Surgical Heritage: You Had to Be There, Ross: The Comeback Kid.

Half a century after the first pulmonary autograft operation (Ross operation), performed in 1967 by Donald Ross in central London, there is a very strong conviction that the Ross operation is the best available valve substitute today, not only for children, but also for younger and older adults. The Ross operation has stimulated a lot of science to do with tissue-engineering and biology of heart valves, which is a promising avenue for the future. For one of us (M.Y.), it has certainly been a privilege to be associated with the comeback of the Ross operation.

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.

Weaker Quadriceps Muscle Strength With a Quadriceps Tendon Graft Compared With a Patellar or Hamstring Tendon Graft at 7 Months After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Impaired quadriceps muscle strength after anterior cruciate ligament reconstruction (ACLR) is associated with worse clinical outcomes and a risk of reinjuries. Yet, we know little about quadriceps muscle strength in patients reconstructed with a quadriceps tendon (QT) graft, which is increasing in popularity worldwide. PURPOSE: To describe and compare isokinetic quadriceps strength in patients undergoing ACLR with a QT, hamstring tendon (HT), or bone-patellar tendon-bone (BPTB) autograft. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We included patients with QT grafts (n = 104) and matched them to patients with HT (n = 104) and BPTB (n = 104) grafts based on age, sex, and associated meniscal surgery. Data were collected through clinical strength testing at a mean of 7 ± 1 months postoperatively. Isokinetic strength was measured at 90 deg/s, and quadriceps strength was expressed as the limb symmetry index (LSI) for peak torque, total work, torque at 30° of knee flexion, and time to peak torque. RESULTS: Patients with QT grafts had the most impaired isokinetic quadriceps strength, with the LSI ranging between 67.5% and 75.1%, followed by those with BPTB grafts (74.4%-81.5%) and HT grafts (84.0%-89.0%). Patients with QT grafts had a significantly lower LSI for all variables compared with patients with HT grafts (mean difference: peak torque: -17.4% [95% CI, -21.7 to -13.2], P < .001; total work: -15.9% [95% CI, -20.6 to -11.1], P < .001; torque at 30° of knee flexion: -8.8% [95% CI, -14.7 to -2.9], P = .001; time to peak torque: -17.7% [95% CI, -25.8 to -9.6], P < .001). Compared with patients with BPTB grafts, patients with QT grafts had a significantly lower LSI for all variables (mean difference: peak torque: -6.9% [95% CI, -11.2 to -2.7], P < .001; total work: -7.7% [95% CI, -12.4 to -2.9], P < .001; torque at 30° of knee flexion: -6.3% [95% CI, -12.2 to -0.5], P = .03; time to peak torque: -8.8% [95% CI, -16.9 to -0.7], P = .03). None of the graft groups reached a mean LSI of >90% for peak torque (QT: 67.5% [95% CI, 64.8-70.1]; HT: 84.9% [95% CI, 82.4-87.4]; BPTB: 74.4% [95% CI, 72.0-76.9]). CONCLUSION: At 7 months after ACLR, patients with QT grafts had significantly worse isokinetic quadriceps strength than patients with HT and BPTB grafts. None of the 3 graft groups reached a mean LSI of >90% in quadriceps strength.

External validation of the Norwegian anterior cruciate ligament reconstruction revision prediction model using patients from the STABILITY 1 Trial.

PURPOSE: A machine learning-based anterior cruciate ligament (ACL) revision prediction model has been developed using Norwegian Knee Ligament Register (NKLR) data, but lacks external validation outside Scandinavia. This study aimed to assess the external validity of the NKLR model (https://swastvedt.shinyapps.io/calculator_rev/) using the STABILITY 1 randomized clinical trial (RCT) data set. The hypothesis was that model performance would be similar. METHODS: The NKLR Cox Lasso model was selected for external validation owing to its superior performance in the original study. STABILITY 1 patients with all five predictors required by the Cox Lasso model were included. The STABILITY 1 RCT was a prospective study which randomized patients to receive either a hamstring tendon autograft (HT) alone or HT plus a lateral extra-articular tenodesis (LET). Since all patients in the STABILITY 1 trial received HT ± LET, three configurations were tested: 1: all patients coded as HT, 2: HT + LET group coded as bone-patellar tendon-bone (BPTB) autograft, 3: HT + LET group coded as unknown/other graft choice. Model performance was assessed via concordance and calibration. RESULTS: In total, 591/618 (95.6%) STABILITY 1 patients were eligible for inclusion, with 39 undergoing revisions within 2 years (6.6%). Model performance was best when patients receiving HT + LET were coded as BPTB. Concordance was similar to the original NKLR prediction model for 1- and 2-year revision prediction (STABILITY: 0.71; NKLR: 0.68-0.69). Concordance 95% confidence interval (CI) ranged from 0.63 to 0.79. The model was well calibrated for 1-year prediction while the 2-year prediction demonstrated evidence of miscalibration. CONCLUSION: When patients in STABILITY 1 who received HT + LET were coded as BPTB in the NKLR prediction model, concordance was similar to the index study. However, due to a wide 95% CI, the true performance of the prediction model with this Canadian and European cohort is unclear and a larger data set is required to definitively determine the external validity. Further, better calibration for 1-year predictions aligns with general prediction modelling challenges over longer periods. While not a large enough sample size to elicit the true accuracy and external validity of the prediction model when applied to North American patients, this analysis provides more support for the notion that HT plus LET performs similarly to BPTB reconstruction. In addition, despite the wide confidence interval, this study suggests optimism regarding the accuracy of the model when applied outside of Scandinavia. LEVEL OF EVIDENCE: Level 3, cohort study.

Approximately half of pediatric or adolescent patients undergoing revision anterior cruciate ligament reconstruction return to the same level of sport or higher: A systematic review.

PURPOSE: To summarise the surgical techniques and clinical outcomes in paediatric and adolescent patients undergoing revision anterior cruciate ligament reconstruction (r-ACLR). METHODS: Three databases (MEDLINE, PubMed and EMBASE) were searched from inception to 29 July 2023. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, surgical details, patient-reported outcome measures (PROMs), rates of instability, rupture and return to sport (RTS) were extracted. RESULTS: Eight studies comprising 706 (711 knees) patients were included (48.7% female). The mean age at r-ACLR was 17.1 years (range: 16.5-18.0). Autografts (67.5%) were more common than allografts (32.2%) in revision, with bone-patellar tendon-bone (BPTB) being the most prevalent autograft source (59.6%). Bone grafts were used in seven patients (4.8% of 146 patients). The most common femoral and tibial fixation techniques were interference screws (37.6% and 38.1%, of 244 patients, respectively). The most common tunnelling strategy was anatomic (69.1% of 236 patients), and meniscus repairs were performed in 39.7% of 256 patients. The re-rupture rate was 13.0% in 293 patients. RTS at the same level or higher was 51.6% in 219 patients. The mean (SD) Lysholm score was 88.1 (12.9) in 78 patients, the mean (SD) Tegner score was 6.0 (1.6) in 78 patients, and the mean (SD) IKDC score was 82.6 (16.0) in 126 patients. CONCLUSION: R-ACLR in paediatric and adolescent patients predominantly uses BPTB autografts and interference screw femoral and tibial fixation with concomitant meniscal procedures. Rates of re-rupture and RTS at the same level or higher were 13.0% and 51.6%, respectively. Information from this review can provide orthopaedic surgeons with a comprehensive understanding of the most commonly used operative techniques and their outcomes for revision ACLR in this population. LEVEL OF EVIDENCE: Level IV.

Maximizing wound coverage in full-thickness skin defects: A randomized-controlled trial of autologous skin cell suspension and widely meshed autograft versus standard autografting.

BACKGROUND: Traumatic insults, infection, and surgical procedures can leave skin defects that are not amenable to primary closure. Split-thickness skin grafting (STSG) is frequently used to achieve closure of these wounds. Although effective, STSG can be associated with donor site morbidity, compounding the burden of illness in patients undergoing soft tissue reconstruction procedures. With an expansion ratio of 1:80, autologous skin cell suspension (ASCS) has been demonstrated to significantly decrease donor skin requirements compared with traditional STSG in burn injuries. We hypothesized that the clinical performance of ASCS would be similar for soft tissue reconstruction of nonburn wounds. METHODS: A multicenter, within-patient, evaluator-blinded, randomized-controlled trial was conducted of 65 patients with acute, nonthermal, full-thickness skin defects requiring autografting. For each patient, two treatment areas were randomly assigned to concurrently receive a predefined standard-of-care meshed STSG (control) or ASCS + more widely meshed STSG (ASCS+STSG). Coprimary endpoints were noninferiority of ASCS+STSG for complete treatment area closure by Week 8, and superiority for relative reduction in donor skin area. RESULTS: At 8 weeks, complete closure was observed for 58% of control areas compared with 65% of ASCS+STSG areas (p = 0.005), establishing noninferiority of ASCS+STSG. On average, 27.4% less donor skin was required with ASCS+ STSG, establishing superiority over control (p < 0.001). Clinical healing (≥95% reepithelialization) was achieved in 87% and 85% of Control and ASCS+STSG areas, respectively, at 8 weeks. The treatment approaches had similar long-term scarring outcomes and safety profiles, with no unanticipated events and no serious ASCS device-related events. CONCLUSION: ASCS+STSG represents a clinically effective and safe solution to reduce the amount of skin required to achieve definitive closure of full-thickness defects without compromising healing, scarring, or safety outcomes. This can lead to reduced donor site morbidity and potentially decreased cost associated with patient care.Clincaltrials.gov identifier: NCT04091672. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level I.

Time to treat the tendon rupture induced by surgery: early hypertrophy of the patellar tendon graft site predicts strong quadriceps after ACLR with bone-patellar tendon-bone autograft.

PURPOSE: Quadriceps dysfunction is ubiquitous after anterior cruciate ligament reconstruction, especially when using bone-patellar tendon-bone (BPTB) autografts. The role of patellar tendon hypertrophy after graft harvest on knee extensor strength is unknown. The purpose of this study was to determine the predictive ability of patellar tendon (PT) and quadriceps muscle (Quad) cross-sectional area (CSA) on knee extensor strength 1-2 months after ACLR using BPTB autografts. METHODS: This is a cross-sectional analysis of a cohort 1-2 months after ACLR using BPTB autograft. Peak knee extensor torque, and PT and Quad CSA measured using ultrasound imaging, were collected in 13 males and 14 females. Simple linear regressions compared quadriceps strength index (QI) against limb symmetry index (LSI) in PT and Quad CSA. Multiple linear regressions with sequential model comparisons predicting peak knee extensor torque were performed for each limb. The base model included demographics. Quad CSA was added in the first model, then PT CSA was added in the second model. RESULTS: Both PT (p < 0.001, R2 = 0.693) and Quadriceps CSA (p = 0.013, R2 = 0.223) LSI had a positive linear relationship with QI. In the involved limb, addition of PT CSA significantly improved the model (R2 = 0.781, ΔR2 = 0.211, p for ΔR2 < 0.001). In the uninvolved limb, the addition of Quad CSA improved the model, but the addition of PT CSA did not. CONCLUSION: PT LSI was more predictive of QI than Quad CSA LSI. Involved limb PT CSA mattered more in predicting peak knee extensor torque than did Quad CSA, but in the uninvolved limb, Quad CSA was the most important predictor of peak knee extensor torque. Graft site patellar tendon hypertrophy is key for strong quadriceps early after ACLR. Early targeted loading via exercise to promote healing of the graft site patellar tendon may bring patients a step closer to winning their battle against quadriceps dysfunction. LEVEL OF EVIDENCE: Level I.

Near complete quadriceps tendon healing 2 years following harvest in anterior cruciate ligament reconstruction.

PURPOSE: Despite the recent increase in the use of quadriceps tendon (QT) autograft in anterior cruciate ligament reconstruction (ACLR); however, there remains a paucity of literature evaluating the postoperative morphology of the QT. The present study aimed to determine the postoperative morphologic change of the QT at a minimum of 2 years following harvesting during ACLR. METHODS: Patients who underwent ACLR with QT autograft and underwent magnetic resonance imaging (MRI) at a minimum of 2 years following harvesting were retrospectively included in the study. The anterior-to-posterior (A-P) thickness, medial-to-lateral (M-L) width, cross-sectional area (CSA), and signal/noise quotient (SNQ) of the QT were assessed at 5 mm, 15 mm, and 30 mm proximal to the superior pole of the patella on MRI. The CSA was adjusted by the angle between the QT and the plane of the axial cut based on a cosine function (adjusted CSA). The A-P thickness, M-L width, adjusted CSA, and SNQ were compared pre- and postoperatively. In addition, defects or scar tissue formation in the harvest site were investigated on postoperative MRI. RESULTS: Thirty patients were recruited for the study. The mean duration between postoperative MRI and surgery was 2.8 ± 1.1 years. The mean A-P thickness was 10.3% and 11.9% larger postoperatively at 5 mm and 15 mm, respectively. The mean M-L width was 7.3% and 6.5% smaller postoperatively at 5 mm and 15 mm, respectively. There were no significant differences in the adjusted CSA between pre- and post-operative states (275.7 ± 71.6 mm2 vs. 286.7 ± 91.8 mm2, n.s.). There was no significant difference in the postoperative change in the SNQ of the QT at all assessment locations. Defect or scar tissue formation at the harvest site was observed in 4 cases (13.3%), and 5 cases (16.6%), respectively. CONCLUSION: At a minimum of 2 years following QT harvest during ACLR, the QT became slightly thicker and narrower (approximately 11% and 7%, respectively). While the current study demonstrates that QT re-harvesting can be considered due to nearly normalized tendon morphology, future histological and biomechanical studies are required to determine the re-harvesting potential of the QT. LEVEL OF EVIDENCE: IV.

Ross procedure with personalized external aortic root support.

The Ross-Personalized External Aortic Root Support procedure is a surgical aortic valve replacement technique in which the autologous pulmonary valve is transposed in the aortic position to replace the malfunctioning aortic valve and a homograft is implanted in the pulmonary position. To prevent autograft dilatation, a Personalized External Aortic Root Support prosthesis is included in the proximal autograft anastomosis and wrapped around the ascending aorta. The aorta is transected transversely, the aortic valve is resected, and the coronary arteries are mobilized and cut out of the sinuses, leaving a rim. The pulmonary autograft is harvested by transecting the pulmonary artery and part of the right ventricular outflow tract. The autograft is approximated to the aortic root and inverted inside the ventricle. The proximal anastomosis is performed including the prosthesis between the aortic root and the autograft. The coronary buttons are threaded through appropriately positioned and sized holes in the prosthesis and reimplanted into the autograft. The ascending aorta is appropriately adapted and anastomosed with the distal autograft. When the patient is off cardiopulmonary bypass, the prosthesis can be closed longitudinally and is anchored to the distal aortic adventitia.

A hamstring autograft diameter ≤ 8 mm is a safe option for smaller, lighter and female athletes who want to return to pivoting sports after ACL reconstruction : Results from a retrospective evaluation of a local ACL register.

PURPOSE: To investigate the association between hamstring autograft diameter and ACL graft failure rate in athletes who successfully returned to pivoting sports after ACL reconstruction. METHODS: Retrospective evaluation of ACL graft failure rates in athletes who underwent ACL reconstruction with all-inside hamstring autograft and successfully returned to pivoting sports following postoperative rehabilitation. Athletes were divided into a ≤ 8 mm group and a > 8 mm group. Data about return to pivoting sports and ACL graft failures after ACL reconstruction were collected via a digital questionnaire. ACL graft failures were in all cases confirmed by an orthopaedic surgeon and/or MRI. The association between hamstring autograft diameter and ACL graft failure rate was investigated using a Fisher's exact test in the subgroup of athletes who completed the digital questionnaire and returned to pivoting sports. RESULTS: Two-hundred and twenty-nine of the 422 athletes who completed the digital questionnaire (54.2%) returned to a pivoting sport and were included for final analyses. Ninety-seven (42.4%) of the athletes who returned to sport were in the ≤ 8 mm group (8 graft failures) and 132 (57.6%) in the > 8 mm group (10 graft failures). There were significantly more women (49.5 and 13.6% respectively; p < 0.001) and significantly smaller (1.75 and 1.81 m respectively; p < 0.001), lighter (72.2 and 79.6 kg respectively; p < 0.001) and younger (23.6 and 26.1 years old respectively; p = 0.015) athletes in the ≤ 8 mm group compared to the > 8 mm group. There was no significant association between hamstring autograft diameter and ACL graft failure rate. CONCLUSION: A hamstring autograft diameter of ≤ 8 mm is a legitimate option for smaller, lighter and female athletes without increasing the risk for ACL graft failure. LEVEL OF EVIDENCE: III.

Variable Adjustment Methods for Hemihamate Autograft Arthroplasty in Proximal Interphalangeal Joint Fracture/Dislocations: A Surgical Technique Revisited and Case Series.

ABSTRACT: Proximal interphalangeal joint fracture/dislocations, even after surgical correction, often lead to long-term complications including posttraumatic arthritis, prolonged joint stiffness, and chronic joint instability. A wide range of surgical techniques has been devised to resolve this issue, but none has been promising enough. Despite this circumstance, arthroplasty using a hemihamate autograft of size and contour that match the middle phalangeal base has progressed into one of more acceptable methods that provide both articular congruency and osseous stability. In this article, we introduce various types of proximal interphalangeal joint fracture/dislocations and individualized surgical approach using hemihamate autograft and lag screw and/or hook plate as fixation methods.

A Web-Based Prediction Tool to Improve Identification of Patients With Undersized Hamstring Tendon Autograft in Anterior Cruciate Ligament Reconstruction.

BACKGROUND: An undersized hamstring tendon (HT) autograft is significantly associated with a higher graft failure rate in anterior cruciate ligament reconstruction (ACLR) surgery. The ability to accurately predict inadequate HT graft diameter is critical, as it could assist surgeons in making better graft choices and surgical plans. PURPOSE: To develop a web-based prediction tool to better assess the size of HT autograft and to help clinicians accurately identify patients with potentially undersized HT grafts in order to make appropriate clinical decisions. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 588 patients who received primary arthroscopic single-bundle ACLR surgery with gracilis tendon (GT) and semitendinosus tendon (ST) autograft were retrospectively reviewed. According to the size of 4-strand HT graft, patients were divided into diameter ≥8 mm and <8 mm groups. The least absolute shrinkage and selection operator method and logistic regression were used to identify the independent factors associated with HT graft diameter and establish the models. The prediction performance of the model was evaluated by concordance index and calibration combined with external validation. The diagnostic performance of the prediction model was assessed by sensitivity, specificity, predictive values, and likelihood ratios. Decision curve analysis was used to evaluate the clinical utility of the model. RESULTS: Among the numerous indicators, sex, weight, height, thigh length, and ST-GT diameter (measured on plane 1 of a magnetic resonance imaging scan) were identified to be highly correlated predictors that could provide satisfactory prediction performance in determining the HT graft diameter. Based on these predictors, a prediction model named the HTD model was developed with satisfactory discrimination (concordance index, 0.932) and calibration (mean absolute error, 0.039). When the probability calculated by the HTD model was >65%, the sensitivity and specificity of predicting 4-strand HT graft diameter ≥8 mm were 86.7% and 90.2%, respectively. CONCLUSION: As a useful supplementary prediction tool, the HTD model could accurately predict the diameter of HT autograft during preoperative planning.

Observing the factors affecting fibrovascular regrowth after pterygium excision and comparing the efficacy and complications of conjunctival autograft with sutures versus fibrin glue.

Aim: To observe the factors affecting fibrovascular regrowth after pterygium excision and to compare the efficacy and complications of conjunctival autograft with sutures versus fibrin glue. Materials and methods: 65 consenting patients with primary pterygium attending the outpatient department having appropriate indications for surgery were enrolled. Data was collected using personal interviews. Routine pre-operative ophthalmic examination was done, including visual acuity assessment, slit lamp examination, and fundus evaluation. Pterygium excision surgery was done on all patients using either Fibrin Glue or 10-0 nylon sutures. Patients were followed up at weeks 1, 4, 12, and 24 and any complications were duly noted. Results: The fibrin glue group showed milder postoperative discomfort, symptoms, and signs compared to the suture group. Pyogenic granuloma (3.12%), corkscrew vessels (6.25%), and subconjunctival hemorrhage (24.99%) were more common in the fibrin glue group. FVG not crossing the limbus was observed in 6.25% of glue cases and 9.09% of suture cases, more in fleshy and large pterygia, while age and gender did not alter the incidence of FVG. No recurrences were observed in any group. Conclusion: The incidence of fibrovascular regrowth (FVG) was not affected by age, gender, smoking, and surgical technique, but was positively correlated with length and grade of pterygium. The complication rate between the two groups was not found to be statistically significant. Despite causing severe postoperative discomfort and requiring prolonged surgical time, suture-assisted pterygium surgery is a cost-effective method still being used with long-term outcomes similar to fibrin glue.

A modified technique for autologous dorsal nasal augmentation rhinoplasty.

OBJECTIVE: Autologous dorsal cartilage grafts are usually the first choice for nasal augmentation. We aimed to describe a modified technique for autologous dorsal nasal augmentation rhinoplasty. PATIENTS AND METHODS: The study group consisted of a retrospective review of patients who underwent augmentation rhinoplasty surgery and were treated with diced cartilage in platelet-rich plasma (PRP) in the last five years at King Abdulaziz University Hospital. Gender, age, smoking history, saddle nose etiology, complications, mean duration of surgery, mean duration of hospital stay, morbidity, mortality, and surgical technique used were assessed and analyzed. The outcome of this technique was compared with other techniques used for augmentation rhinoplasty published in the current literature. RESULTS: A selective, retrospective analysis was conducted on patients undergoing rhinoplasty between 2017 and 2022. A total number of 30 patients' files were reviewed; of those, eight patients were males, and 22 were females. The average age of the participants was 33, with a minimum of 19 years and a maximum of 55. The indications for surgery are listed in Table II. Cartilage graft was harvested from the concha in 14 patients, from the septum in eight patients, and from both sites in eight. Male and female samples are shown in Figures 1 and 2. We have only observed graft resorption in two female cases, and none of the patients had any complications. CONCLUSIONS: We have assessed the patients who underwent rhinoplasty with the modified technique for autologous dorsal augmentation. The combination of diced cartilage and PRP yielded good results with a low resorption incidence; when done correctly, no complications were observed. Platelet-rich plasma (PRP) contains a greater volume of platelets and Platelet-Derived Growth Factors, which exert multiple actions on different aspects of reparative and regenerative tissue phenomena. Augmentation rhinoplasty using PRP offers stabilization and enclosure of diced cartilage without the risks of hypersensitivity or disease transmission.

Contralateral hamstring autografts do not provide benefit compared to ipsilateral hamstring autografts in primary or revision anterior cruciate ligament reconstruction: a systematic review.

PURPOSE: To evaluate the clinical outcomes of primary or revision ACL reconstruction (ACLR) after contralateral hamstring autografts versus ipsilateral hamstring autograft harvest. METHODS: Three databases (MEDLINE, PubMed and EMBASE) were searched from inception to April 27th, 2023 for studies investigating contralateral hamstring autografts in primary or revision ACLR. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, strength measures, patient-reported outcome measures (PROMs), and rates of positive Lachman test, positive pivot-shift test and graft rupture were extracted. PROMs included Lysholm, International Knee Documentation Committee (IKDC) and Tegner scores. RESULTS: Nine studies comprising 371 patients were included in this review. In primary ACLR, there were no significant differences between contralateral and ipsilateral groups in isokinetic hamstring torque in the non-ACLR limb or isokinetic quadriceps torque in both limbs when tested at 60, 90, 120 or 180 degrees/second. Isokinetic hamstring torque in the non-ACLR limb was significantly weaker in the contralateral group at six months for primary ACLR; however, these deficits did not persist. There were no significant differences in postoperative median Tegner scores and Lysholm scores between contralateral and ipsilateral groups in primary ACLR. There were no significant differences in postoperative median Tegner, mean Lysholm and IKDC scores between groups in revision ACLR. There were no significant differences in positive Lachman, positive pivot-shift and rupture rates in primary ACLR between groups. Rates of positive Lachman and pivot-shift were slightly higher in the contralateral than ipsilateral group for revision ACLR. CONCLUSION: Contralateral hamstring autografts results in comparable muscle strength to ipsilateral hamstring autografts, with the exception of weaker hamstring strengths in the early postoperative period. Patient-reported outcome measures were similar between the two groups across both primary and revision ACLR, with rates of instability and failure being similar between groups for primary ACLR. Contralateral hamstring grafts do not provide additional benefit when compared to ipsilateral options for either primary or revision ACLR, and should be used only in select circumstances including insufficient ipsilateral hamstring grafts or situations where quadriceps or patella autografts are not optimal. LEVEL OF EVIDENCE: Level IV.

There is no difference in the efficacy of anterior cruciate ligament reconstruction using autograft combined with or without ligament augmentation: a systematic review and meta-analysis.

PURPOSE: This study aims to determine the efficacy of anterior cruciate ligament reconstruction (ACLR) using autograft combined with or without ligament augmentation. METHODS: A computerized search of the databases was conducted, including PubMed, Web of Science, Embase, Scopus and the Cochrane Library. Only prospective or retrospective comparative studies with a minimum 2-year follow-up were considered for inclusion. Two independent reviewers performed data extraction and methodological quality assessment. A Mantel-Haenszel analysis was used for the pooling of results. Sensitivity analysis was performed to maintain the stability of results. The egger test was applied to assess the publication bias. RESULTS: Fourteen studies were included. The total cohort was 1353 patients (non-augmented group: 763 patients; augmented group: 590 patients). There were three Randomized Controlled Trials (RCTs, Level I), six retrospective comparative studies (Level III) and five case-control studies (Level III). The follow-up rate was ≥ 88% and the follow-up periods were ≥ 24 months in all included studies. The augmented graft used to compare with autograft included the Ligament Augmentation Device (LAD), the Ligament Advanced Reinforcement System (LARS) artificial ligament, FiberTape, hamstring tendon allograft, degradable poly (urethane urea). No significant differences were observed between the augmented and non-augmented groups regarding postoperative patient-reported outcomes (PROs), including the International Knee Documentation Committee score, Lysholm score and Tegner score, knee laxity, including KT-1000, side-to-side difference, Lachman test and pivot shift and rate of graft failure. CONCLUSIONS: ACLR using autografts combined with ligament augmentation shows no advantages in PROs, knee laxity and graft failure rate compared with using autografts only. LEVEL OF EVIDENCE: Level III. TRIAL REGISTRATION: The research protocol was registered at the PROSPERO database (CRD42022324784).

Quadriceps tendon autograft has similar clinical outcomes when compared to hamstring tendon and bone-patellar tendon-bone autografts for revision ACL reconstruction: a systematic review and meta-analysis.

PURPOSE: Research regarding revision anterior cruciate ligament reconstruction (RACLR) with quadriceps tendon (QT) autografts is lacking. The purpose of this study was to perform a systematic review and meta-analysis of RACLR with QT and compare its patient outcomes to RACLR with hamstring tendon (HT) and bone-patellar tendon-bone (BTB) autografts. METHODS: Adhering to PRISMA guidelines, a search for studies using QT in RACLR was performed within PubMed, Scopus, and CINAHL from database date of inception through December 26, 2022. Primary outcomes sought included: failure rate, Lysholm scores, International Knee Documentation Committee (IKDC) scores, IKDC grades, arthrometric knee side-to-side differences (STSD), pivot shift grade, donor site morbidity, return to sport, visual analog scale (VAS) pain scores. RESULTS: Nine studies were included consisting of 606 RACLR: 349 QT, 169 HT, and 88 BTB. Overall failure rates were 7.6% QT, 13.3% HT, and 8.7% BTB. Mean weighted Lysholm scores were 85.8 ± 3.8 QT, 82.5 ± 3.8 HT and 86.6 ± 4.5 BTB. IKDC average scores were 82.3 ± 1.6 QT, 80.1 ± 1.7 HT, and 81.7 ± 5.5BTB. Combined rates of IKDC A/B grades were 88.4% and 80.0% for QT and HT, respectively. VAS average scores were 0.9 ± 1.1 QT, 1.4 ± 0.2 HT, and 0.7 ± 0.8 for BTB. Side-to-side difference was reported for QT and HT with average values of 1.7 ± 0.6 mm and 2.1 ± 0.5 mm, respectively. Grade 0 or 1 pivot shifts were reported in 96.2% of QT patients and 91.3% of HT. Donor site morbidity, only reported for QT and HT, was 14.6 ± 9.7% and 23.6 ± 14.1%, respectively. QT resulted in a mean Tegner score of 5.9 ± 1.5 versus HT 5.7 ± 1.5. Rate of return to pivoting sports was 38.0% QT, 48.6% HT, and 76.9% BTB. Across all outcomes, there was no significant difference when comparing QT to HT, QT to BTB, and QT compared to HT and BTB combined. CONCLUSIONS: RACLR with QT yields satisfactory patient reported outcomes, satisfactory improvement in knee laxity, expected return to sport rates, and has an overall 7.6% failure rate. Outcomes are comparative to those of HT and BTB making it an acceptable graft choice for RACLR. Surgeons should consider using QT autograft for RACLR, especially when other autografts are unavailable. LEVEL OF EVIDENCE: IV.

Comparison of Knee Pain and Difficulty With Kneeling Between Patellar Tendon and Hamstring Tendon Autografts After Anterior Cruciate Ligament Reconstruction: A Study From the New Zealand ACL Registry.

BACKGROUND: The bone-patellar tendon-bone (BTB) autograft is associated with difficulty with kneeling after anterior cruciate ligament (ACL) reconstruction; however, it is unclear whether it results in a more painful or symptomatic knee compared with the hamstring tendon autograft. PURPOSE: To identify the rate and risk factors for knee pain and difficulty with kneeling after ACL reconstruction. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Primary ACL reconstruction procedures prospectively recorded in the New Zealand ACL Registry from April 2014 to May 2021 were analyzed. The Knee injury and Osteoarthritis Outcome Score (KOOS) was used to identify patients reporting consequential knee pain (CKP), defined as a KOOS Pain subscore of ≤72 points, and severe kneeling difficulty (SKD), defined as a self-report of "severe" or "extreme" difficulty with kneeling. Absolute values of the KOOS Pain and Symptoms subscales were also compared. RESULTS: A total of 10,999 patients were analyzed. At 2-year follow-up, 9.3% (420/4492) reported CKP, and 12.0% (537/4471) reported SKD. The most important predictor of CKP at 2-year follow-up was having significant pain before surgery (adjusted odds ratio, 4.10; P < .001). The most important predictor of SKD at 2-year follow-up was the use of a BTB autograft rather than a hamstring tendon autograft (21.3% vs 9.4%, respectively; adjusted odds ratio, 3.12; P < .001). There was no difference between the BTB and hamstring tendon grafts in terms of CKP (9.9% vs 9.2%, respectively; P = .494) or in absolute values of the KOOS Pain (mean, 88.7 vs 89.0, respectively; P = .37) and KOOS Symptoms (mean, 82.5 vs 82.1, respectively; P = .49) subscales. CONCLUSION: At 2-year follow-up after primary ACL reconstruction, 9.3% of patients reported CKP, and 12.0% reported SKD. The BTB autograft was associated with difficulty with kneeling, but it did not result in a more painful or symptomatic knee compared with the hamstring tendon autograft.

Semitendinosus tendons are commonly contaminated with skin flora during graft harvest for anterior cruciate ligament reconstruction.

PURPOSE: To investigate the rate of bacterial contamination of semitendinosus (ST) tendons during graft harvest in anterior cruciate ligament reconstruction (ACLR), in order to precisely specify the underlying pathogens and obtain data on their susceptibility to potential antibiotics. METHODS: In a prospective study, a total of 59 consecutive patients undergoing primary ACLR were recruited from one centre. No patient had history of previous surgery to the knee or showed clinical signs of infection. Four tissue samples of harvested ST tendons for anterior cruciate ligament (ACL) autografts (case group; ST) were examined for evidence of bacterial colonisation and compared to four tissue samples of the native ACL as negative controls (control group; ACL). Three of the respective samples were subjected to cultural microbiological examination and one to 16S rRNA-PCR. Antibiotic susceptibility testing was performed for each pathogen that was identified. RESULTS: A total of 342 samples were analysed by culture. Significantly more patients showed a positive culture of the ST (33.9%; n = 20/59) compared to 3.4% of patients (n = 2/59) with positive culturing of the ACL (p < 0.0001). Including 16S rRNA-PCR, in a total of 42.4% (25/59) of patients, bacteria were detected in at least one ST sample either by PCR and/or culture. All species found (n = 33) belong to the typical skin flora with Staphylococcus epidermidis (39.4%; n = 13/33) being the most common species, followed by Staphylococcus capitis (24.2%; n = 8/33). All tested isolates (n = 29) were susceptible to vancomycin (29/29, 100%), 69% (n = 20/29) to oxacillin and 65.5% (n = 19/29) to clindamycin. CONCLUSION: ST autografts for ACLR were commonly contaminated with skin commensal bacteria during harvest. One-third of the isolates showed resistance to typical perioperative intravenous antibiotics, whereas all isolates were sensitive to vancomycin. Therefore, routine prophylactic decontamination of all hamstring autografts before implantation should be recommended, preferably with topical vancomycin. LEVEL OF EVIDENCE: Level III.

Contralateral grafts have comparable efficacy to ipsilateral grafts in anterior cruciate ligament reconstructions: a systematic review.

PURPOSE: To perform a systematic review of the clinical outcomes of anterior cruciate ligament reconstruction using either contralateral or ipsilateral tendon autografts. METHODS: A systematic review of literature published from inception to December 9, 2022, in multiple databases (PubMed, Embase, Scopus, and the Cochrane Library) was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews) guidelines. Two reviewers independently screened the literature, extracted the data, performed the risk of bias assessment and assessed the study quality. At least one of the following outcomes was evaluated for each study: muscle strength (isometric strength of the quadriceps or hamstring muscles, isokinetic peak flexion torque of the hamstring, or isokinetic peak extension torque of the hamstring), knee laxity examination, Lysholm score, pivot shift, International Knee Documentation Committee (IKDC) score, Knee Injury and Osteoarthritis Outcome Score (KOOS), Lachman test result, return to sports time, or incidence of complications. A random effects model was used for all analyses. RESULTS: Four hundred scientific manuscripts were recovered in the initial search. After screening, 12 studies (2 randomized controlled trials, 9 cohort studies, and 1 case- control study) met the search criteria for the qualitative analysis. Among them, 9 cohort studies were used for the quantitative analysis. The results showed few statistically significant differences in terms of muscle strength (contralateral group versus ipsilateral group or donor site group versus ipsilateral group or donor site group versus nonoperative group), Lysholm score, and return to sports time. A comparison showed no significant differences in knee laxity, IKDC score, Tegner activity score, Lachman test score, or incidence of complication, or contralateral rupture. CONCLUSIONS: In anterior cruciate ligament reconstruction, the contralateral autologous tendon has a similar effect as the ipsilateral autologous tendon.