Quadriceps tendon autograft for primary anterior cruciate ligament reconstruction show comparable clinical, functional, and patient-reported outcome measures, but lower donor-site morbidity compared with hamstring tendon autograft: A matched-pairs study with a mean follow-up of 6.5 ​years.

OBJECTIVES: To compare clinical and functional outcomes of patients after primary anterior cruciate ligament reconstruction (ACLR) using quadriceps tendon- (QT-A) and hamstring tendon (HT-A) autograft with a minimum follow-up (FU) of 5 years. METHODS: Between 2010 and 2014, all patients undergoing ACLR were recorded in a prospectively administered database. All patients with primary, isolated QT-A ACLR and without any concomitant injuries or high grade of osteoarthritis were extracted from the database and matched to patients treated with HT-A. Re-rupture rates, anterior-posterior (ap) knee laxity, single-leg hop test (SLHT) performance, distal thigh circumference (DTC) and patient-reported outcome measures (PROMs) were recorded. Between group comparisons were performed using chi-square-, independent-samples T- or Mann-Whitney-U tests. RESULTS: 45 QT-A patients were matched to 45 HT-A patients (n â€‹= â€‹90). The mean FU was 78.9 â€‹± â€‹13.6 months. 18 patients (20.0%/QT-A: N â€‹= â€‹8, 17.8%; HT-A: n â€‹= â€‹10, 22.2%; p â€‹= â€‹.60) sustained a graft rupture and 17 subjects (18.9%/QT-A: n â€‹= â€‹9, 20.0%; HT-A: n â€‹= â€‹8, 17.8%; p â€‹= â€‹.79) suffered a contralateral ACL injury. In high active patients (Tegner activity level ≥ 7) rerupture rates increased to 37.5% (HT-A) and 22.2% (QT-A; p â€‹= â€‹.32), respectively. Patients with graft failure did not differ between both groups in terms of mean age at surgery (QT-A: 26.5 â€‹± â€‹11.6 years, HT-A: 23.3 â€‹± â€‹9.5 years, p â€‹= â€‹.63) or graft thickness (mean graft square area: QT-A: 43.6 â€‹± â€‹4.7 mm2, HT-A: 48.1 â€‹± â€‹7.9 mm2, p â€‹= â€‹.27). No statistical between-group differences were found in ap knee laxity side-to-side (SSD) measurements (QT-A: 1.9 â€‹± â€‹1.2 â€‹mm, HT-A: 2.1 â€‹± â€‹1.5 â€‹mm; p â€‹= â€‹.60), subjective IKDC- (QT-A: 93.8 â€‹± â€‹6.8, HT-A: 91.2 â€‹± â€‹7.8, p â€‹= â€‹.17), Lysholm- (QT-A 91.9 â€‹± â€‹7.2, HT-A: 91.5 â€‹± â€‹9.7, p â€‹= â€‹.75) or any of the five subscales of the KOOS score (all p â€‹> â€‹.05). Furthermore, Tegner activity level (QT-A: 6(1.5), HT-A: 6(2), p â€‹= â€‹.62), VAS for pain (QT-A: 0.5 â€‹± â€‹0.9, HT-A: 0.6 â€‹± â€‹1.0, p â€‹= â€‹.64), Shelbourne-Trumper score (QT-A: 96.5 â€‹± â€‹5.6, HT-A: 95.2 â€‹± â€‹8.2, p â€‹= â€‹.50), Patient and Observer Scar -Assessment scale (POSAS) (QT-A: 9.4 â€‹± â€‹3.2, HT-A: 10.7 â€‹± â€‹4.9, p â€‹= â€‹.24), SSD-DTC (QT-A: 0.5 â€‹± â€‹0.5, HT.- A: 0.5 â€‹± â€‹0.6, p â€‹= â€‹.97), return to sports rates (QT-A: 82.1%, HT-A: 86.7%) and SLHT (QT -A: 95.9 â€‹± â€‹3.8%, HT-A: 93.7 â€‹± â€‹7.0%) did not differ between groups. Donor-site morbidity (HT-A n â€‹= â€‹14, 46.7%; QT-A n â€‹= â€‹3, 11.5%; p â€‹= â€‹.008) was statistically significantly lower in the QT-A group. Five patients (11.1%) of the HT-group and three patients (6.7%) in the QT-group required revision surgery (p â€‹= â€‹.29). CONCLUSION: Patient-reported outcome measures, knee laxity, functional testing results and re-rupture rates are similar between patients treated with QT- and HT- autografts. However, patients with QT-autograft have a smaller tibial postoperative scar length and lower postoperative donor-site morbidity. There is a tendency towards higher graft rupture rates in highly active patients treated with HT autograft. LEVEL OF EVIDENCE: II.

Physical Fitness after Anterior Cruciate Ligament Reconstruction: Influence of Graft, Age, and Sex.

Functional tests are used to facilitate return-to-sports decisions after anterior cruciate ligament reconstruction (ACLR). This study presents comprehensive physical fitness test data acquired in highly active patients within the first year after ACLR, for comparison between different grafts, age groups, and sexes. The outcomes from a specific seven-item test battery and isokinetic strength test data were extracted from a patient database. Results were compared to normative data from age- and sex-matched controls and between subgroups of patients. A total of 245 patients (94 women, 23.8 ± 8.4 years, pre-injury Tegner 7.4 ± 1.6) were tested 185 ± 44 days after surgery. In 116 patients (47.3%), one or more test results were classified as "poor" or "very poor" after comparison with normative data, with failures being most frequent during single-leg squat jump and plyometric strength tests. Test failures were more prevalent in adults than in adolescents <19 years (61.4%-62.2% vs. 24.5%, p < 0.001) and in men (61.6% vs. 24.5%, p < 0.001), but no differences were found between grafts. Isokinetic knee extensor strength was lower by 24.1% on the injured side. Six months after ACLR, nearly 50% of highly active patients presented with strength and functional fitness deficits. These deficits are particularly prevalent in older patients and men.

Fitness, knee function and competition performance in professional alpine skiers after ACL injury.

OBJECTIVES: To assess the fitness of elite alpine skiers during recovery from anterior cruciate ligament (ACL) reconstruction and changes in performance level after return to competition. DESIGN: Retrospective cohort study. METHODS: The database of a specialized sports clinic was screened for professional alpine skiers with a history of ACL rupture and reconstruction. Strength and further functional tests as well as questionnaire data reflecting the athletes' subjective perception of pain, function in activities of daily living and physical activity levels were extracted. The website of the International Ski Federation (FIS) was used to obtain FIS points reflecting the competition performance level prior to injury, after return to competition as well as one year later. RESULTS: Questionnaire data revealed the highest patient satisfaction. Measurements performed 161.5±24.2days after surgery showed persistent muscle strength and power deficits, which primarily affected the knee extensor muscles and were more pronounced following reconstruction using quadriceps as compared to hamstring tendon grafts. FIS points increased immediately after return to competition (364.3±142.5days post-reconstruction) but dropped below pre-injury levels within the first year. CONCLUSIONS: ACL injuries sustained by professional skiers entail muscle strength and power deficits that persist for more than five months after surgery. The rate of recovery of knee extensor muscle function may be slower following ACL reconstruction using quadriceps tendon grafts. On average, athletes returned to competition within one year after surgery and succeeded in surpassing their baseline performance level within the first year after return to competition.

Non-operative treatment of ACL injury is associated with opposing subjective and objective outcomes over 20 years of follow-up.

PURPOSE: The aim of this study was the evaluation of long-term clinical and radiological outcomes of non-operative treatment of anterior cruciate ligament (ACL) deficiency. The hypothesis was that conservative treatment would be associated with a deterioration of subjective and objective measures of joint health and disability over time. METHODS: From an initial sample of 41 patients conservatively treated for ACL rupture, 10 received secondary ACL reconstruction, 1 was excluded due to contralateral ACL injury, and 1 patient required total knee replacement and a high tibial osteotomy. Seven further patients were lost to follow-up. The remaining 21 patients (15 male, 6 female, mean age 53.1 ± 9.2 years at the last follow-up) were evaluated by the same two examiners 5-7, 10-13 and 20-22 years after the injury. The evaluation was based on objective and subjective scores, instrumented testing, radiographic examination and assessment of sports activity. RESULTS: While subjective patient satisfaction improved over time, objective scores stayed constant or deteriorated (radiologic evaluation). Instrumented knee laxity testing showed an initial tendency to increasing instability, followed by a decrease in anterior tibial translation in the second half of the observation period. Physical activity levels, particularly in high-risk sports, decreased significantly (p < 0.05) compared to preinjury levels. All patients developed significant arthritic degenerative changes over time compared to the uninjured contralateral knee. No correlation to activities in high- or low-risk pivoting sports was found. CONCLUSIONS: Patient satisfaction with conservative treatment of ACL injuries is good in spite of objective measures indicating increasing degenerative changes. LEVEL OF EVIDENCE: IV.

Minimally Invasive Quadriceps Tendon Single-Bundle, Arthroscopic, Anatomic Anterior Cruciate Ligament Reconstruction With Rectangular Bone Tunnels.

Many surgeons use quadriceps tendon (QT) graft for anterior cruciate ligament (ACL) revision surgery; however, despite excellent clinical results, the QT has not achieved universal acceptance for primary ACL reconstruction. One of the reasons for this may be that the QT is technically demanding to harvest and the scar from open harvesting techniques is less cosmetically favorable than that from hamstring tendon techniques. Recent evidence has suggested that broad flat QT grafts may more closely mimic native ACL "ribbon-like" morphology than hamstring tendon grafts. Furthermore, rectangular bone tunnels may more accurately re-create native ACL attachments, allowing grafts to simulate native ACL rotation during knee flexion and potentially improving biomechanics. Rectangular tunnels have further advantages in revision cases, in which-in comparison with round tunnels-they have reduced overlap with pre-existing transtibial tunnels, increasing the chance of bypassing primary tunnels during revision surgery. Finally, instrumentation for minimally invasive QT harvesting has reduced technical difficulty and improved cosmetic results. Hence, technical and cosmetic concerns are no longer barriers to QT use. These anatomic and biomechanical advantages and technical developments make the QT an increasingly attractive option for both primary and revision ACL reconstruction.

Higher hamstring-to-quadriceps isokinetic strength ratio during the first post-operative months in patients with quadriceps tendon compared to hamstring tendon graft following ACL reconstruction.

PURPOSE: The aim of this study was to compare isokinetic quadriceps and hamstring muscle strength in patients following anterior cruciate ligament (ACL) reconstruction who received either hamstring (HT) or quadriceps (QT) tendon autografts at two time intervals within the first year after surgery. METHODS: One hundred twenty-four patients, 81 males (age 22.0 ± 6.2 years) and 43 females (age 20.9 ± 8.7 years), participated in this study. ACL reconstruction was performed with either quadriceps tendon autografts (QT; n = 61) or hamstring tendon autografts (HT; n = 63). Two isokinetic muscle strength tests (t1: 5.5 ± 1.2 months; t2: 7.6 ± 1.6 months) were performed at an angular velocity of 60°/s in both the injured and contralateral knees. An independent t test as well as a two-factor analysis of variance with repeated measurements was used. The significance level was set at p < 0.05. RESULTS: A statistically significant lower knee extensor strength was observed in the QT group within one year after surgery (p < 0.001). Additionally, data showed a significant higher H/Q ratio in QT patients compared to the HT group at t1 (p < 0.001) and t2 (p = 0.001) as well as a significant effect over time (p < 0.001) and interaction effect of time and graft (p = 0.007). Side-to-side values for extensor muscle strength were significantly (p < 0.001) greater in HT graft patients, while QT patients showed significantly (p < 0.001) greater values for flexor muscle strength at both time points of isokinetic testing, respectively. CONCLUSION: The results of this study indicate that graft choice has an impact on extensor strength in the first months after ACL reconstruction; however, there is no impact on flexor strength. The finding of a higher H/Q ratio in patients with QT grafts within the first months following surgery is possibly of clinical relevance. This may potentially be associated with lower stress on the maturing ACL graft. Furthermore, normal thigh strength can be restored over time. LEVEL OF EVIDENCE: III.

There is no difference between quadriceps- and hamstring tendon autografts in primary anterior cruciate ligament reconstruction: a 2-year patient-reported outcome study.

PURPOSE: Graft choice for anterior cruciate ligament (ACL) reconstruction is crucial, however the optimal graft source remains a topic of controversy. The purpose of this study is to compare subjective and functional patient-reported outcomes (PRO) after single-bundle ACL reconstruction using quadriceps tendon (QT) or hamstring tendon (HT) autografts for single-bundle ACL reconstruction. We hypothesize that there is no difference in patient-reported functional outcomes after ACL reconstruction using either HT- or QT autograft. METHODS: All data were extracted from a prospectively collected ACL registry. A total of 80 patients with at least 2-year follow-up were included in this study. A total of 40 patients with primary ACL reconstruction using a QT autograft harvested via a minimally invasive technique were matched by sex, age and pre-injury Tegner and Lysholm score to 40 patients who received HT autografts. Subjective and functional PRO scores including Lysholm score, Tegner activity level and visual analogue scale for pain were obtained at 6, 12 and 24 months after index surgery. RESULTS: No significant difference between the QT and the HT group was seen at any follow-up in regard to any of the PRO scores for function or pain. 24 months post-surgery the mean Tegner activity score of the HT group was significantly (p = 0.04) lower compared to the pre-injury status. At final follow-up, 27 patients (67.5%) in the QT group and 32 patients (80.0%) in the HT returned to their pre-injury activity level (n.s.). A total of 37 patients (92.5%) of the QT cohort and 35 patients (87.5%) of the HT cohort reported "good" or "excellent" results according to the Lysholm score (n.s.). "No pain" or "slight pain" during severe exertion was reported by 33 patients (82.5%) with QT autograft and 28 patients (82.4%) with HT autograft (n.s.). CONCLUSION: There is no significant difference between PRO 2 years post-operative using either QT or HT autografts. Both QT and HT grafts show acceptable and comparable PRO scores making the QT a reliable graft alternative to HT for primary ACL reconstruction. LEVEL OF EVIDENCE: III.

Sports activity is maintained or increased following total knee arthroplasty.

PURPOSE: The purpose of this study was to investigate sports activities and functional abilities in patients following total knee arthroplasty (TKA). It was hypothesized that patients who had undergone TKA would return to a higher activity level as that experienced preoperatively. METHODS: Two hundred patients were included in this prospective single-cohort study. All the patients completed subjective questionnaires (Tegner Activity Level, Oxford Knee Score, Visual Analog Scale for pain) prior to surgery as well as at 6, 12, and 24 months postoperatively. Additionally, sports behaviour was evaluated. Sports frequency was divided into four categories: more than 5 times a week, 2-3 times a week, occasionally, and no sports activities. Additionally, the patients were asked to state their three favourite summer and winter sports. RESULTS: All patient-reported outcome scores improved significantly over time (p ≤ 0.005). The Tegner Activity Level increased significantly from the preoperative state to 24 months postsurgery (p = 0.005). Six months after surgery, 43% of the patients returned to the same and 35% to a higher Tegner Activity Level than prior to surgery. Gender-related differences were observed for the Tegner Activity Level showing a higher activity level for the male than for the female patients. Overall, 24 months postsurgery 83% of the patients practiced sports in comparison with 79% prior to surgery. CONCLUSIONS: Following TKA, the patients were able to increase sports performance, while pain was reduced. Therefore, patients who want to continue their desired sports may safely consider TKA. LEVEL OF EVIDENCE: II.

Acute ACL reconstruction in patients over 40 years of age.

PURPOSE: The purpose of this study is to compare the clinical outcome of ACL reconstructions in patients older than 40 years of age to younger subjects. It has been hypothesized that patients older than 40 years of age achieve comparable clinical outcomes following acute ACL reconstruction using a hamstring tendon autograft than younger patients. METHODS: Patients with an isolated ACL tear without any concomitant injuries and subsequent ACL reconstruction within 48 h from injury were included in this prospective study. According to patients' age, subjects were assigned to two groups: (A) 18-40 years and (B) 40-60 years. Functional outcomes, pain, post-operative radiographs and return to sports were recorded and analysed. The follow-up period was 24 months. RESULTS: A total of 59 patients were included in the study. Group A consisted of 39 patients (14 women, 25 men; median 27 years), group B of 20 patients (12 women, 8 men; median 45 years) respectively. At final follow-up, the Lysholm score showed no significant difference between group A (median 90; range 68-100) and group B (median 94.5; range 63-100) (n.s.). The final Tegner score showed a significant difference between group A (median 6; range 2-9) and group B (median 5.5; range 3-8) (p < 0.05). The mean VAS pain score was 1.3 (range 0-6) in group A and 1 (range 0-7) in group B, respectively (n.s.). Both groups returned to their pre-injury activity level and did not significantly change their activity in respect of pivoting sports and sports frequency at final follow-up (n.s.). According to the IKDC score, all except one of the patients in group A and all patients in group B had a normal or nearly normal final outcome (n.s.). CONCLUSION: Patients older than 40 years of age achieve comparable clinical outcomes following acute ACL reconstruction using a hamstring tendon autograft than younger patients. LEVEL OF EVIDENCE: Cohort study, Level III.

Impact of surgical timing on the outcome of anterior cruciate ligament reconstruction.

PURPOSE: The purpose of the present study is the comparison of acute ACL reconstruction with or without meniscus repair within 48 h after injury and a delayed surgery during the inflammation-free interval. It was hypothesized that acute ACL reconstruction results in inferior patient reported outcomes and higher frequency of range of motion deficits. METHODS: The effect of acute (within 48 h) and delayed (during the inflammation-free interval) ACL surgery was prospectively studied on 160 consecutive patients with ACL injury between January 2010 and December 2011. Subgroup analyses were performed to evaluate patients with an additional meniscus repair separately from isolated ACL surgeries. During the study period, partial meniscectomies were recorded to evaluate time dependent meniscus reparability. Patient reported outcomes, objective IKDC and manual stability measurements were documented during the 24-month follow-up period. The Pearson Chi-squared test was used to evaluate objective outcome measures. The Mann-Whitney U test was performed to analyse the results of patient reported outcomes. Statistical significance was set at p < 0.05. RESULTS: For patients who underwent isolated ACL reconstruction, no statistical significant difference was observed at any time point regarding objective and subjective outcome measures. Significantly fewer patients who underwent acute combined ACL reconstruction and meniscus repair had an extension deficit between 3° and 5° at 12 months following surgery (3.7 vs. 22.2 %, p < 0.05). No difference regarding cyclops removal, re-injury of ACL or meniscus was found between the two surgical timing groups. Further, surgical timing did not influence the reparability of the meniscus. CONCLUSION: An acute ACL reconstruction within 48 h is preferable in highly active patients or competitive athletes. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

The effects of a 3-month controlled hiking programme on the functional abilities of patients following total knee arthroplasty: a prospective, randomized trial.

PURPOSE AND HYPOTHESIS: Improvements in pain, function and sports activity are the main goals of patients following total knee arthroplasty (TKA). Participation in sports has become an increasingly important contributor to patients' quality of life (QoL). Hiking is one of the most popular summer activities among elderly people in alpine regions. Consequently, this randomized controlled trial investigates the impact of a 3-month guided hiking programme on patients' functional abilities and QoL following TKA. It was hypothesized that patients who participate in this programme would demonstrate improvements in functional and QoL parameters compared with a control group. METHODS: Forty-eight TKA patients were included and randomized into either the intervention group (IG; n = 25) or the control group (CG; n = 23). The IG participated in a 3-month hiking programme (2-3 times a week), whereas the CG performed activities of daily living. The stair climb test (SCT), QoL questionnaires and isokinetic force measurements were completed at three time points (i.e. pre-test, post-test, retention-test). ANOVAs for repeated measurements were conducted for the SCT results. The Friedman test and the Mann-Whitney U test were performed for the QoL parameters. RESULTS: After the 3-month hiking programme, the IG achieved faster overall walking times on the SCT. The time decreased from 4.3 ± 0.6 s (pre-test) to 3.6 ± 0.4 s (post-test) for the stair ascent (p = 0.060) and from 3.6 ± 0.6 s (pre-test) to 3.2 ± 0.5 s (post-test) for the stair descent (p = 0.036). The IG showed significant improvement on some of the subscales of the Knee Injury and Osteoarthritis Outcome Score from pre-test to retention-test (p < 0.01). In the CG, no significant changes were observed (n.s.). CONCLUSIONS: The results indicate moderate improvement in the functional abilities and QoL of TKA patients who participated in a 3-month guided hiking programme compared with the patients in the CG. Hiking did not have any acute detrimental effects on the TKA patients during this study period. LEVEL OF EVIDENCE: II.

Anatomical MCL reconstruction following TKA.

Adequate ligament balancing has a tremendous impact on successful total knee arthroplasty. In case of instability, severely disabling symptoms require revision surgery. Here we present a case of early total knee arthroplasty failure due to secondary valgus laxity, which was successfully treated with medial collateral ligament (MCL) reconstruction. For anatomical MCL reconstruction, a flattened semitendinosus autograft was used to reconstruct the superficial medial collateral and the posterior oblique ligament.