgeon, whether a combined reconstruction is required, the type of graft that was previously used, whether the tunnels are enlarged and the availability of allograft. Cite this article: Bone Joint J 2017;99-B:714-23.

Efficacy of Two Techniques in Anterior Cruciate Ligament Reconstruction.

The purpose of this study is to compare failure rate and functional outcome in young, active patients (< 25 years) with two-incision (rear-entry) versus transtibial (all-endoscopic) anterior cruciate ligament (ACL) reconstructions.Utilizing a computerized relational database (Access 2007, Microsoft Inc., Redmond, WA), 480 patients were identified that underwent ACL reconstruction, using a bone-patellar-tendon-bone autograft, by a single surgeon between January 2000 and December 2010 via a transtibial or two-incision technique. Totally, 377 (78.6%) of these patients were less than 25 years of age. Data for each patient were collected at their initial clinic visit, at the time of surgery, and at each follow-up clinic visit and entered into the computerized relational database. Overall, 274 patients (72.7%) underwent ACL reconstruction with a transtibial technique, and 103 patients (27.3%) underwent reconstruction with a two-incision technique. Failures were identified as a 2+ Lachman, 1+ or greater pivot shift, or a KT-1000 arthrometer difference of five or more.In patients < 25 years of age, there were 10 failures (9.7%) out of 103 patients undergoing a two-incision reconstruction and 28 failures (10.2%) out of 274 patients undergoing a transtibial reconstruction (p = 1.000). There was no statistical significance between the failure rate in the two different groups in regards to gender, meniscal tear, activity level, or any other factor that was analyzed.Our study showed no statistical difference between the two-incision technique and the transtibial technique for ACL reconstruction using bone-patellar-tendon-bone autograft with an overall 10.1% failure rate in young, active patients (< 25 years of age). The level of evidence is level IV.