Reliability of Continuous Shear Wave Elastography in the Pathological Patellar Tendon.

OBJECTIVES: Patellar tendon injuries occur via various mechanisms such as overuse, or due to surgical graft harvest for anterior cruciate ligament reconstruction (ACLR). Quantified patellar tendon stiffness after injury may help guide clinical care. Continuous shear wave elastography (cSWE) allows for the assessment of viscosity and shear modulus in tendons. The reliability of the measure, however, has not been established in the patellar tendon. The purpose of this study was to investigate the interrater reliability, intrarater reliability, and between-day stability of cSWE in both healthy and pathological patellar tendons. METHODS: Participants with patellar tendinopathy (n = 13), history of ACLR using bone-patellar tendon-bone autograft (n = 9), and with no history of patellar tendon injury (n = 13) were recruited. cSWE was performed 4 times by multiple raters over 2 days. Intraclass correlations (ICC) and minimum detectable change (MDC95% ) were calculated. RESULTS: Good to excellent between-day stability were found for viscosity (ICC = 0.905, MDC95%  = 8.3 Pa seconds) and shear modulus (ICC = 0.805, MDC95%  = 27.4 kPa). The interrater reliability measures, however, were not as reliable (ICC = 0.591 and 0.532). CONCLUSIONS: cSWE is a reliable assessment tool for quantifying patellar tendon viscoelastic properties over time. It is recommended, however, that a single rater performs the measure as the interrater reliability was less than ideal.

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

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

Anatomical rectangular tunnel anterior cruciate ligament reconstruction provides excellent clinical outcomes.

PURPOSE: The purpose of this study was to prospectively evaluate the clinical outcomes following anatomical rectangular tunnel anterior cruciate ligament (ACL) reconstruction with a bone-patellar tendon-bone (BTB) graft using an adjustable-length femoral cortical fixation device with enough patients and a high follow-up rate. METHODS: This study included 125 patients who underwent anatomical rectangular tunnel ACL reconstruction with a BTB graft. A BTB TightRope® was used for femoral graft fixation. Clinical evaluations were performed more than 2 years after surgery using the International Knee Documentation Committee (IKDC) Form. Patients interviewed by telephone were only subjectively evaluated. The side-to-side difference in anterior laxity at a manual maximum force was measured using the KT-2000 Arthrometer®. RESULTS: Among the 125 patients, 99 were ultimately included and 26 were lost to follow-up (follow-up rate: 79%). Eight patients had re-tear (re-tear rate: 8%) and six patients had ACL injuries to the contralateral knee. Three patients did not follow our rehabilitation programme. One patient suffered septic arthritis. These 18 patients were considered ineligible for clinical evaluations. Therefore, clinical evaluations were performed in 81 of the 99 patients (64 were available for direct follow-up and 17 were available for a telephone interview). The follow-up period was 30 ± 10 months (range 24-68 months). According to the IKDC subjective assessment, 48 (59%) and 33 (41%) knees were graded as normal and nearly normal, respectively. A loss of extension (3°-5°) was observed in five patients (8%), whereas one patient (2%) exhibited a loss of flexion (3°-5°). The Lachman test was negative in 63 patients (98%). The pivot shift test was negative in 59 patients (92%). The side-to-side difference in KT value was 0.4 ± 0.7 mm (range - 1-4 mm). CONCLUSION: Anatomical rectangular tunnel ACL reconstruction with a BTB graft using an adjustable-length femoral cortical fixation device provided excellent clinical outcomes both subjectively and objectively more than 2 years after surgery, whereas 8 of the 99 patients had re-tear of the graft. The adjustable-length femoral cortical fixation device could be safely used in anatomical rectangular tunnel ACL reconstruction with a BTB graft. LEVEL OF EVIDENCE: III.

Predicting adequacy of free quadriceps tendon autograft, for primary and revision ACL reconstruction, from patients' physical parameters.

PURPOSE: Free quadriceps tendon autograft (QTA) has gained popularity for both primary and revision ACL reconstruction. The aim of this study is to measure the dimensions of quadriceps tendon and determine its correlation with patient's height, weight and BMI. This is to provide a guide for patients and surgeons in predicting the suitability of QTA for ACL reconstructions. METHODS: A cross-sectional study in which the length and thickness of the quadriceps tendon was measured in 51 Caucasian patients who underwent primary total knee arthroplasty. Exclusion criteria include non-Caucasians and previous tendon pathology. Patients were selected from routine elective total knee arthroplasty list. Tendon length is taken from musculotendinous junction to its insertion. Thickness was measured at midpoint and at distal insertion. Patients' height, weight and BMI were recorded. The correlation between patient physical parameters and tendon dimensions were determined. RESULTS: Subjects' median age was 65 years (range 44-87), with 34 females and 17 males. Median length of the tendon was 9 mm (range 70-110), and median insertional thickness was 9 mm (7-10 mm). Median thickness at midpoint was 7 mm (range 4-10 mm). There was moderately positive correlation between subjects' height and tendon length (correlation coefficient 0.50), and also between weight and tendon length (correlation coefficient 0.47). There was no significant correlation between subjects' BMI and the tendon length. There was also no significant correlation between tendon thickness and subject's physical parameters. CONCLUSION: This study has shown that most patients could provide adequate QTA for ACL reconstruction. It also points to the fact that no investigation is required to predict the adequacy of QTA. Though further studies with larger sample size are required to confirm this, clinician can rely on analysing patients' physical parameter in predicting the adequacy of QTA for ACL reconstruction. LEVEL OF EVIDENCE: II.

Anatomical rectangular tunnels identified with the arthroscopic landmarks result in excellent outcomes in ACL reconstruction with a BTB graft.

PURPOSE: To elucidate tunnel locations and clinical outcomes after anatomic rectangular tunnel (ART) anterior cruciate ligament reconstruction (ACLR) using a bone-patellar tendon-bone (BTB) graft. METHODS: Sixty-one patients with a primary unilateral ACL injury were included. Tunnels were created inside the ACL attachment areas after carefully removing the ACL remnant and clearly identifying the bony landmarks. Using 3-dimensional computed tomography (3-D CT) images, the proportion of the tunnel apertures to the anatomical attachment areas was evaluated at 3 weeks. The clinical outcomes were evaluated at 2 years postoperatively. RESULTS: Geographically, the 3-D CT evaluation showed the entire femoral tunnel aperture; at least 75% of the entire tibial tunnel aperture area was consistently located inside the anatomical attachment areas surrounded by the bony landmarks. In the International Knee Documentation Committee (IKDC) subjective assessment, all patients were classified as 'normal' or 'nearly normal'. The Lachman test and pivot-shift test were negative in 98.4% and 95.1% of patients, respectively. The mean side-to-side difference of the anterior laxity at the maximum manual force with a KT- 1000 Knee Arthrometer was 0.2 ± 0.9 mm, with 95.1% of patients ranging from - 1 to + 2 mm. CONCLUSION: By identifying arthroscopic landmarks, the entire femoral tunnel aperture and at least 75% of the entire tibial tunnel aperture area were consistently located inside the anatomical attachment areas. With properly created tunnels inside the anatomical attachment areas, the ART ACLR using a BTB graft could provide satisfactory outcomes both subjectively and objectively in more than 95% of patients. LEVEL OF EVIDENCE: Case series, Level IV.

Bone-to-bone integrations were complete within 5 months after anatomical rectangular tunnel anterior cruciate ligament reconstruction using a bone-patellar tendon-bone graft.

PURPOSE: Anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone (BTB) graft is known to provide secure fixation due to the direct bone-to-bone integration of the bone plug and bone tunnel. It is important to know the time required for bone integration when designing the postoperative rehabilitation protocol or deciding when the patient can return to competition-level activity, especially if the patient is an athlete. However, because reports are scarce, the period necessary for bone-to-bone integration after ACL reconstruction using a BTB graft remains unclear. The purpose of this study was to clarify this issue. It was hypothesised that ACL reconstruction using a BTB graft via an anatomical rectangular tunnel would help in the integration between bone plugs and bone tunnels on both the femoral and tibial sides after at least 6 months, at which point basic exercises similar to pre-injury sporting activity levels can be resumed. METHODS: This study included 40 knees treated with ACL reconstruction using a BTB graft via anatomical rectangular tunnel reconstruction between 2013 and 2014 in a single institute. The integration between bone plugs and bone tunnels was evaluated using multi-slice tomosynthesis, which is a technique for producing slice images using conventional radiographic systems, at 1, 3, and 5 months postoperatively. All procedures were performed by two experienced surgeons. Bone integration was evaluated by two orthopaedic doctors. RESULTS: The rates of integration of the bone plug and femoral bone tunnel on tomosynthesis at 1, 3, and 5 months postoperatively were 0, 55, and 100%, respectively. On the tibial side, the corresponding rates were 0, 75, and 100%, respectively. The rate of integration on the tibial side was significantly higher than that on the femoral side at 3 months postoperatively (p = 0.031). CONCLUSIONS: Bone-to-bone integration on the femoral and tibial sides was complete within 5 months after surgery in all cases. Since the time required for bone integration is important in designing the postoperative rehabilitation approach, these results will serve as a useful guideline for planning rehabilitation protocols. LEVEL OF EVIDENCE: IV.

Effects of initial graft tension on femoral tunnel widening after anatomic anterior cruciate ligament reconstruction using a bone-patellar tendon-bone graft.

INTRODUCTION: The effects of initial graft tension upon tunnel widening (TW) following anatomic anterior cruciate ligament (ACL) reconstruction have not been elucidated. The purpose of this study was to retrospectively investigate the effect of two different graft-tensioning protocols upon femoral TW following anatomic ACL reconstruction using a bone-patellar tendon-bone (BPTB) graft and a three-dimensional (3D) computed tomography (CT) model. METHODS: Forty-three patients who underwent isolated ACL reconstruction using BPTB grafts were included in this study. In 18 out of the 43 patients, the graft was fixed at full knee extension with manual maximum pull (Group H). These patients were compared with 25 patients in whom the BPTB graft was fixed at full knee extension with 80-N pull (Group L). Tunnel aperture area was measured using 3D CT 1 week and 1 year postoperatively, thus enabling us to calculate the percentage change in the area of femoral tunnel aperture. Clinical assessment was performed 1 year postoperatively, corresponding to the time period of CT assessment, and involved the evaluation of Lysholm score, anterior knee stability using a KneeLax3 arthrometer, and the pivot-shift test. RESULTS: When measured at 1 year postoperatively, the mean area of the femoral tunnel aperture had increased by 78.6 ± 36.8% in Group H when compared with at 1 week postoperatively, whereas that of Group L had increased by 27.7 ± 32.3%. Furthermore, TW (%) in Group H was significantly greater than that of Group L (P < 0.001). No significant differences were detected between the two groups with regard to any of the clinical outcomes evaluated. CONCLUSION: High levels of initial graft tension resulted in greater TW of the femoral tunnel aperture following anatomical ACL reconstruction using BPTB grafts. However, such levels of graft tension did not affect clinical outcome.

Biomechanical Evaluation of TensionLoc Versus the Double Spike Plate for ACL Graft Tibial Fixation.

Background: The optimal tibial fixation of anterior cruciate ligament (ACL) reconstruction (ACLR) grafts remains controversial. Purpose/Hypothesis: The purpose of this study was to compare the biomechanical characteristics of the TensionLoc (TL) cortical fixation device with the Double Spike Plate (DSP) fixation device for ACL tibial fixation using both bone-patellar tendon-bone (BTB) and quadriceps grafts. It was hypothesized that there would be no differences in biomechanical characteristics between the fixation devices regardless of graft type. Study Design: Controlled laboratory study. Methods: ACLR was performed on 14 matched-pair cadaveric knee specimens-7 pairs using quadriceps grafts (n = 3 male cadaveric knee specimens; n = 4 female cadaveric knee specimens; age, 51 ± 8 years) and 7 pairs using BTB grafts (n = 3 male cadaveric knee specimens; n = 4 female cadaveric knee specimens; age, 50 ± 7 years). One side of each pair was randomized to receive DSP fixation, and the contralateral side received TL fixation. Specimens underwent cyclic ramp loading (10 cycles each at 50-100 N, 50-250 N, and 50-400 N), followed by load-to-failure testing, with the tensile force in line with the tibial tunnel. Results between the 2 fixation types were compared with a paired t test. Results: For the quadriceps graft, there were no significant differences in cyclic loading or load-to-failure characteristics between fixation types (P≥ .092 for all parameters). For the BTB graft, TL fixation resulted in higher stiffness than DSP at all cyclic testing cycles except for cycle 1 during 100-N loading and had lower displacement at 250-N loading (3.4 ± 0.1 vs 5.4 ± 0.3 mm; P = .045). For load to failure, TL fixation resulted in higher stiffness than DSP fixation (232 ± 3.1 vs 188.4 ± 6.4 N/mm; P = .046); however, all other load-to-failure parameters were not statistically different (P≥ .135 for all parameters). Conclusion: With the quadriceps tendon graft, there were no significant differences in biomechanical characteristics between TL and DSP ACL tibial fixations; however, with BTB grafts, the TL tibial fixation demonstrated greater biomechanical integrity than the DSP tibial fixation. Clinical Relevance: The TL fixation device may provide an alternative ACL tibial fixation option for BTB and soft tissue grafts.

Bone Grafting of the Bone Defects after Harvesting the Bone Patellar Tendon Bone Graft - A Novel Surgical Technique.

Introduction: The anterior knee pain is the most common post-operative complaint associated with anterior cruciate ligament reconstruction (ACLR) using bone patellar tendon bone graft. It has been attributed to various factors such as loss of terminal extension, infrapatellar branch neuroma, and also due to the bone harvest site defect itself. Bone grafting of the defects in the patella and tibia has been shown to decrease anterior knee pain. At the same time, it also prevents post-operative stress fractures. Surgical Technique: Numerous bone pieces were produced in the knee joint as a result of the drilling during ACL reconstruction. Using a wash cannula and tissue grasper, all the bone fragments were gathered into a kidney tray. The bony fragments with the saline which were collected in the metal container were allowed to sediment at the bottom. The bone that was sedimented in the metal container was collected by decantation and placed into the bony defects of the patellar and tibial sides. Conclusion: Bone grafting of the defects in the patella and tibia has been shown to decrease anterior knee pain. Our technique is cost-effective as there is no requirement for special instrumentation like coring reamers, and no requirement for allograft or bone substitutes. Second, there is no morbidity associated with autografts harvested from elsewhere, we used the bone generated during the ACLR itself.

Lateral posterior tibial slope does not affect femoral but does affect tibial tunnel widening following anatomic anterior cruciate ligament reconstruction using a Bone-Patellar Tendon-Bone graft.

Background: Tunnel widening (TW) after anterior cruciate ligament (ACL) reconstruction has been a research area of interest in ACL reconstruction. In recent years, it has been noted that posterior tibial slope (PTS) affects several types of outcomes after ACL reconstruction including TW. However, the relationships between femoral and tibial TW and between PTS and TW following anatomical ACL reconstruction using a bone-patellar tendon-bone (BTB) graft are often not understood. Therefore, the purpose of this study was to retrospectively clarify the magnitude of femoral and tibial TW and the effect of PTS on TW following anatomical ACL reconstruction using a BTB graft. Methods: A total of 111 patients who underwent isolated ACL reconstructions using BTB grafts were included in this study. Femoral and tibial tunnel aperture areas were measured using three-dimensional computed tomography (3D CT) at 1 week and 1 year postoperatively, and femoral and tibial TW (%) was calculated. Lateral and medial PTS was also measured using 3D CT. Results: As compared with 1 week postoperatively, the mean tibial tunnel aperture areas increased by 30.6% ± 28.5%, and the mean femoral tunnel aperture areas increased by 28.3% ± 27.9% when measured at 1 year postoperatively. Although no significant difference was observed between femoral and tibial TW, a significant positive correlation was noted between femoral and tibial TW (r = 0.240, p = 0.011). A significant correlation was observed only between lateral PTS and tibial TW (r = 0.354, p < 0.001). There was no significant correlation between medial PTS and tibial TW, lateral PTS and femoral TW, or medial PTS and femoral TW. Conclusion: Significant positive correlation was observed between femoral and tibial TW. Steeper lateral PTS correlated with greater tibial TW; on the other hand, medial PTS did not correlate with tibial TW. Although lateral PTS affected tibial TW, it did not affect femoral TW.

Prominent Resident's Ridge as a Potential Cause of Anterior Cruciate Ligament Impingement: A Case Report.

BACKGROUND: The resident's ridge is an arthroscopic landmark that is consistent with the anterior border of the anterior cruciate ligament (ACL) femoral attachment. The identification of the landmark allows for accurate graft placement. CASE REPORT: We report a case of a 30-year athletic individual with an ACL-deficient knee, who had an abnormally large resident's ridge, abutting the midsubstance of the torn ACL; the residual femoral attachment was behind the ridge. Resection and burring of this ridge were needed to expose the posterior aspect of the intercondylar notch; even after bone-patellar tendon-bone graft placement, some additional removal of bone had to be done to reduce graft impingement on this area in extension. CONCLUSION: Abnormal resident's ridge may be misleading about the anatomy of the lateral femoral condyle area. Appropriate resection of abnormal bone is the key to the identification of femoral footprint and graft placement. We speculate that this bony projection may even have contributed to the ACL injury, and extra bone had to be removed to minimize subsequent impingement.

Blumensaat Line as a Prediction of Native Anterior Cruciate Ligament Length.

BACKGROUND: Graft-tunnel mismatch (GTM) is a condition in which the anterior cruciate ligament (ACL) graft is either too long or too short. GTM is particularly problematic when bone-patellar tendon-bone grafts are used because of a potential compromise in fixation of the bone plug on the tibia. HYPOTHESIS: The Blumensaat line (BL), a radiographic landmark representing the roof of the intercondylar fossa, will accurately approximate the native ACL (nACL) length and may aid in the prevention of GTM. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: A total of 130 patients (66 males, 64 females) underwent direct measurement of the nACL during knee arthroscopy. The lengths of the nACL and patellar ligament (PL) were measured intraoperatively, and BL length was measured on lateral knee radiographs. The nACL length was compared with PL and BL lengths to calculate the absolute difference (AD). Mean AD was calculated and used to determine mean percentage difference (MPD). Pearson correlation coefficients (CC) between BL, PL, and nACL length were calculated, along with inter- and intraobserver reliability coefficients for the measurement of BL. RESULTS: For male patients, the mean length of the nACL was 32.5 mm, BL was 30.4 mm, and PL was 49.2 mm. The AD between the BL and nACL was 2.4 ± 1.3 mm, MPD was 2.6% ± 1.9%, and CC was 0.88. The CC between the PL and nACL was 0.08. For female patients, the mean length of the nACL was 30.2 mm, BL was 27.5 mm, and PL was 44.4 mm. The AD between the BL and nACL was 2.7 ± 1.7 mm, MPD was 4.5% ± 2.4%, and CC was 0.93. The CC between the PL and nACL was 0.1. The inter- and intraobserver reliability coefficients for the measurement of BL were 0.86 and 0.83, respectively. CONCLUSION: A strong correlation was found between BL and nACL with a high inter- and intraobserver reliability. This correlation provides a simple and reliable method to closely approximate nACL length before reconstruction and may aid in the prevention of graft-tunnel mismatch.

Morphology of the patellar tendon and its insertion sites using three-dimensional computed tomography: A cadaveric study.

BACKGROUND: To clarify, with three-dimensional (3D) images, the morphological properties of the patellar tendon and both of its insertion sites. METHODS: Thirty-two human cadaveric left knees were evaluated, and 3D computed tomography images were created. These images were used to analyse the morphology of both insertion sites of the patellar tendon, and the width, length and thickness of each region of the patellar tendon. RESULTS: The insertion sites of the patellar tendon on the patellar and tibial sides were V-shaped and crescent-shaped, respectively, with the respective bony apexes located at 44.5 ±â€¯2.2% (standard deviation) and 35.5 ±â€¯2.8% of the tendon width from its medial edge. The proximal, central and distal widths of the patellar tendon were 29.9 ±â€¯2.7 mm, 27.3 ±â€¯2.5 mm and 25.0 ±â€¯2.4 mm, respectively. The length of the patellar tendon was shortest at 40.6% ±â€¯6.7% of the central width and gradually became longer toward both edges. The patellar tendon was thickest in the central portion of 40-75% and gradually became thinner toward both edges. CONCLUSIONS: The morphological properties of the patellar tendon and its insertion sites on both the patellar and tibial sides were consistent. These findings indicate that the characteristics of the bone-patellar tendon-bone graft markedly depend on the location from which it is harvested, and that these characteristics contribute to predicting the length, width and shapes of the bone plugs of the graft when performing bone-patellar tendon-bone surgery.

Anterior Cruciate Ligament Graft Conditioning Required to Prevent an Abnormal Lachman and Pivot Shift After ACL Reconstruction: A Robotic Study of 3 ACL Graft Constructs.

BACKGROUND: Anterior cruciate ligament (ACL) graft conditioning protocols to decrease postoperative increases in anterior tibial translation and pivot-shift instability have not been established. PURPOSE: To determine what ACL graft conditioning protocols should be performed at surgery to decrease postoperative graft elongation after ACL reconstruction. STUDY DESIGN: Controlled laboratory study. METHODS: A 6 degrees of freedom robotic simulator evaluated 3 ACL graft constructs in 7 cadaver knees for a total of 19 graft specimens. Knees were tested before and after ACL sectioning and after ACL graft conditioning protocols before reconstruction. The ACL grafts consisted of a 6-strand semitendinosus-gracilis TightRope, bone-patellar tendon-bone TightRope, and bone-patellar tendon-bone with interference screws. Two graft conditioning protocols were used: (1) graft board tensioning (20 minutes, 80 N) and (2) cyclic conditioning (5°-120° of flexion, 90-N anterior tibial load) after graft reconstruction to determine the number of cycles needed to obtain a steady state with no graft elongation. After conditioning, the grafts were cycled a second time under anterior-posterior loading (100 N, 25° of flexion) and under pivot-shift loading (100 N anterior, 5-N·m internal rotation, 7 N·m valgus) to verify that the ACL flexion-extension conditioning protocol was effective. RESULTS: Graft board tensioning did not produce a steady-state graft. Major increases in anterior tibial translation occurred in the flexion-extension graft-loading protocol at 25° of flexion (mean ± SD: semitendinosus-gracilis TightRope, 3.4 ± 1.1 mm; bone-patellar tendon-bone TightRope, 3.2 ± 1.0 mm; bone-patellar tendon-bone with interference screws, 2.4 ± 1.5 mm). The second method of graft conditioning (40 cycles, 5°-120° of flexion, 90-N anterior load) produced a stable conditioned state for all grafts, as the anterior translations of the anterior-posterior and pivot-shift cycles were statistically equivalent ( P < .05, 1-20 cycles). CONCLUSION: ACL graft board conditioning protocols are not effective, leading to deleterious ACL graft elongations after reconstruction. A secondary ACL graft conditioning protocol of 40 flexion-extension cycles under 90-N graft loading was required for a well-conditioned graft, preventing further elongation and restoring normal anterior-posterior and pivot-shift translations. CLINICAL RELEVANCE: There is a combined need for graft board tensioning and robust cyclic ACL graft loading before final graft fixation to restore knee stability.

A difference in rotational alignment of the tibio-femoral joint after anterior cruciate ligament reconstruction between the bone-patellar tendon-bone and semitendinosus-gracilis grafts.

BACKGROUND: A question as to the effect of the graft choice on rotational kinematics after anterior cruciate ligament reconstruction remains unclear. The purpose of this study was to determine if there were any differences in rotational alignment of the knee after anterior cruciate ligament (ACL) reconstruction using bone-patellar tendon-bone (BTB) graft compared to that using semitendinosus-gracilis (STG) graft. METHODS: Ten patients with BTB graft and 10 patients with STG graft were assessed at 3 months after ACL reconstruction. We compared the 6 degrees-of-freedom alignment of the tibiofemoral joint in the fully extended position between knees reconstructed with BTB graft and STG graft using the uninvolved knee as a control. FINDINGS: The BTB graft group showed no difference in knee alignment between the ACL reconstructed knee and uninvolved knee, whereas the STG graft group showed greater external rotation in the ACL reconstructed knee than in the uninvolved knee (median values, 8.4° vs 5.8°; p = 0.022). INTERPRETATION: ACL reconstruction with the STG graft leads to increased external tibial rotation. Our findings suggest that clinicians should make an effort to prevent increased external tibial rotation during the rehabilitation process in patients with STG graft.

Quantifying anterior knee pain during specific activities after using the bone-patellar tendon-bone graft for arthroscopic anterior cruciate ligament reconstruction.

BACKGROUND/OBJECTIVE: There has been much debate about the optimal graft choice for an anterior cruciate ligament (ACL) reconstruction. Anterior knee pain is a common donor site problem when using a bone-patellar tendon-bone (BPTB) graft. However, knowledge of the characteristics of anterior knee pain during different daily activities is still limited. This study aimed to determine the incidence of anterior knee pain and to quantify the degree of pain during a range of daily living activities. METHODS: Thirty-five patients who were scheduled to undergo an ACL reconstruction with an autologous BPTB graft between February 2015 and December 2016 were enrolled. A visual analogue scale (VAS) for pain was recorded during each of the following activities: ascending at 30-degree slope, ascending and descending stairs, running, jumping, squatting, kneeling, sitting cross-legged, and sitting one-legged. Demographic data, the range of motion, the area of decreased sensation, and the IKDC score were collected and compared 3 and 6 months postoperatively. RESULTS: The 35 male patients had a mean age of 29.7 years. Postoperatively, the mean IKDC scores were 58.1 ±â€¯9.8 at 3 months and 72.7 ±â€¯10.5 at 6 months. The incidences of overall anterior knee pain were 62.9% and 34.3% at the 3- and 6-month time points. Kneeling was the only activity that produced severe pain. At 3 months postoperatively, kneeling's mean VAS pain score was 3.9 ±â€¯2.9 (2.9, 4.9; 95% CI for mean for 17 patients [48.5%] with considerable pain), whereas at 6 months postoperatively, it was 2 ±â€¯2.5 (1.2-2.9; 95% CI for mean for 9 patients [25.7%] with considerable pain). The area of numbness of the proximal leg decreased from 12.8 ±â€¯18.3 cm2 (6.4, 19.2; 95% CI for mean) to 3.2 ±â€¯9.1 cm2 (0.1, 6.5; 95% CI for mean) at 3 and 6 months postoperatively. CONCLUSIONS: Kneeling was the most challenging activity in terms of creating considerable levels of anterior knee pain in patients who had undergone an ACL reconstruction using a BPTB graft. Other knee activities, however, did not create moderate or severe degrees of anterior knee pain. Both anterior knee pain and numbness at the proximal leg improved over time.Trial registration number: TCTR2018-0630002.

Determination of patellar tendon length for anterior cruciate ligament reconstruction using an anteroposterior knee radiograph.

BACKGROUND/OBJECTIVE: Graft-tunnel length mismatch is a common intraoperative technical problem for anterior cruciate ligament reconstruction (ACLR) using a bone-patellar tendon-bone graft (BPTB). The patella-to-condyle and the patella-to-notch distances are two measurements in an anteroposterior knee radiograph. The objective of this study was to evaluate the sensitivities, specificities and reliabilities of those 2 measurements for detecting patients who had a patellar tendon length exceeding 45 mm. METHODS: Preoperative plain radiographs of patients who underwent ACLR with a BPTB graft were evaluated independently by two orthopaedic surgeons 3 times each at 2-weekly intervals. The sensitivities and specificities of the two measurements for detecting patients who have a patellar tendon length exceeding 45 mm were calculated. The optimal cutoff point was estimated using Youden index, and the receiver operating characteristic (ROC) curve and area under the curve (AUC) were evaluated with a 95% CI. As for the inter- and intra-rater reliabilities, intraclass correlation coefficients (ICC) were determined. RESULTS: One hundred and twenty-seven patients with an average age of 29.5 years old were evaluated. The mean patellar tendon length was 41.3 ±â€¯5.0 mm. Patients with a length more than 45 mm (20 patients, 16%) had significantly higher patella-to-condyle and patella-to-notch distances, and more frequent use of bone staples for distal graft fixation than patients with a length ≤ 45 mm. To detect patients with a patellar tendon length over 45 mm, the optimal cutoff point for the patella-to-condyle distance was set at 14.5 mm, which had a sensitivity of 80%, specificity of 71%, and AUC of 0.76. In the case of the patella-to-notch distance, the cutoff point of 5.5 mm had a sensitivity of 80%, specificity of 66%, and AUC of 0.73. The intra- and inter-rater reliabilities of the two measurements were excellent, with ICCs of over 0.90. CONCLUSIONS: Preoperative measurements of the patella-to-condyle and the patella-to-notch distances in AP knee radiographs can be valuable tools, with good sensitivities and specificities, for the determination of the patellar tendon length when using a BPTB graft for an ACLR. They had an acceptable level of discrimination capability and excellent reliability.

Improved ACL reconstruction outcome using double-layer BPTB allograft compared to that using four-strand hamstring tendon allograft.

BACKGROUND: This study compared the clinical outcomes of anterior cruciate ligament reconstruction using double-layer bone-patellar tendon-bone (DBPTB) allografts and four-strand hamstring (4SHS) grafts. METHODS: This prospective randomized controlled trial included 101 patients. Of these, 50 patients received DBPTB allografts, and 51 received 4SHS grafts. Evaluations included KT-1000 arthrometer measurements, Lachman tests, pivot-shift tests, the International Knee Documentation Committee (IKDC) classification and Lysholm scores at three year postoperative follow-up. RESULTS: Two DBPTB patients (four percent) and nine 4SHS patients (17.6%) had graft failures, which was significantly different (P=0.028). The DBPTB group had significantly better Lachman test, IKDC knee score and Lysholm score results than the 4SHS group (P<0.05). However, these differences were below the threshold for clinical significance. CONCLUSIONS: DBPTB allografts had fewer graft failures at three years than 4SHS grafts for anterior cruciate ligament reconstruction; and there were statistically significant differences but not clinically significant differences between DBPTB and 4SHS grafts in terms of the KT1000 test, IKDC and Lysholm scores.

Remnant-preserving, selective single-bundle augmentation of the anterior cruciate ligament using a bone-patellar tendon-bone autograft: A technical note.

BACKGROUND: To the best of our knowledge, there has been no detailed study on bone-patellar tendon-bone (BTB) grafts for remnant-preserving, selective-bundle anterior cruciate ligament (ACL) augmentation. Therefore, we aimed to develop such a technique using a BTB graft. METHOD: A total of five patients underwent surgery using the presented procedure. These patients were young, male, and with high body mass index, and hence required very high durability of reconstructed ACL. A femoral bone tunnel was created using the inside-out technique via an accessory far-medial portal, protecting the remnant using a probe, regardless of the presence of an anteromedial (AM) or posterolateral (PL) tunnel. A single tibial tunnel was drilled at the center of the AM or PL attachment and two transverse skin incisions were made in the ipsilateral knee. The central third of the patellar tendon attached to a patellar and tibial bone plug autograft with a width of seven millimeters was harvested by subcutaneous tunneling. The femoral side was fixed using a cortical fixation device for BTB and the tibial bone plug was fixed using an interference screw with the knee at an angle of 20° of flexion by applying maximal manual traction. RESULTS: Bone tunnel enlargement, which was measured by computed digital radiography, was not observed in all cases. A BTB autograft for remnant-preserving, selective-bundle ACL augmentation offers reduced risk of tunnel enlargement. CONCLUSION: The presented procedure might be considered one of the potentially available options for patients with ACL partial tear who require very high durability of reconstructed ACL. LEVEL OF EVIDENCE: 5.

One-stage revision anatomic anterior cruciate ligament reconstruction with rectangular tunnel technique.

We developed the anatomic rectangular tunnel anterior cruciate ligament reconstruction (ART ACLR) with a bone-patellar tendon-bone graft to mimic fibre arrangement inside the native ACL via tunnels with smaller apertures. With a 10-mm-wide graft, the cross-sectional area of the tunnels of 50 mm2 in ART ACLR is less than that of 79 mm2 in a 10-mm round tunnel one. Because tunnel encroachment would be less of a problem, the ART ACLR technique could be most frequently applied to patients after a failed primary ACLR. In this instructional lecture, the indication and technical considerations for ART ACLR as one-stage revision ACLR are described.