Editorial Commentary: Quadriceps Tendon Anterior Cruciate Ligament Graft Shows Advantages and Disadvantages.

A quadriceps tendon autograft is becoming an increasingly popular graft option for both primary and revision ACL reconstruction. The biomechanical properties of a QT autograft are favorable compared to a bone-patellar tendon-bone (BPTB) or a doubled hamstring (HS) autograft. A QT autograft is associated with less donor site morbidity, such as anterior knee pain and difficulty with kneeling, than a BPTB autograft, and short-term studies have shown comparable clinical results when compared to a BPTB or a HS autograft. However, if harvested with a bone block, a QT autograft carries a higher risk of patellar fracture than a BPTB autograft. Other potential disadvantages include persistent quadriceps weakness, and registry data have shown a higher revision rate compared to a BPTB or HS ACL reconstruction, which is thought to be due to a high learning curve, leading to higher revision rates in low volume centers. Finally, a graft-fixation construct with good time 0 biomechanical characteristics may only be successful in the long term if the graft heals effectively. Time will tell.

The impact of bone graft type used to fill bone defects in patients undergoing ACL reconstruction with bone-patellar tendon-bone (BPTB) autograft on kneeling, anterior knee pain and knee functional outcomes.

PURPOSE: Multiple different materials are used for filling bone defects following bone-patellar tendon-bone (BPTB) graft ACL reconstruction surgery. The theoretical objective being to minimize kneeling pain, improve clinical outcomes and reduce anterior knee pain following surgery. The impact of these materials is assessed in this study. METHODS: A prospective monocentric cohort study was conducted from January 2018 to March 2020. There were 128 skeletally mature athletic patients who underwent ACL reconstruction using the same arthroscopic-assisted BPTB technique, with a minimum follow-up of two years identified in our database. After obtaining approval from the local ethics committee, 102 patients were included in the study. Patients were divided into three groups based on type of bone substitute. The Bioactive glass 45S5 ceramic Glassbone™ (GB), collagen and hydroxyapatite bone void filler in sponge form Collapat® II (CP), and treated human bone graft Osteopure®(OP) bone substitutes were used according to availability. Clinical evaluation of patients at follow-up was performed using the WebSurvey software. A questionnaire completed in the 2nd post-operative year included three items: The ability to kneel, the presence of donor site pain, and the palpation of a defect. Another assessment tool included the IKDC subjective score and Lysholm score. These two tools were completed by patients preoperatively, and postoperatively on three occasions (6 months, 1 year, and 2 years). RESULTS: A total of 102 patients were included in this study. In terms of Kneeling pain, the percentage of GB and CP patients' who kneel with ease were much higher than that of OP patients (77.78%, 76.5% vs 65.6%, respectively). All three groups experienced an important increase in IKDC and Lysholm scores. There was no difference in anterior knee pain between the groups. CONCLUSION: The use of Glassbone® and Collapat II® bone substitutes reduced the incidence of kneeling pain compared to Osteopure®. There was no influence of the bone substitute type on the functional outcome of the knee or on the anterior knee pain at two years of follow.

Consistent Indications and Good Outcomes Despite High Variability in Techniques for Two-Stage Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: To systematically review the current literature regarding the indications, techniques, and outcomes after 2-stage revision anterior cruciate ligament reconstruction (ACLR). METHODS: A literature search was performed using SCOPUS, PubMed, Medline, and the Cochrane Central Register for Controlled Trials according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta Analyses statement. Inclusion criteria was limited to Level I-IV human studies reporting on indications, surgical techniques, imaging, and/or clinical outcomes of 2-stage revision ACLR. RESULTS: Thirteen studies with 355 patients treated with 2-stage revision ACLR were identified. The most commonly reported indications were tunnel malposition and tunnel widening, with knee instability being the most common symptomatic indication. Tunnel diameter threshold for 2-stage reconstruction ranged from 10 to 14 mm. The most common grafts used for primary ACLR were bone-patellar tendon-bone (BPTB) autograft, hamstring graft, and LARS (polyethylene terephthalate) synthetic graft. The time elapsed from primary ACLR to the first stage surgery ranged from 1.7 years to 9.7 years, whereas the time elapsed between the first and second stage ranged from 21 weeks to 13.6 months. Six different bone grafting options were reported, with the most common being iliac crest autograft, allograft bone dowels, and allograft bone chips. During definitive reconstruction, hamstring autograft and BPTB autograft were the most commonly used grafts. Studies reporting patient-reported outcome measures showed improvement from preoperative to postoperative levels in Lysholm, Tegner, and objective International Knee and Documentation Committee scores. CONCLUSIONS: Tunnel malpositioning and widening remain the most common indications for 2-stage revision ACLR. Bone grafting is commonly reported using iliac crest autograft and allograft bone chips and dowels, whereas hamstring autograft and BPTB autograft were the most used grafts during the second-stage definitive reconstruction. Studies showed improvements from preoperative to postoperative levels in commonly used patient reported outcomes measures. LEVEL OF EVIDENCE: Level IV, systematic review of Level I, III, and IV studies.

The reverse fragility index: RCTs reporting non-significant differences in failure rates between hamstring and bone-patellar tendon-bone autografts have fragile results.

PURPOSE: The reverse fragility index (RFI) is a novel metric to appraise the results of studies reporting statistically non-significant results. The purpose of this study was to determine the statistical robustness of randomized controlled trials (RCTs) reporting non-significant differences in anterior cruciate ligament reconstruction (ACLR) graft failure rates, defined as re-rupture/revision ACLR rate, between hamstring tendon (HT) and bone-patellar tendon-bone (BTB) autografts by calculating RFIs. METHODS: A systematic review was performed to identify RCTs that compared HT to BTB grafts for ACLR through January 2022. Studies reporting non-significant differences in graft re-rupture and revision ACLR rate (n.s.) were included. The RFI, defined as the fewest number of event reversals needed to change the non-significant graft re-rupture/revision outcome to statistically significant (P < 0.05), was recorded for each study. In addition, the number of studies in which the loss to follow-up exceeded the RFI was recorded. RESULTS: Among the 16 included RCTs, the median (interquartile range [IQR]) sample size was 71 (64-114), and the median (IQR) total number of graft re-rupture/revision ACLR events was 4 (4-6). The median (IQR) graft re-rupture/revision ACLR rate was 4.3% (3.0-6.4) overall, 4.1% (2.6-6.7) in the BTB group, and 5.4% (3.0-6.3) in the HT group. The median (IQR) RFI was 3 (3-4), signifying that a reversal of the outcome in 3 patients in one arm was needed to flip the studies' result from non-significant to statistically significant (P < 0.05). The median (IQR) number of participants lost to follow-up was 11 (3-13), and 13 (81.3%) of the included studies had a loss to follow-up greater than the studies' RFI. CONCLUSION: The results of RCTs reporting statistically non-significant re-rupture/revision ACLR rates between HT and BTB autografts would become significant if the outcome were reversed in a small number of patients-a number that was less than the loss to follow-up in the majority of studies. Thus, the neutrality of these studies is fragile, and a true statistically significant difference in re-rupture/revision rates may have been undetected. LEVEL OF EVIDENCE: Level I.

Revision ACL reconstruction using quadriceps, hamstring and patellar tendon autografts leads to similar functional outcomes but hamstring graft has a higher tendency of graft failure.

PURPOSE: The purpose of this study was to evaluate the differences in the patient-reported functional outcomes, and graft failure in revision ACL reconstruction using quadriceps tendon (QT), Hamstring tendon (HT) and bone-patellar tendon-bone (BPTB) autografts. METHODS: Between 2010 and 2020, 97 patients who underwent revision ACL reconstruction (40 patients received a QT, 26 an HT and 31 a BPTB graft) met the inclusion criteria. Pre-injury and at 2-year postoperatively patients were evaluated for patient-reported functional outcomes; Lysholm knee score, Tegner activity level and VAS (visual analogue scale) for pain; and graft failure. Patient-reported outcomes and graft failure were compared between the QT, HT and BPTB groups. The patients with graft failure were not included for outcome analysis at 2-years of follow-up. RESULTS: All three revision groups with QT, HT and BPTB autograft did not differ significantly in terms of age, sex, time from injury to surgery, concomitant injuries and single-stage or double-stage procedures (n.s.). No significant difference was found in the pre-injury patient-reported outcome; Lysholm knee score, Tegner activity and VAS for pain (n.s.) between the three groups. At the 2-year follow-up functional outcomes improved in all three groups and all the patients returned to pre-injury activity level; however, no significant difference was found in functional outcomes at the 2-year follow-up between the three groups (n.s.). Graft failure occurred in 4 (10%), 5 (19%) and 3 (10%) patients of QT, HT and BPTB groups, respectively. However, the rate of failure did not differ significantly between groups. CONCLUSION: All three autografts (QT, HT and BPTB) demonstrated satisfactory patient-reported outcomes in revision ACL reconstruction. Compared with QT and BPTB grafts, HT graft showed a higher tendency for failure rates. With the increasing incidence of revision ACL reconstruction, surgeons should be aware of all the available graft options. The findings of this study will assist the surgeons in the graft selection for revision ACL reconstruction. LEVEL OF EVIDENCE: Level III.

Lower donor site morbidity with hamstring and quadriceps tendon autograft compared with bone-patellar tendon-bone autograft after anterior cruciate ligament reconstruction: a systematic review and network meta-analysis of randomized controlled trials.

PURPOSE: To perform a meta-analysis of RCTs evaluating donor site morbidity after bone-patellar tendon-bone (BTB), hamstring tendon (HT) and quadriceps tendon (QT) autograft harvest for anterior cruciate ligament reconstruction (ACLR). METHODS: PubMed, OVID/Medline and Cochrane databases were queried in July 2022. All level one articles reporting the frequency of specific donor-site morbidity were included. Frequentist model network meta-analyses with P-scores were conducted to compare the prevalence of donor-site morbidity, complications, all-cause reoperations and revision ACLR among the three treatment groups. RESULTS: Twenty-one RCTs comprising the outcomes of 1726 patients were included. The overall pooled rate of donor-site morbidity (defined as anterior knee pain, difficulty/impossibility kneeling, or combination) was 47.3% (range, 3.8-86.7%). A 69% (95% confidence interval [95% CI]: 0.18-0.56) and 88% (95% CI: 0.04-0.33) lower odds of incurring donor-site morbidity was observed with HT and QT autografts, respectively (p < 0.0001, both), when compared to BTB autograft. QT autograft was associated with a non-statistically significant reduction in donor-site morbidity compared with HT autograft (OR: 0.37, 95% CI: 0.14-1.03, n.s.). Treatment rankings (ordered from best-to-worst autograft choice with respect to donor-site morbidity) were as follows: (1) QT (P-score = 0.99), (2) HT (P-score = 0.51) and (3) BTB (P-score = 0.00). No statistically significant associations were observed between autograft and complications (n.s.), reoperations (n.s.) or revision ACLR (n.s.). CONCLUSION: ACLR using HT and QT autograft tissue was associated with a significant reduction in donor-site morbidity compared to BTB autograft. Autograft selection was not associated with complications, all-cause reoperations, or revision ACLR. Based on the current data, there is sufficient evidence to recommend that autograft selection should be personalized through considering differential rates of donor-site morbidity in the context of patient expectations and activity level without concern for a clinically important change in the rate of adverse events. LEVEL OF EVIDENCE: Level I.

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.

Changes in patellar height after anatomical ACL reconstruction with BTB autograft with a focus on patellar tendon removal volume.

BACKGROUND: Although anatomical anterior cruciate ligament reconstruction (ACLR) can provide satisfactory outcomes, little is known about how this procedure impacts patellar height. Since harvesting bone-patellar tendon-bone (BTB) autografts is a potential risk factor for decreased patellar height, we examined changes in patellar height after anatomical ACLR with BTB autograft with a focus on the size of the harvested graft. METHODS: Subjects were 84 patients (49 males, 35 females; mean age, 23 years) who underwent primary anatomical ACLR with central third BTB autograft. Preoperative to postoperative Caton-Deschamps index (CDI) ratio was calculated using lateral knee radiographs before and 6 months after surgery. The length and cross-sectional area (CSA) of the graft were measured intraoperatively, and the CSA of the contralateral patellar tendon was measured by ultrasound 6 months postoperatively. The difference in graft CSA relative to the contralateral tendon CSA, expressed as a percentage (gCSA:ctCSA percentage), was also calculated. RESULTS: Patellar height decreased slightly after surgery (preoperative CDI: 0.856 ± 0.113; postoperative CDI: 0.841 ± 0.113), with a mean difference between preoperative and postoperative CDIs of -0.015 (range: -0.293 to 0.101). Although the CDI of male subjects significantly decreased after surgery (preoperative: 0.852 ± 0.117; postoperative: 0.827 ± 0.115), no significant changes were noted in female subjects (preoperative: 0.862 ± 0.108; postoperative: 0.861 ± 0.108). Graft length and CSA did not significantly impact the CDI ratio (r = -0.138 and r = -0.038, respectively). Moreover, no significant relationship was observed between the gCSA:ctCSA percentage and CDI ratio (r = 0.118). CONCLUSIONS: Although patellar height slightly, but significantly, decreased at 6 months after anatomical ACLR with BTB autograft, it was not affected by the length and CSA of harvested grafts. The decrease in postoperative patellar height was observed only in male subjects, suggesting the potential importance of sex differences in soft tissue healing during the postoperative period.

Evaluation of Serum Albumin-Coated Bone Allograft for Bone Regeneration: A Seven-Year Follow-Up Study of 26 Cases.

We have previously reported that serum albumin-coated bone allograft (BoneAlbumin, BA) is an effective bone substitute. It improves bone regeneration at the patellar and tibial donor sites six months after harvesting bone-patellar tendon-bone (BPTB) autografts for primary anterior cruciate ligament reconstruction (ACLR). In the present study, we examined these donor sites seven years after implantation. The study group (N = 10) received BA-enhanced autologous cancellous bone at the tibial and BA alone at the patellar site. The control group (N = 16) received autologous cancellous bone at the tibial and blood clot at the patellar site. We evaluated subcortical density, cortical thickness, and bone defect volume via CT scans. At the patellar site, subcortical density was significantly higher in the BA group at both time points. There was no significant difference in cortical thickness between the two groups at either donor site. The control group's bone defect significantly improved and reached the BA group's values at both sites by year seven. Meanwhile, the bone defects in the BA group did not change significantly and were comparable to the six-month measurements. No complications were observed. There are two limitations in this study: The number of patients recruited is small, and the randomization of the patients could have improved the quality of the study as the control group patients were older compared to the study group patients. Our 7-year results seem to demonstrate that BA is a safe and effective bone substitute that supports faster regeneration of donor sites and results in good-quality bone tissue at the time of ACLR with BPTB autografts. However, studies with a larger number of patients are required to definitively confirm the preliminary results of our study.

Long-term results after anterior cruciate ligament reconstruction using patellar tendon versus hamstring tendon autograft with a minimum follow-up of 10 years-a systematic review.

INTRODUCTION: A lot of research addresses superiority of the two commonly used autografts bone-patellar tendon-bone (BPTB) and hamstring tendon for anterior cruciate ligament (ACL) reconstruction, without getting to consensus. While there are numerous studies and reviews on short- to mid-term follow-up, not much literature is available on long-term follow-up. As patients suffering ACL injuries are often of young age and high athletic activity, it is crucial to have the best evidence possible for graft choice to minimize consequences, like osteoarthritis later on. MATERIALS AND METHODS: A search of the online databases, PubMed and Embase, was carried out last on 31st March 2022 for studies comparing BPTB and hamstring tendon (HT) autografts for ACL reconstruction in human patients with a minimum follow-up of 10 years. The methodological quality of each study has been evaluated using the modified Coleman Methodology Score. Results on the three variables patient-oriented outcomes, clinical testing and measurements and radiographic outcomes were gathered and are presented in this review. RESULTS: Of 1299 records found, nine studies with a total of 1833 patients were identified and included in this systematic review. The methodological quality of the studies ranged from a Coleman Score of 63-88. Many studies reported no or only few statistically significant differences. Significant results in favour of BPTB were found for activity levels and for instrumented laxity testing with the KT-1000 arthrometer. Better outcomes for HT were found in IKDC-SKF, the KOOS, donor site morbidity, pivot shift test, radiographic osteoarthritis (IKDC C or D) and contralateral ACL rupture. No studies presented significant differences in terms of Lysholm Score or Tegner Activity Score, Lachman test, single-legged hop test, deficits in range of motion, osteoarthritis using the Kellgren and Lawrence classification or graft rupture. CONCLUSION: We cannot recommend one graft to be superior, since both grafts show disadvantages in the long-term follow-up. Considering the limitation of our systematic review of no quantitative analysis, we cannot draw further conclusions from the many insignificant results presented by individual studies. LEVEL OF EVIDENCE: IV.

[Efficacy comparison between a new generation of artificial ligaments and bone-patellar tendon-bone autograft for anterior cruciate ligament revision].

Objective: To compare the clinical efficacy of a new generation of ligaments (LARS artificial ligament) and bone-patellar tendon-bone (BPTB) autograft as grafts in anterior cruciate ligament (ACL) revision. Methods: A retrospective cohort study. The clinical data of 54 patients who underwent ACL revision from January 2018 to June 2020 in the First Hospital Affiliated to Army Medical University were retrospectively analyzed. There were 44 males and 10 females with a mean age of (28.5±7.7) years (15-45 years). Among them, 24 cases underwent ACL revision with LARS artificial ligament (LARS group), the other 30 cases underwent ACL revision with BPTB (BPTB group). The subjective and objective knee joint evaluation indexes were compared between the two groups to evaluate the clinical efficacy. The subjective evaluation indexes included Tegner score, Lysholm score and the International Knee Documentation Committee (IKDC) score. The objective evaluation indexes included the Lachman test, pivot-shift test, the anterior tibial translation (ATT) measurement at the weight-bearing position and the rate of patients returned to pre-injury sports. Results: The follow-up period was (32.8±5.3) months (24-42 months). At the last follow-up, the IKDC score, Tegner score and Lysholm score in the two groups significantly increased when compared with those before surgery (all P<0.05), and there was no significant difference in those indexes between the two groups (all P>0.05). The ATT measurement in the weight-bearing position was (3.1±0.7) mm in the LARS group and it was (4.1±0.9) mm in the BPTB group, which were significantly improved when compared with those before surgery (both P<0.05), and it was better in the LARS group than in the BPTB group (P<0.05). Postoperative Lachman test and pivot-shift test results in the LARS group were better than those in the BPTB group with statistically significant difference (both P<0.05). The rate of patients returned to pre-injury sports one year after surgery was 79.2%(19/24) in the LARS group and it was 50.0%(15/30) in the BPTB group, and the difference was statistically significant (P=0.029). Conclusions: Both LARS artificial ligament and BPTB autograft can achieve good short-term clinical efficacy in ACL revision, but LARS artificial ligament group has more advantages than BPTB autograft group in knee stability and early return to sports.

Clinical outcomes and complications after anterior cruciate ligament reconstruction with bone-patellar tendon-bone in patient Tanner 3 and 4: a systematic review.

BACKGROUND: Clinical outcomes and potential complications associated with Bone-Patellar Tendon-Bone (BPTB) graft in skeletally immature ACL reconstruction (ACLR) are poorly defined. Considering that in Tanner 1-2 patients this kind of graft is not recommended, we focused our systematic review on the evaluation of all the studies in the literature that reported clinical outcomes and rate of complications of the ACLR using BPTB graft in Tanner 3-4 patients. METHODS: This review was conducted in accordance with the PRISMA statement. PubMed, Cochrane Library, EMBASE and Scopus were examined from 1965 to 2020 using different combinations of the following keywords: "ACL reconstruction", "skeletally immature", "young", "patellar tendon" and "BPTB". The database search yielded 742 studies, on which we performed a primary evaluation. After carrying out a full-text evaluation for the inclusion criteria, 4 studies were included in the final review and assessed using the Newcastle-Ottawa scale. Ninety-six cases with mean age of 14.2 years were reported. RESULTS: Good stability and functional outcomes were reported with a mean follow-up of 49.5 months. Return to sport rate ranged from 91.7% to 100%. A KT-1000 side-to-side difference higher than 5 mm was observed in five patients (5.2%). No lower limb length discrepancy and angulation were reported. Graft rupture rate was 5.2%. CONCLUSION: According to these results, BTPB graft could be a good choice in Tanner 3-4 patients who want to achieve their preinjury sport level with a low risk of growth disturbances and graft failure. Further investigations in a wider population are needed.

Editorial Commentary: Bone Marrow Aspirate Concentrate May Accelerate Anterior Cruciate Ligament Allograft Using Bone Patellar Tendon Bone Maturation on Magnetic Resonance Imaging, but Clinical Differences Have Not Been Demonstrated.

Accelerating graft healing in anterior cruciate ligament reconstruction (ACLR) continues to be an elusive proposition. In vivo assessments of graft histology are challenging to perform, especially in human subjects. Multiple authors have reported on the utility of magnetic resonance imaging as a noninvasive modality in characterizing postoperative changes, suggestive of graft maturation. However, previous literature, by and large, has been limited by heterogenous scanning protocols and underpowered comparisons of dissimilar treatment techniques, and these issues complicate efforts to assess the benefits (if any) of adjuncts focused on improving graft healing after ACLR. Particularly in cases of allograft ACLR, where concerns persist regarding the pace and quality of tissue healing and graft integration, the use of orthobiologic adjuncts represents a promising area for ongoing investigation. Although there has been great enthusiasm for the use of bone marrow aspirate concentrate as an adjunct in a variety of applications, high level evidence substantiating its use in ACLR is lacking. Even when significant differences between groups treated with and without such adjuncts may be apparent radiographically, demonstrating a concrete, clinical benefit will continue to be a difficult proposition.

Failure rates of common grafts used in ACL reconstructions: a systematic review of studies published in the last decade.

INTRODUCTION: In this review paper, graft failure rates of different graft types (hamstring tendon autografts, bone-patellar tendon-bone autografts, quadriceps tendon autografts and diverse allografts) that are used for surgical reconstruction of the anterior cruciate ligament are compared and statistically analysed. METHODS: Literature search was conducted in PubMed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) criteria. A total of 194 studies, which reported graft failure rates of at least one of the anterior cruciate ligament reconstruction methods mentioned above, were included in this systematic review. To be able to compare studies with different follow-up periods, a yearly graft failure rate for each reconstruction group was calculated and then investigated for significant differences by using the Kruskal-Wallis test. RESULTS: Overall, a total of 152,548 patients treated with an anterior cruciate ligament reconstruction were included in the calculations. Comparison of graft types showed that hamstring tendon autografts had a yearly graft failure rate of 1.70%, whereas the bone-patellar tendon-bone autograft group had 1.16%, the quadriceps tendon autograft group 0.72%, and the allografts 1.76%. CONCLUSION: The findings of this meta-data study indicate that reconstructing the anterior cruciate ligament using quadriceps tendon autografts, hamstring tendon autografts, patellar tendon autografts or allografts does not show significant differences in terms of graft failure rates.

Effectiveness of thicker hamstring or patella tendon grafts to reduce graft failure rate in anterior cruciate ligament reconstruction in young patients.

PURPOSE: The purpose of this study was to determine the anterior cruciate ligament reconstruction (ACLR) failure rate in young patients utilizing the New Zealand (NZ) anterior cruciate ligament (ACL) Registry. The hypothesis was that the ACLR rupture rate would be lower for thicker hamstring graft and bone patellar tendon bone (BPB) grafts in comparison to the classic hamstring technique. The ACLR failure rate was assessed according to graft type and patients' sex. METHODS: The NZ ACL registry was utilized to identify all patients aged 20 years or younger at the time of surgery who were skeletally mature and had a minimum 2-year follow-up. Graft ruptures, defined as an ACL revision, were identified according to graft type (traditional 4 strands hamstring semitendinosus and gracilis, 4 strands semitendinosus, 5-6 strands semitendinosus and gracilis, 7-8 strands semitendinosus and gracilis, bone-patella-bone graft). RESULTS: Nine-hundred and ninety-two patients were included. At a mean follow-up of 38 months, 52 cases of graft rupture were recorded, (overall failure rate: 5.2%). The failure rate was not statistically influenced by the graft diameter. Patients with a thinner graft (< 8 mm-196 patients) had a similar failure rate (6%) to patients with a thicker graft (8 mm or more-485 patients) (6.2%). There was a lower failure rate in the BPB group (3.1%) versus all hamstrings group (6%) (ns). Finally, BPB in females had a lower failure rate than all hamstring constructs together (0% versus 5.1%; p = 0.023) CONCLUSION: In a young population traditional four-strand hamstring grafts, multiple strand configurations or BPB ACLR, whatever their size (> or < 8 mm), showed no significant difference in the failure rate in the NZ ACL registry. Female patients who had an ACL reconstruction with BPB graft had a significant lower failure rate than patients who had a hamstring graft. LEVEL OF EVIDENCE: III.

Similar risk of ACL graft revision for alpine skiers, football and handball players: the graft revision rate is influenced by age and graft choice.

OBJECTIVES: The risk of graft revision following ACL reconstruction may depend on the sport type the individuals are engaged in. The purpose of this study was to report the ACL graft revision rate in alpine skiers, football and handball players. MATERIALS AND METHODS: Primary ACL reconstructions and graft revision data from 2004 to December 2016 were obtained from the Norwegian Cruciate Ligament Registry. The graft survival rates were calculated for individuals in each of the three sport types, for bone patellar tendon bone (BPTB) and hamstring tendons (HT) grafts separately, and related to age at primary operation and sex. RESULTS: A total of 711 grafts in 14 201 primary ACL reconstructions were revised (5.0%) after median 6 years, 3.8% in alpine skiers, 5.0% in soccer and 6.1% in handball players (p<0.001). Adjusted Cox regression showed similar ACL graft survival rates in the three groups. The HR for graft revision was 5 times higher for individuals aged ≤18 years than for those aged ≥35 years (p<0.001). The corresponding HR for graft type was 1.8 times higher for HT than for BPTB grafts (p<0.001), but 2.8 times higher for individuals aged ≤18 years (p<0.001). The 12 years survival of BPTB grafts was 96% compared with 93% for HT grafts (p <0.001). CONCLUSION: The revision rate for ACL grafts was similar among alpine skiers, football and handball players, and the results support the use of BPTB grafts in young athletes with closed growth zones in the knee. STUDY DESIGN: Cohort study; level of evidence, 2.

Does Bone Plug and Graft Orientation (Inferior Versus Posterior) Alter Native Femoral Footprint Coverage in Bone Patellar Tendon Bone Anterior Cruciate Ligament Reconstruction?

PURPOSE: The purpose of this study was to compare the percentage of native femoral anterior cruciate ligament (ACL) footprint covered by the 2 most clinically relevant bone plug/graft orientations used with interference screw fixation in ACL reconstruction. A secondary purpose was to assess whether a transtibial or tibia-independent drilling technique would affect this outcome. METHODS: Five matched pairs of cadaver knees were used. Each matched pair had 1 knee assigned to a 10-mm femoral socket prepared via a transtibial (TT) drilling technique and the other via an anteromedial (AM) drilling technique. The bone plug of each graft was press-fitted into the femoral socket with the graft collagen in 2 distinct clinically relevant orientations (collagen inferior or posterior). The digitized graft collagen cross-sectional area (CSA) in each orientation was overlaid onto the native femoral ACL footprint CSA to generate a percentage of native ACL footprint covered by graft collagen. RESULTS: The average native ACL femoral footprint CSA was 110.5 ± 9.1 mm2, with no difference between knees assigned to TT or AM drilling (112.6 ± 2.7 vs 108.4 ± 13.0 mm2, P = .49). The average femoral socket CSA was 95.4 ± 8.7 mm2, with no difference between TT and AM tunnels (95.5 ± 9.9 vs 95.3 ± 8.4 mm2, P = .96). There was no difference between the percentage of native footprint covered between TT and AM sockets (76.8% ± 7.8% vs 82.2% ± 13.7%, P = .47). Irrespective of drilling technique, there was significantly greater native ACL footprint covered by graft collagen when the bone plug was oriented with graft collagen inferior rather than posterior (75.6% ± 6.3% vs 65.4% ± 11.4%, P = .02). CONCLUSION: Orienting the femoral bone plug such that the graft collagen is inferior rather than posterior significantly increases native ACL femoral footprint coverage in bone-patellar tendon-bone ACL reconstruction. This effect is consistent across AM and TT drilling techniques. CLINICAL RELEVANCE: Surgeons attempting to restore an anatomic ACL footprint should consider bone plug-graft orientation when performing ACL reconstruction. STUDY DESIGN: Controlled laboratory study.

Anterior Cruciate Ligament Reconstruction with Platelet-Rich Plasma: A Systematic Review of Randomized Control Trials.

PURPOSE: To perform a systematic review of the randomized controlled trials (RCTs) evaluating the efficacy of platelet-rich plasma (PRP) to augment anterior cruciate ligament (ACL) reconstruction. METHODS: Two independent reviewers screened the MEDLINE, The Cochrane Library, and EMBASE databases using Preferred Reporting for Systematic Reviews and Meta-Analyses guidelines for applicable RCTs evaluating the efficacy of PRP in ACL reconstruction. A meta-analysis was performed on the papers involving bone-patellar tendon-bone (BPTB) grafting. RESULTS: Thirteen RCTs fulfilled the inclusion criteria involving 765 patients. There was no clinical improvement (Tegner, Lysholm, Knee Injury and Osteoarthritis Outcome Score, or International Knee Documentation Committee scores) in any of the 7 studies evaluating PRP alongside the hamstring tendon autograft ACL reconstructions versus the control. Two studies evaluating PRP for hamstring tendon autograft demonstrated significantly improved magnetic resonance imaging findings. Two studies analyzed the use of PRP with allograft ACL reconstruction showed no clinical, biochemical, or radiologic improvements in postoperative follow-up. No functional improvements were found when PRP was used alongside BPTB in 4 studies. There was no significant difference in visual analog scale score in the BPTB group (1.1 vs 1.5, P = .18), or tibial filling defects (P = .30). CONCLUSIONS: This study found that the current level I evidence does not support the use of PRP to improve graft healing, improve donor-site morbidity, reduce postoperative pain levels, or improve functional outcomes following ACL reconstruction. LEVEL OF EVIDENCE: Level I; systematic review of level I evidence.

Lower donor-site morbidity using QT autografts for ACL reconstruction.

PURPOSE: Comparing scar cosmesis and regional hypoesthesia at the incision site between quadriceps tendon (QT), bone-patellar tendon-bone (BPTB), and hamstring tendon (HT) for anterior cruciate ligament (ACL) reconstruction. METHODS: Ninety patients undergoing ACL reconstruction with QT, HT or BPTB were evaluated at 1-year post-op. Scar cosmesis was assessed using the patient and observer scar assessment scale (POSAS) and length of the incision. Sensory outcome was analyzed by calculating the area of hypoesthesia around the scar. The classical ACL reconstruction functional follow-up was measured using the Lysholm score and KOOS. RESULTS: Concerning QT versus BPTB group, QT patients have a significantly lower mean POSAS (24.8 ± 6.3 vs. 39.6 ± 5.8; p < 0.0001), shorter mean incision (2.8 ± 0.4 cm vs. 6.4 ± 1.3 cm; p < 0.0001), lower extent of hypoesthesia (8.7 ± 5.1 cm2 vs. 88.2 ± 57 cm2; p < 0.0001), and better Lysholm score (90.1 ± 10.1 vs. 82.6 ± 13.5; n.s.). No significant difference was seen in KOOS (90.7 ± 7.2 vs. 88.4 ± 7.0; n.s.). Concerning QT versus HT group, no significant difference was found regarding mean POSAS score (24.8 ± 6.3 vs. 31.8 ± 6.2; n.s.), mean length of the incision (2.8 ± 0.4 cm vs. 2.5 ± 0.6 cm; n.s.), KOOS (90.7 ± 7.2 vs. 89.8 ± 8.2; n.s.) and mean Lysholm score (90.1 ± 10.1 vs. 87.8 ± 0.6; n.s.). The mean measured area of hypoesthesia was significantly higher in the HT group (70.3 ± 77.1 cm2 vs. 8.7 ± 5.1 cm2; p < 0.0001). CONCLUSION: Quadriceps tendon harvesting technique has the safest incision by causing less sensory loss compared to BPTB and HT. It also has the advantage of a short incision with more cosmetic scar compared to BPTB, with no difference compared to HT. However, no significant difference in terms of functional outcome was shown between the three autografts. These findings provide surgeons evidence about their clinical practice and help with graft choice decisions. LEVEL OF EVIDENCE: III.

Combined ACL reconstruction and opening wedge high tibial osteotomy at 10-year follow-up: excellent laxity control but uncertain return to high level sport.

PURPOSE: The purpose of this study was to report the long-term outcomes of a continuous series of patients who underwent simultaneous anterior cruciate ligament (ACL) reconstruction and opening wedge high tibial osteotomy (HTO) for varus-related early medial tibio-femoral osteoarthritis. It was hypothesized that this combined surgery sustainably allowed return to sport with efficient clinical and radiological results. METHODS: From 1995 to 2015, all combined ACL reconstruction (bone-patellar tendon-bone graft) and opening wedge HTO for anterior laxity and early medial arthritis were included. Clinical evaluation at final follow-up used Tegner activity score, Lysholm score, subjective and objective IKDC scores. Radiologic evaluation consisted in full-length, standing, hip-to-ankle X-rays, monopodal weight-bearing X-rays and skyline views. AP laxity assessment used Telos™ at 150 N load. Student's t test was performed for matched parametric data, Wilcoxon for nonparametric variables and Friedman test was used to compare small cohorts, with p < 0.05. RESULTS: 35 Patients (36 knees) were reviewed with a mean follow-up of 10 ± 5.2 years. The mean age at surgery was 39 ± 9. At final follow-up 28 patients (80%) returned to sport (IKDC ≥ B): 11 patients (31%) returned to sport at the same level and 6 (17%) to competitive sports. Mean subjective IKDC and Lysholm scores were 71.8 ± 14.9 and 82 ± 14.1, respectively. The mean decrease of the Tegner activity level from preinjury state to follow-up was 0.8 (p < 0.01). Mean side-to-side difference in anterior tibial translation was 5.1 ± 3.8 mm. Three patients were considered as failures. The mean preoperative mechanical axis was 4.2° ± 2.6° varus and 0.8° ± 2.7° valgus at follow-up. Osteoarthritis progression for medial, lateral, and femoro-patellar compartments was recorded for 12 (33%, p < 0.05), 6 (17%, p < 0.001), and 8 (22%, p < 0.05) knees, respectively. No femoro-tibial osteoarthritis progression was observed in 22 knees (61%). CONCLUSIONS: Combined ACL reconstruction and opening wedge HTO allowed sustainable stabilization of the knee at 10-year follow-up. However, return to sport at the same level was possible just for one-third of patients, with femoro-tibial osteoarthritis progression in 39% of cases. LEVEL OF EVIDENCE: III.