Reduced Knee Flexion Strength 18 Years After ACL Reconstruction With Hamstring Tendon Versus Patellar Tendon.

BACKGROUND: Bone-patellar tendon-bone (BPTB) and double-looped semitendinosus and gracilis (hamstring) grafts are commonly used for anterior cruciate ligament (ACL) reconstruction. Short-term and midterm studies show little or no differences between the 2 grafts; however, there are only a few long-term studies to compare results between the 2 grafts. PURPOSE: To compare the results after using either BPTB grafts or hamstring tendon grafts 18 years after ACL reconstruction. STUDY DESIGN: Randomized controlled trial; Level of evidence 2. METHODS: A total of 114 patients with ACL rupture between 2001 and 2004 were randomized to reconstruction with either a BPTB graft or a hamstring tendon graft. Patients were operated on at 4 major hospitals. The 18-year follow-up evaluation included anterior knee laxity measured with a KT-1000 arthrometer, defined as the primary outcome, while clinical examination (Lachman and pivot-shift tests), isokinetic testing of muscle strength, patient-reported outcome measures, and an assessment of radiographic osteoarthritis using the Kellgren-Lawrence classification were defined as secondary outcomes. RESULTS: A total of 96 patients (84%, 47 BPTB and 49 hamstring grafts) were available for follow-up, 71 of these for clinical examination. Seven of 96 patients were excluded for ACL revision (n = 5) or knee replacement (n = 2) surgery. In total, 25 patients (10 BPTB and 15 hamstring grafts) had undergone additional surgery other than ACL revision or total knee arthroplasty. There were no significant differences between the groups in terms of anterior laxity test with KT-1000 arthrometer (primary outcome). In secondary outcomes, no significant differences between groups were reported regarding clinical examination, patient-reported outcome scores, or radiographic osteoarthritis (Kellgren-Lawrence grade 2-4 for patellofemoral joint [18 hamstring and 14 BPTB] or tibiofemoral joint [20 hamstring and 19 BPTB]), while isokinetic testing revealed that the hamstring group had a 10.7% reduction in mean peak flexion torque compared with the BPTB group at 60 deg/s (df = 59; P = .011). At 60 deg/s the mean total flexion work in the hamstring group was reduced by 17.2% compared with the BPTB group (df = 59; P = .002). CONCLUSION: The flexion strength in the hamstring group was significantly reduced in the operated knee after 18 years. There were no significant differences between the groups regarding subjective outcomes, patient-reported outcomes, range of motion, clinical and instrumented knee laxity, and the development of osteoarthritis. REGISTRATION: NCT05876013 (ClinicalTrials.gov identifier).

Long-Term Outcomes of Arthroscopically Verified Focal Cartilage Lesions in the Knee: A 19-Year Multicenter Follow-up with Patient-Reported Outcomes.

BACKGROUND: Focal cartilage lesions (FCLs) are frequently found during knee arthroscopies and may impair quality of life (QoL) significantly. Several treatment options with good short-term results are available, but the natural history without any treatment is largely unknown. The aim of this study was to evaluate patient-reported outcome measures (PROMs), the need for subsequent cartilage surgery, and the risk of treatment failure 20 years after diagnosis of an FCL in the knee. METHODS: Patients undergoing any knee arthroscopy for an FCL between 1999 and 2012 in 6 major Norwegian hospitals were identified. Inclusion criteria were an arthroscopically classified FCL in the knee, patient age of ≥18 years at surgery, and any preoperative PROM. Exclusion criteria were lesions representing knee osteoarthritis or "kissing lesions" at surgery. Demographic data, later knee surgery, and PROMs were collected by questionnaire. Regression models were used to adjust for and evaluate the factors impacting the long-term PROMs and risk factors for treatment failure (defined as knee arthroplasty, osteotomy, or a Knee injury and Osteoarthritis Outcome Score-Quality of Life [KOOS QoL] subscore of <50). RESULTS: Of the 553 eligible patients, 322 evaluated patients (328 knees) were included and analyzed. The mean follow-up was 19.1 years, and the mean age at index FCL surgery was 36.8 years (95% confidence interval [CI], 35.6 to 38.0 years). The patients without knee arthroplasty or osteotomy had significantly better mean PROMs (pain, Lysholm, and KOOS) at the time of final follow-up than preoperatively. At the time of follow-up, 17.7% of the knees had undergone subsequent cartilage surgery. Nearly 50% of the patients had treatment failure, and the main risk factors were a body mass index of ≥25 kg/m2 (odds ratio [OR] for overweight patients, 2.0 [95% CI, 1.1 to 3.6]), >1 FCL (OR, 1.9 [CI, 1.1 to 3.3]), a full-thickness lesion (OR, 2.5 [95% CI, 1.3 to 5.0]), and a lower level of education (OR, 1.8 [95% Cl, 1.1 to 2.8]). Autologous chondrocyte implantation (ACI) was associated with significantly higher KOOS QoL, by 17.5 (95% CI, 3.2 to 31.7) points, and a lower risk of treatment failure compared with no cartilage treatment, microfracture, or mosaicplasty. CONCLUSIONS: After a mean follow-up of 19 years, patients with an FCL who did not require a subsequent knee arthroplasty had significantly higher PROM scores than preoperatively. Nonsurgical treatment of FCLs had results equal to those of the surgical FCL treatments except for ACI, which was associated with a better KOOS and lower risk of treatment failure. Full-thickness lesions, >1 FCL, a lower level of education, and a greater BMI were the main risk factors associated with poorer results. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Arthroscopic Subscapular Sling Procedure Results in Low Recurrent Anterior Shoulder Instability at 24 Months of Follow-Up.

PURPOSE: To analyze the results of the subscapular sling procedure developed for anterior shoulder instability in patients with less than 10% anterior glenoid bone loss. METHODS: Patients were treated surgically with the arthroscopic subscapular sling procedure. A semitendinosus graft was used to reconstruct the anterior labrum and to establish a sling suspension around the upper part of the subscapularis tendon. The patients were followed up with radiographs (at 12 and 24 months). Magnetic resonance imaging (MRI) of the shoulder region and clinical examinations were performed at 3, 12, and 24 months. Recurrent dislocation was the primary endpoint. The Western Ontario Shoulder Instability Index (WOSI) and MRI results were secondary outcome measures. An independent physiotherapist assessed residual instability and range of motion. RESULTS: Fifteen patients were included with a dislocation rate of 0% after 24 months follow-up. There was a significant clinical improvement of the WOSI score from 57% (904) at baseline to 88% (241) at 24 months (P < .001). The proportion of patients with an improvement in the WOSI Total score larger than the estimated minimal clinically important difference was 100% both at 12 and 24 months. MRI showed an intact sling in all patients. External rotation was not significantly reduced (52° at baseline vs 47° at 24 months, P = .211). Flexion and abduction were significantly improved from 152° to 174° (P = .001) and 141° to 170° (P < .001) after 24 months. The surgical procedures were completed without any intraoperative complications. CONCLUSIONS: The subscapular sling procedure resulted in low recurrent shoulder instability and improved patient-reported outcome measures at 24 months of follow-up. LEVEL OF EVIDENCE: Level IV, case series.

Increased risk for early revision with quadriceps graft compared with patellar tendon graft in primary ACL reconstructions.

PURPOSE: Bone patella-tendon bone (BPTB) and hamstring tendon (HT) autografts are the most used grafts in primary anterior cruciate ligament (ACL) reconstructions (ACLR) in Norway. Quadriceps tendon (QT) autograft has gained more popularity during the past years. The purpose of this study is to compare revision rates and patient-reported outcomes of primary QT with BPTB and HT autograft ACL reconstructions in Norway at 2-year follow-up. It was hypothesized that there would be no difference in 2-year revision rates between all three autografts. METHODS: Data included primary ACLR without concomitant ligament surgeries, registered in the Norwegian Knee Ligament Register from 2004 through 2021. Revision rates at 2 years were calculated using Kaplan-Meier analysis. Hazard ratios (HR) for revision were estimated using multivariable Cox regression analysis with revision within 2 years as endpoint. Mean change in patient-reported outcome was recorded preoperatively and at 2 years through the Knee Injury and Osteoarthritis Outcome Score (KOOS) subcategories 'Sport' and 'Quality of Life' was measured for patients that were not revised and analysed with multiple linear regression. RESULTS: A total of 24,790 primary ACLRs were identified, 10,924 with BPTB, 13,263 with HT and 603 with a QT graft. Patients in the QT group were younger (23.5 years), more of them were women (58.2%) and over 50% had surgery <3 months after injury. The QT group had the highest prevalence of meniscal injuries (61.9%). Revision estimates at 2-years were 3.6%, 2.5% and 1.2% for QT, HT and BPTB, respectively (p < 0.001). In a Cox regression analysis with QT as reference, BPTB had a lower risk of revision (HR 0.4, 95% Cl 0.2-0.7, p < 0.001). No significant difference was observed in the revision risk between QT and HT (HR 1.1, 95% Cl 0.7-1.8, n.s.). The two most common reported reasons for revision were: traumatic graft rupture and nontraumatic graft failure. There were no differences between the groups in change of KOOS in subcategories 'Sport' and 'Quality of Life' at 2-years follow-up. CONCLUSION: The 2-year risk of revision after ACLR with QT was higher than BPTB and similar to HT. No difference was found between the groups in patient-reported outcomes. This study provides valuable insights for both surgeons and patients when making decisions about the choice of autografts in primary ACL reconstructions. LEVEL OF EVIDENCE: Level II.

Previous cartilage surgery is associated with inferior patient-reported outcomes after knee arthroplasty.

PURPOSE: The hypothesis of the present study assumed that a history of focal cartilage lesions would not affect Knee Injury and Osteoarthritis Outcome scores (KOOSs) following knee arthroplasty compared to a matched national cohort of knee arthroplasty patients. METHODS: Fifty-eight knee arthroplasty patients with previous surgery for focal cartilage lesions (cartilage cohort) were compared to a matched cohort of 116 knee arthroplasty patients from the Norwegian Arthroplasty Register (control group). Age, sex, primary or revision arthroplasty, type of arthroplasty (total, unicondylar or patellofemoral), year of arthroplasty surgery and arthroplasty brand were used as matching criteria. Demographic data and KOOS were obtained through questionnaires. Regression models were employed to adjust for confounding factors. RESULTS: Mean follow-up post knee arthroplasty surgery was 7.6 years (range 1.2-20.3) in the cartilage cohort and 8.1 (range 1.0-20.9) in the control group. The responding patients were at the time of surgery 54.3 versus 59.0 years in the cartilage and control group, respectively. At follow-up the control group demonstrated higher adjusted Knee Injury and Osteoarthritis Outcome subscores than the previous focal cartilage patients with a mean adjusted difference (95% confidence interval in parentheses): Symptoms 8.4 (0.3, 16.4), Pain 11.8 (2.2, 21.4), Activities of daily living (ADL) 9.3 (-1.2, 18.6), Sport and recreation 8.9 (-1.6, 19.4) and Quality of Life (QoL) 10.6 (0.2, 21.1). The control group also demonstrated higher odds of reaching the patient-acceptable symptom state threshold for the Knee Injury and Osteoarthritis Outcome subscores with odds ratio: Symptoms 2.7 (1.2, 6.4), Pain 3.0 (1.3, 7.0), ADL 2.1 (0.9, 4.6) and QoL 2.4 (1.0, 5.5). CONCLUSION: Previous cartilage surgery was associated with inferior patient-reported outcomes after knee arthroplasty. These patients also exhibited significantly lower odds of reaching the patient-acceptable symptom state threshold for the Knee Injury and Osteoarthritis Outcome subscores. LEVEL OF EVIDENCE: Level III.

The Long-Term Risk of Knee Arthroplasty in Patients with Arthroscopically Verified Focal Cartilage Lesions: A Linkage Study with the Norwegian Arthroplasty Register, 1999 to 2020.

BACKGROUND: Focal cartilage lesions are common in the knee. The risk of later ipsilateral knee arthroplasty remains unknown. The purposes of the present study were to evaluate the long-term cumulative risk of knee arthroplasty after arthroscopic identification of focal cartilage lesions in the knee, to investigate the risk factors for subsequent knee arthroplasty, and to estimate the subsequent cumulative risk of knee arthroplasty compared with that in the general population. METHODS: Patients who had undergone surgical treatment of focal cartilage lesions at 6 major Norwegian hospitals between 1999 and 2012 were identified. The inclusion criteria were an arthroscopically classified focal cartilage lesion in the knee, an age of ≥18 years at the time of surgery, and available preoperative patient-reported outcomes (PROMs). The exclusion criteria were osteoarthritis or "kissing lesions" at the time of surgery. Demographic data, later knee surgery, and PROMs were collected with use of a questionnaire. A Cox regression model was used to adjust for and investigate the impact of risk factors, and Kaplan-Meier analysis was performed to estimate cumulative risk. The risk of knee arthroplasty in the present cohort was compared with that in the age-matched general Norwegian population. RESULTS: Of the 516 patients who were eligible, 322 patients (328 knees) consented to participate. The mean age at the time of the index procedure was 36.8 years, and the mean duration of follow-up was 19.8 years. The 20-year cumulative risk of knee arthroplasty in the cartilage cohort was 19.1% (95% CI, 14.6% to 23.6%). Variables that had an impact on the risk of knee arthroplasty included an ICRS grade of 3 to 4 (hazard ratio [HR], 3.1; 95% CI, 1.1 to 8.7), an age of ≥40 years at time of cartilage surgery (HR, 3.7; 95% CI, 1.8 to 7.7), a BMI of 25 to 29 kg/m 2 (HR, 3.9; 95% CI, 1.7 to 9.0), a BMI of ≥30 kg/m 2 (HR, 5.9; 95% CI, 2.4 to 14.3) at the time of follow-up, autologous chondrocyte implantation (ACI) at the time of the index procedure (HR, 3.4; 95% CI, 1.0 to 11.4), >1 focal cartilage lesion (HR, 2.1; 95% CI, 1.1 to 3.7), and a high preoperative visual analog scale (VAS) score for pain at the time of the index procedure (HR, 1.1; 95% CI, 1.0 to 1.1). The risk ratio of later knee arthroplasty in the cartilage cohort as compared with the age-matched general Norwegian population was 415.7 (95% CI, 168.8 to 1,023.5) in the 30 to 39-year age group. CONCLUSIONS: In the present study, we found that the 20-year cumulative risk of knee arthroplasty after a focal cartilage lesion in the knee was 19%. Deep lesions, higher age at the time of cartilage surgery, high BMI at the time of follow-up, ACI, and >1 cartilage lesion were associated with a higher risk of knee arthroplasty. LEVEL OF EVIDENCE: Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

A Randomized Trial of Autologous Chondrocyte Implantation Versus Alternative Forms of Surgical Cartilage Management in Patients With a Failed Primary Treatment for Chondral or Osteochondral Defects in the Knee.

BACKGROUND: There are limited randomized controlled trials with long-term outcomes comparing autologous chondrocyte implantation (ACI) versus alternative forms of surgical cartilage management within the knee. PURPOSE: To determine at 5 years after surgery whether ACI was superior to alternative forms of cartilage management in patients after a failed previous treatment for chondral or osteochondral defects in the knee. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: In total, 390 participants were randomly assigned to receive either ACI or alternative management. Patients aged 18 to 55 years with one or two symptomatic cartilage defects who had failed 1 previous therapeutic surgical procedure in excess of 6 months prior were included. Dual primary outcome measures were used: (1) patient-completed Lysholm knee score and (2) time from surgery to cessation of treatment benefit. Secondary outcome measures included International Knee Documentation Committee and Cincinnati Knee Rating System scores, as well as number of serious adverse events. Analysis was performed on an intention-to-treat basis. RESULTS: Lysholm scores were improved by 1 year in both groups (15.4 points [95% CI, 11.9 to 18.8] and 15.2 points [95% CI, 11.6 to 18.9]) for ACI and alternative, with this improvement sustained over the duration of the trial. However, no evidence of a difference was found between the groups at 5 years (2.9 points; 95% CI, -1.8 to 7.5; P = .46). Approximately half of the participants (55%; 95% CI, 47% to 64% with ACI) were still experiencing benefit at 5 years, with time to cessation of treatment benefit similar in both groups (hazard ratio, 0.97; 95% CI, 0.72 to 1.32; P > .99). There was a differential effect on Lysholm scores in patients without previous marrow stimulation compared with those with marrow stimulation (P = .03; 6.4 points in favor of ACI; 95% CI, -0.4 to 13.1). More participants experienced a serious adverse event with ACI (P = .02). CONCLUSION: Over 5 years, there was no evidence of a difference in Lysholm scores between ACI and alternative management in patients who had previously failed treatment. Previous marrow stimulation had a detrimental effect on the outcome of ACI. REGISTRATION: International Standard Randomised Controlled Trial Number: 48911177.

Low annual hospital volume of anterior cruciate ligament reconstruction is not associated with higher revision rates.

PURPOSE: Surgery performed in low-volume centres has been associated with longer operating time, longer hospital stays, lower functional outcomes, and higher rates of revision surgery, complications and mortality. This has been reported consistently in the arthroplasty literature, but there is a paucity of data regarding the relationship between surgical volume and outcome following anterior cruciate ligament (ACL) reconstruction. The purpose was to compare ACL reconstruction failure rates between hospitals performing different annual surgical volumes. METHODS: All patients from the Norwegian Knee Ligament Register having primary autograft ACL reconstruction between 2004 and 2016 were included. Hospital volume was divided into quintiles based on the number of ACL reconstructions performed annually, defined arbitrarily as: 1-12 (V1), 13-24 (V2), 25-49 (V3), 50-99 (V4) and ≥ 100 (V5) annual procedures. Kaplan-Meier estimated survival curves and survival percentages were calculated with revision ACL reconstruction as the end point. Secondary outcome measures included (1) mean change in Knee Injury and Osteoarthritis Outcome Score (KOOS) Quality of Life (QoL) and Sport subsections from pre-operative to 5-year follow-up and (2) subjective failure defined as KOOS QoL < 44. RESULTS: Twenty thousand eight hundred and fifty patients met the inclusion criteria and 1195 (5.7%) underwent subsequent revision ACL reconstruction over the study period. Revision rates were lower in the lower volume hospitals compared with the higher volume hospitals (p < 0.001). There was no clinically significant difference in improvement between pre-operative and 5-year follow-up KOOS scores between hospital volume categories, but a higher proportion of patients having surgery at lower volume hospitals reported a subjective failure. Patients in the lower volume categories (V1-3) were more often male and older compared to the higher volume hospitals (V4-5). Concomitant meniscal injuries and participation in pivoting sports were most common in V5 compared with V1 (p < 0.001). Median operative time decreased as hospital volume increased, ranging from 90 min at V1 hospitals to 56 min at V5 hospitals (p < 0.001). CONCLUSION: Patients having ACL reconstruction at lower volume hospitals had a lower rate of subsequent revision surgery relative to higher volume hospitals. However, complications occurred more frequently, operative duration was longer, and the number of patients reporting a subjective failure of ACL reconstruction was highest at these lower volume hospitals. LEVEL OF EVIDENCE: Level III.

Clinical outcome after knee ligament reconstruction with tendon allografts.

PURPOSE: The purpose of this study is to investigate the clinical outcome for patients after knee ligament reconstructions with allografts at a university hospital. METHODS: A total of 33 patients received allografts for reconstructive knee surgery between 2007 and 2017. The follow up evaluation consisted of a clinical knee examination including evaluation of range of motion (ROM), lateral and medial laxity, the Lachman test, the Pivot shift test, the sag test, the posterior drawer test and checking for patellofemoral pain. The following patient-reported outcome measures (PROMs) were used; the Lysholm Function Score, the Tegner activity score, and the Knee injury and Osteoarthritis Outcome Score (KOOS). RESULTS: Twenty-one (64%) patients were available for the follow-up evaluation and the mean follow-up time was 4.8 years. A total of 16 out of 21 patients had multiligament injuries of which the ACL was the ligament most frequently ruptured. At the time of follow-up, 14 out of 16 patients (87%) with ACL injury had Lachman test grade 0 or grade 1 + , and 12 out of 13 (92%) had a pivot shift grade 0 or 1 + . The mean Lysholm Score was 74. All mean KOOS subscale values were ≥ 59 at the follow-up. The preoperative Tegner activity score was 3 (range, 1-6) and 4 (range, 2-6) at follow up. There were no deep postoperative infections. A total of 19 out of 21 patients (90%) reported that they would have undergone surgery again had they known the clinical outcome in advance. CONCLUSIONS: The patients improved from the preoperative score to the follow-up score in the knee-related Quality of Life (QoL) KOOS subscale. None of the patients were diagnosed with deep postoperative infections.

The novel arthroscopic subscapular quadriceps tendon-bone sling procedure provides increased stability in shoulder cadavers with severe glenoid bone loss.

PURPOSE: Treatment of anterior glenoid bone loss in patients with recurrent anterior shoulder instability is a challenge. The subscapular sling method with quadriceps tendon bone (QTB) graft is a modification of the subscapular sling with a semitendinosus (ST) graft. The aim of the study was to test the biomechanical stability of the QTB sling procedure in human shoulder cadavers with severe anterior glenoid bone loss. METHODS: Fourteen cadaveric shoulders were tested with a force-moment-guided robot in three conditions: physiologically intact, anterior glenoid bone resection, and the subscapular sling procedure with a QTB graft. Joint stability was measured in anterior, anterior inferior and inferior directions in four glenohumeral joint positions: 0° and 60° of glenohumeral abduction, with each at 0° and 60° of external rotation. Maximum external rotation was measured at 0° and 60° glenohumeral abduction. Computer tomography scans were obtained preoperatively to plan the glenoid bone resection, as well as postoperatively to calculate the proportion of the glenoid bone actually resected. RESULTS: Significantly decreased translations were observed in the shoulders with the QTB sling compared to the intact joint and the glenoid bone loss model. No significant differences in maximum external rotation were observed between the three different conditions. CONCLUSION: This biomechanical study revealed a significant stabilizing effect of the arthroscopic subscapular QTB graft sling procedure in human shoulder cadavers without compromising external rotation. Clinical trials may reveal the usefulness of this experimental method.

Correction to: No effect of graft size or body mass index on risk of revision after ACL reconstruction using hamstrings autograft.

Unfortunately, the author Jon Olav Drogset was incorrectly published in the original version and updated here. The original article has been corrected.

No effect of graft size or body mass index on risk of revision after ACL reconstruction using hamstrings autograft.

PURPOSE: The current study investigated the distribution of hamstrings graft size and body mass index and any potential effect on the risk of revision surgery in a large prospective cohort of patients undergoing ACL reconstruction. More specifically, the aim of the study was to investigate whether larger graft size or smaller BMI would decrease the risk of revision after ACL reconstruction. METHODS: A total of 4029 patients, prospectively registered in the Norwegian Knee Ligament Registry, were included in the study. Univariate Kaplan-Meier survival analyses (with log-rank tests) and the Cox proportional hazard (PH) regression model were applied to compare risk of revision between groups of patients. Mutual adjustment for gender, age, activity at the time of injury and fixation method of the graft was performed. RESULTS: Graft sizes spanned from 5.5 to 11.0 mm and the median of 8.0 mm was reported in 42% of patients in the cohort. BMI was reported from 15 to 57 with a median of 25. 46% of patients were classified as overweight (WHO standards), while 23% of patients were obese. At a median of 2.5 years after surgery, 150 patients had undergone revision surgery. Although certain effects were seen in the unadjusted analyses, neither graft size (diameter) nor patient BMI did affect the risk of undergoing revision surgery in the adjusted analyses. CONCLUSIONS: Graft size and BMI was not found to be independent risk factors for undergoing ACL revision surgery. In contrast to other studies, graft size of 8 mm or larger did not have a better outcome than smaller graft sizes. A relatively large group of overweight patients undergoing ACL surgery reflects the general increase in weight seen in Western societies. Although the current study differs from previous findings, it might indicate that graft diameter is less important than previously stated. LEVEL OF EVIDENCE: Cohort study, II.

Autologous BPTB ACL Reconstruction Results in Lower Failure Rates Than ACL Repair with and without Synthetic Augmentation at 30 Years of Follow-up: A Prospective Randomized Study.

BACKGROUND: The aim of this study was to compare the 30-year follow-up results after treatment of anterior cruciate ligament (ACL) ruptures with 3 different surgical procedures. METHODS: A total of 150 patients with acute rupture of the ACL who were managed between 1986 and 1988 were randomized into 1 of 3 open repair methods: acute primary repair (n = 49), acute repair with a synthetic ligament augmentation device (LAD) (n = 50), or reconstruction with an autologous bone-patellar tendon-bone (BPTB) graft with retention of the ACL remnants (n = 51). The 30-year follow-up included evaluation of clinical findings, the Tegner and Lysholm questionnaires, radiographic examination, and registration of revisions and knee arthroplasties. RESULTS: A total of 113 patients (75%) were available for the follow-up evaluation; 39 patients were in the primary repair group, 39 in the LAD group, and 35 in the BPTB group. Through telephone calls and investigation of patient medical records, 40 of these patients were excluded from further analyses because of revision surgery, knee arthroplasty in the involved or contralateral knee, or ACL reconstruction in the contralateral knee. One patient in the BPTB group had undergone revision ACL reconstruction compared with 12 in the primary repair group (p = 0.002) and 9 in the LAD group (p = 0.015). Seven patients had undergone knee arthroplasty in the involved knee, with no significant difference among the groups. In the remaining patients, no significant differences were found among the 3 groups with regard to range of motion, laxity, or Tegner and Lysholm scores. Radiographic evidence of osteoarthritis, defined as an Ahlbäck grade of 2 through 5, was found in 42% of the operatively treated knees, with no significant differences among the groups. CONCLUSIONS: In the present 30-year follow-up results of a randomized controlled study, the BPTB graft augmented with the remnants of the ruptured ligament provided superior results with regard to the number of revisions compared with both the primary repair and LAD groups. No significant differences were found with respect to range of motion, laxity, activity, function, radiographic evidence of osteoarthritis, and knee arthroplasties. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Graft fixation influences revision risk after ACL reconstruction with hamstring tendon autografts.

Background and purpose - A large number of fixation methods of hamstring tendon autograft (HT) are available for anterior cruciate ligament reconstruction (ACLR). Some studies report an association between fixation method and the risk of revision ACLR. We compared the risk of revision of various femoral and tibial fixation methods used for HT in Scandinavia 2004-2011. Materials and methods - A register-based study of 38,666 patients undergoing primary ACLRs with HT, with 1,042 revision ACLRs. The overall median follow-up time was 2.8 (0-8) years. Fixation devices used in a small number of patients were grouped according to design and the point of fixation. Results - The most common fixation methods were Endobutton (36%) and Rigidfix (31%) in the femur; and interference screw (48%) and Intrafix (34%) in the tibia. In a multivariable Cox regression model, the transfemoral fixations Rigidfix and Transfix had a lower risk of revision (HR 0.7 [95% CI 0.6-0.8] and 0.7 [CI 0.6-0.9] respectively) compared with Endobutton. In the tibia the retro interference screw had a higher risk of revision (HR 1.9 [CI 1.3-2.9]) compared with an interference screw. Interpretation - The choice of graft fixation influences the risk of revision after primary ACLR with hamstring tendon autograft.

A Randomized Multicenter Trial Comparing Autologous Chondrocyte Implantation with Microfracture: Long-Term Follow-up at 14 to 15 Years.

BACKGROUND: The management of cartilage and osteochondral lesions in the knee remains problematic and controversial. Our group reported the 2-year and 5-year results of a randomized controlled trial comparing autologous chondrocyte implantation (ACI) and microfracture in patients with focal femoral cartilage injuries. The objective of the present study was to report the long-term results. METHODS: Eighty patients with a single symptomatic chronic cartilage defect on the femoral condyle without general osteoarthritis were included in the study at the time of the index operation (January 1999 to February 2000). We used the International Cartilage Repair Society (ICRS), Lysholm, Short Form-36 (SF-36), and Tegner forms to collect data at the time of inclusion and at follow-up evaluations. Standing weight-bearing radiographs were evaluated for evidence of osteoarthritis according to the method described by Kellgren and Lawrence. For the long-term follow-up in 2014, we used the Synaflexer frame to standardize the radiographs. The operation was considered to have failed if a reoperation was performed because of symptoms from a lack of healing of the treated defect. RESULTS: At the long-term follow-up evaluation, no significant differences between the treatment groups were detected with respect to the results on the clinical scoring systems. At the 15-year evaluation, there were 17 failures in the ACI group compared with 13 in the microfracture group. We observed that more total knee replacements were needed in the ACI group than in the microfracture group (6 compared with 3). The surviving patients in both groups, i.e., those who had not had a failure, had significant improvement in the clinical scores compared with baseline. Fifty-seven percent of the surviving patients in the ACI group and 48% of such patients in the microfracture group had radiographic evidence of early osteoarthritis (a Kellgren and Lawrence grade of ≥2); the difference was not significant. CONCLUSIONS: The survivors in both groups improved their clinical scores in the short, medium, and long-term evaluations, and no significant difference between the groups was found at the long-term follow-up. The risk of treatment failure and the frequency of radiographic osteoarthritis are problematic. Our findings raise serious concerns regarding the efficacy of these procedures in delaying osteoarthritis and preventing further surgery. Continued basic and clinical research is needed in this field. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

All-inside suture device is superior to meniscal arrows in meniscal repair: a prospective randomized multicenter clinical trial with 2-year follow-up.

PURPOSE: Multiple techniques and implants are available for all-inside meniscal repair, but the knowledge about their failure rates and functional outcome is still incomplete. The hypothesis was that there might be differences between meniscal arrows and suture devices regarding reoperation rates and functional outcome. Thereby, the aim of this study was to compare clinical results following repair with the Biofix(®) arrows or the FasT-Fix(®) suture devices. METHODS: In this RCT, 46 patients were treated either by Biofix(®) (n = 21) or FasT-Fix(®) (n = 25). The main outcome was reoperation within 2 years. Knee function and activity level were evaluated by KOOS and Tegner activity scale. RESULTS: Twelve out of 46 (26%) patients were reoperated within 2 years, nine out of 21 (43%) in the Biofix(®)-group versus three out of 25 (12%) in the FasT-Fix(®)-group (p = 0.018). The relative risk of reoperation was 3.6 times higher for Biofix(®) compared to FasT-Fix(®) (95% confidence interval 1.1-11.5). Both treatment groups had significant increase in all KOOS subscales, but there were no major differences between the groups. The subgroup of reoperated patients differed from the other patients with higher Tegner score preoperatively (median 5 vs. 4) (p = 0.037) and at 3-month follow-up (median 4 vs. 3) (p = 0.010). CONCLUSIONS: These results indicate that FasT-Fix(®) suture is superior to Biofix(®) arrows with significant lower failure rate. Functional outcome did not depend on repair technique. Higher activity score preoperatively and at 3-month follow-up in the reoperated patients indicates that activity level may influence on the risk of reoperation. LEVEL OF EVIDENCE: I.

Lower risk of revision with patellar tendon autografts compared with hamstring autografts: a registry study based on 45,998 primary ACL reconstructions in Scandinavia.

BACKGROUND: A number of studies have found comparable results after anterior cruciate ligament (ACL) reconstruction with patellar tendon autografts and hamstring autografts; however, few studies have been large enough to reveal differences in risk of revision with regard to clinical and demographic factors. PURPOSE: To present the distribution of grafts for ACL reconstruction based on data in the Scandinavian ACL registries and to compare the risk of revision between patellar tendon autografts and hamstring autografts. Potential associations with other clinical and demographic factors were also explored. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 45,998 primary ACL reconstructions, including 6736 patellar tendon autografts and 38,666 hamstring autografts, were identified in the Scandinavian ACL registries. The overall median follow-up time was 3 years (range, 0-8 years). To compare the risk of revision between groups of patients, univariate Kaplan-Meier analysis (with log-rank test) and the Cox proportional hazard regression model were applied. The hazard rate ratio with 95% CI was reported as a measure of effect. RESULTS: Patellar tendon and hamstring autografts were used in 14.6% and 84.1% of the patients, respectively. The remaining patients received allografts, direct sutures, or other graft types (1.3%). The primary ACL injury occurred during soccer, team handball, or alpine activities in 67.5% of the patients in the patellar tendon group and 66.2% in the hamstring group. A total of 156 patients in the patellar tendon group and 1042 patients in the hamstring group underwent revision. The overall risk of revision was significantly lower in the patellar tendon group versus the hamstring group (hazard rate ratio = 0.63; 95% CI, 0.53-0.74), and it decreased with increasing age at surgery, although not strictly linearly. The lower risk of revision in the patellar tendon group was consistently observed across subgroups of patient sex, age, and concomitant cartilage injury (P > .05, test for interaction) but seemed to be slightly more pronounced for patients injured during certain pivoting activities (soccer, team handball, and alpine activities) compared with other activities (hazard rate ratio = 0.57 vs 0.81; P = .058, test for interaction). CONCLUSION: The majority of primary ACL reconstructions in Scandinavia are performed with hamstring autografts. Results from the present large prospective study show that patients receiving patellar tendon autografts have a statistically significantly lower risk of revision compared with patients receiving hamstring autografts.

Femoral fixation of hamstring tendon grafts in ACL reconstructions: the 2-year follow-up results of a prospective randomized controlled study.

PURPOSE: Hamstring tendon grafts are commonly used in anterior cruciate ligament (ACL) reconstructions. A number of fixation devices are available; however, several have limited clinical support. To our knowledge, no randomized controlled study comparing the EZLoc and the Bone Mulch Screw for femoral fixation in ACL reconstruction exists. Therefore, the purpose of this study was to compare the results following the use of these two femoral fixation devices. Time in surgery for the two methods was also to be compared. METHODS: A total of 110 patients between 18 and 45 years old at two orthopaedic departments, A (n = 55) and B (n = 55), were randomized to ACL reconstruction with femoral fixation of the hamstring graft with either the EZLoc or the Bone Mulch Screw. Surgical time was measured for each group. The patients were evaluated after 6 weeks and 3, 6, 12 and 24 months. The clinical examination included range of motion, evaluation of intraarticular swelling, tenderness at the lateral femoral condyle, the Lachman test, the Pivot shift test and the KT-1000 arthrometer. In addition, the visual analogue scale score for pain, the Tegner activity score, the Lysholm functional score and the knee injury and osteoarthritis outcome score were recorded. Knee extension and flexion muscle strength were also measured with a Biodex. RESULTS: There were no significant differences in any of the parameters mentioned above at the 2-year follow-up evaluation. Three patients in each group underwent revision ACL reconstruction during the study. More than 95% of the knees in both groups were found to be stable. Good to excellent results were found for all selected knee scores in both groups. There were no statistically significant differences between the two groups in any of the muscle strength parameters. Time in surgery was statistically significantly shorter in the EZLoc group compared with the Bone Mulch group. CONCLUSION: There were no statistically significant differences in clinical findings, knee scores or in muscle strength between the EZLoc group and the Bone Mulch group at the 2-year follow-up evaluation. Time in surgery was statistically significantly shorter for patients undergoing ACL reconstruction with hamstring grafts when the EZLoc femoral fixation device was used. LEVEL OF EVIDENCE: II.

Inferior results after revision ACL reconstructions: a comparison with primary ACL reconstructions.

PURPOSE: Anterior cruciate ligament (ACL) ruptures are common, especially among young athletes, and such injuries may have considerable impact on both sport careers and everyday life. ACL reconstructions are successful for most patients, but some suffer from persistent giving-way symptoms and/or re-ruptures requiring revision surgery. The aim of this study was to evaluate the results after revision ACL reconstructions and compare them with the results in a control group consisting of primary ACL reconstructions. METHODS: This retrospective study included 56 patients undergoing revision ACL reconstruction and 52 patients receiving primary ACL reconstructions. The follow-up evaluation included clinical examination, instrumented laxity testing, testing of muscle strength, Tegner activity score, Lysholm score, Knee injury and osteoarthritis outcome score (KOOS) and radiological grading of osteoarthritis. RESULTS: The median time from the last ACL reconstruction to follow-up was 90 months in the revision ACL reconstruction group and 96 months in the primary ACL reconstruction group. The revision group had significantly inferior KOOS and Lysholm scores compared with the primary group. Patients in the revision group also showed greater laxity measured with the pivot shift test, a larger reduction in the Tegner activity score, reduced muscle strength in the injured knee, and more severe radiological osteoarthritis; however, no difference in anterior-posterior translation was found. CONCLUSION: Inferior results were found on several of the testing parameters in the revision group compared with the primary group. Patients should receive this information prior to revision ACL reconstructions. LEVEL OF EVIDENCE: III.

Long-term follow-up of patellar tendon grafts or hamstring tendon grafts in endoscopic ACL reconstructions.

PURPOSE: Several studies compare the short- and long-term results of anterior cruciate ligament (ACL) reconstruction using bone-patellar tendon-bone (BPTB) graft or double-looped semitendinosus and gracilis (DLSG) graft. However, no studies evaluate the long-term results of BPTB grafts fixed with metal interference screws and DLSG grafts fixed with the Bone Mulch Screw and the Washer Loc. This prospective randomized multicentre study has the null hypothesis that there is no difference in long-term outcome between the two procedures. METHODS: A total of 114 patients with a symptomatic ACL rupture were randomized to reconstruction with either a BPTB graft (N = 58) or a DLSG graft (N = 56). Follow-up was conducted after one, two and seven years. At the seven-year follow-up, 102 of the 114 patients (89%) were available for evaluation; however, 16 of these by telephone-interview only. RESULTS: Ten patients in the BPTB group and 19 patients in the DLSG group underwent additional knee surgery (P = 0.048), two and three, respectively, of these were ACL revisions (n.s.). The total flexion work was lower in the DLSG group (P = 0.001). The mean peak flexion torque and extension work, however, showed no difference between the groups. No significant differences were found between the groups regarding the Tegner activity score, the Lysholm functional score, the Knee injury and osteoarthritis outcome score (KOOS), subjective knee function, anterior knee pain or mobility. There was no significant difference in laxity between the groups on the Lachman test or the KT-1,000 maximum manual force test. CONCLUSIONS: Both grafts and fixation methods resulted in satisfactory subjective outcome and objective stability. Both these methods can therefore be considered as suitable alternatives for ACL reconstructions. LEVEL OF EVIDENCE: II.