Bone-patellar tendon-bone, hamstring, and quadriceps tendon autografts for anterior cruciate ligament reconstruction in skeletally immature patients: a systematic review.

INTRODUCTION: Historically, anterior cruciate ligament (ACL) ruptures in the paediatric age group were managed conservatively with bracing, casting, activity modification, and physical therapy. However, most of these patients had to reduce their sports activities, and secondary damages to the affected knee were prevalent. SOURCE OF DATA: Published scientific literature in Embase, Web of Science, PubMed, and Google Scholar databases. AREAS OF AGREEMENT: ACL reconstruction in children with open physes patients is debated. Any damage to the physes around the knee could lead to growth abnormalities and axial deviation of the knee. AREAS OF CONTROVERSY: Different grafts are available and suitable for ACL reconstruction in skeletally immature patients; however, which graft performs better remains unclear. GROWING POINTS: This systematic review compared bone-patellar tendon-bone (BPTB), hamstring tendon (HT), and quadriceps tendon (QT) autografts for ACL reconstruction in skeletally immature patients. The joint laxity, Patient-reported outcome measures (PROMs), return to sport, and complications were compared. AREAS TIMELY FOR DEVELOPING RESEARCH: In skeletally immature patients, HT, BPTB, and QT autografts for ACL reconstruction yielded good outcomes. Comparative studies are strongly required to establish the most suitable autograft.

Outcomes and Complications of Limbal Stem Cell Allograft Transplantation: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the published literature on the safety and outcomes of keratolimbal allograft (KLAL) transplantation and living-related conjunctival limbal allograft (lr-CLAL) transplantation for bilateral severe/total limbal stem cell deficiency (LSCD). METHODS: Literature searches were last conducted in the PubMed database in February 2023 and were limited to the English language. They yielded 523 citations; 76 were reviewed in full text, and 21 met the inclusion criteria. Two studies were rated level II, and the remaining 19 studies were rated level III. There were no level I studies. RESULTS: After KLAL surgery, best-corrected visual acuity (BCVA) improved in 42% to 92% of eyes at final follow-up (range, 12-95 months). The BCVA was unchanged in 17% to 39% of eyes and decreased in 8% to 29% of eyes. Two of 14 studies that evaluated the results of KLAL reported a notable decline in visual acuity over time postoperatively. Survival of KLAL was variable, ranging from 21% to 90% at last follow-up (range, 12-95 months) and decreased over time. For patients undergoing lr-CLAL surgery, BCVA improved in 31% to 100% of eyes at final follow-up (range, 16-49 months). Of the 9 studies evaluating lr-CLAL, 4 reported BCVA unchanged in 30% to 39% of patients, and 3 reported a decline in BCVA in 8% to 10% of patients. The survival rate of lr-CLAL ranged from 50% to 100% at final follow-up (range, 16-49 months). The most common complications were postoperative elevation of intraocular pressure, persistent epithelial defects, and acute allograft immune rejections. CONCLUSIONS: Given limited options for patients with bilateral LSCD, both KLAL and lr-CLAL are viable choices that may provide improvement of vision and ocular surface findings. The studies trend toward a lower rejection rate and graft failure with lr-CLAL. However, the level and duration of immunosuppression vary widely between the studies and may impact allograft rejections and long-term graft survival. Complications related to immunosuppression are minimal. Repeat surgery may be needed to maintain a viable ocular surface. Reasonable long-term success can be achieved with both KLAL and lr-CLAL with appropriate systemic immunosuppression. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Assessment of conjunctival autograft reperfusion after pterygium surgery by optical coherence tomography angiography (OCT-A).

PURPOSE: To investigate the healing process of conjunctival autografts (CAG) following pterygium surgery using optical coherence tomography angiography (OCTA). METHODS: Twenty-one eyes of 21 patients diagnosed with pterygium underwent pterygium excision with CAG without using Mitomycin-C. Over a 12-week follow-up period, changes in vascular density (VD), vascular density index (VDI), and vascular length density (VLD) were assessed at two distinct depths: superficial (<200 µm) and deep (>200 µm) using OCTA. Additionally, the revascularization rate and pattern were evaluated. RESULTS: During the first week, the CAG was edematous and no sign of neovascularization was observed. In 4th week edema decreased and early signs of vascular formation appeared. In the 12th week, the deep vasculature demonstrated a greater density of interconnectivity compared to the superficial layers. VD and VLD significantly increased during the follow-up period (P < 0.05). The CAG blood flow signals exhibited a chaotic pattern, deviating from the expected centrifugal vascular pattern in the surrounding normal conjunctiva. CONCLUSION: OCTA imaging emerges as a reliable tool for the assessment of CAG vascularization, improving the monitoring of the healing process in the postoperative period. The evaluation of CAG revascularization patterns appears to be promising biomarkers that can predict the potential future recurrence.

The effect of different pterygium surgery techniques on the ocular surface parameters in different durations: a systematic review and meta-analysis.

PURPOSE: To evaluate the effects of different pterygium surgery techniques on ocular surface (OS) in different follow-up periods. METHODS: PubMed, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wan Fang, and China Biology Medicine disc were searched for studies reporting pre- and post-operative OS parameters in pterygium. RESULTS: A total of 33 articles were finally included. Three OS parameters showed relatively consistent changing trends after surgery including ocular surface disease index (OSDI), tear film break-up time (BUT), and score of corneal fluorescein staining (SCFS). They worsened significantly at 1w post-operation and then gradually improved: OSDI and BUT showed obvious improvement in 1 m post-operation (SMD = - 0.58, 95%CI = [- 1.04, - 0.13]; SMD = 0.42, 95%CI = [0.06, 0.78]); SCFS was restored to preoperative levels in 3 m after surgery (SMD = - 0.54, 95%CI = [- 1.16, 0.07]). Another parameter, Schirmer test without anesthesia (SIT), presented transient increase at 1w post-operation (SMD = 0.87, 95%CI = [0.27, 1.47]) and presented a relatively stable improvement after 1 m post-operation (SMD = 0.52, 95%CI = [0.16, 0.89]). All parameters in amniotic membrane graft (AMT) showed better improvement in early stage and they showed non-inferior improvements in the long term compared with conjunctival autograft (CAG). Limbal-conjunctival autograft (LCAG) made excellent improvement to OS in the long term while pterygium excision (PE) showed the worst OS. The type of pterygium (primary and secondary), diabetes mellitus (DM) status, and fixation method had certain effects on the results. CONCLUSIONS: OS of pterygium is deteriorated at 1w post-operation then gradually improved to preoperative levels after 1 m post-operation. Among various surgery techniques, LCAG had the best improvement to OS which especially displayed in the long-term outcomes.

Late Pulmonary Autograft Dilation: Can We Make a Good Operation Great? The Tailored Approach.

While it is the main viable option in the growing child and young adult, the Ross procedure has expanded its applicability to older patients, for whom long-term results are equivalent, if not superior, to prosthetic aortic valve replacement. Strategies aiming at mitigating long-term autograft failure from root enlargement and valve regurgitation have led some to advocate for root reinforcement with prosthetic graft material. On the contrary, we will discuss herein the rationale for a tailored approach to the Ross procedure; this strategy is aimed at maintaining the natural physiology and interplay between the various autograft components. Several technical maneuvers, including careful matching of aortic and autograft annuli and sino-tubular junction as well as external support by autologous aortic tissue maintain these physiologic relationships and the viability of the autograft, and could translate in a lower need for late reintervention because of dilation and/or valve regurgitation.

The fusion rates at different times of cortical iliac crest autograft or allograft compared with cages after anterior cervical discectomy and fusion: a meta-analysis.

OBJECTIVE: The cortical iliac crest autograft (CICA)/structural allograft (SA) has still been recognized as the gold standard for the ACDF technique for its high degree of histocompatibility and osteoinduction ability though the flourishing and evolving cage development. However, there was no further indication for using CICA/SA in ACDF based on basic information of inpatients. Our operative experience implied that applying CICA/SA has an advantage on faster fusion but not the long-term fusion rate. Therefore, our study aimed to compare the fusion rates between CICA and cage, between SA and cage, and between CICA/CA and cage. METHODS: Based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), a comprehensive literature search of electronic databases including PubMed, Embase, Cochrane Library and Web of Science was conducted to identify these clinical trials that investigated the postoperative 3, 6, 12 and 24 months fusion rates of CICA/structural SA versus cage. Assessment of risk of bias, data extraction and statistical analysis were then carried out by two independent authors with the resolve-by-consensus method. The primary outcome was fusion rate at 3, 6, 12 and 24 months postoperatively. The secondary outcomes were also meta-analyzed such as hardware complications, operative duration and hospitalization time. Our meta-analysis was registered with PROSPERO (Identifier: CRD42022345247). RESULT: A total of 3451 segments (2398 patients) derived from 34 studies were included after the screening of 3366 articles. The segmental fusion rates of CICA were higher than cages at 3 (P = 0.184, I2 = 40.9%) and 6 (P = 0.147, I2 = 38.8%) months postoperatively, but not 12 (P = 0.988, I2 = 0.0%) and 24 (P = 0.055, I2 = 65.6%) months postoperatively. And there was no significant difference in segmental fusion rates between SA and cage at none of 3 (P = 0.047, I2 = 62.2%), 6 (P = 0.179, I2 = 41.9%) and 12 (P = 0.049, I2 = 58.0%) months after operations. As for secondary outcomes, the CICA was inferior to cages in terms of hardware complications, operative time, blood loss, hospitalization time, interbody height, disk height and Odom rating. The hardware complication of using SA was significantly higher than the cage, but not the hospitalization time, disk height, NDI and Odom rating. CONCLUSION: Applying CICA has an advantage on faster fusion than using a cage but not the long-term fusion rate in ACDF. Future high-quality RCTs regarding the hardware complications between CICA and cage in younger patients are warranted for the deduced indication.

Inactivation and replantation of the knee joint: an infeasible surgical method.

BACKGROUND: The inactivation and replantation of autologous tumor bones are important surgical methods for limb salvage in patients with malignancies. Currently, there are few reports on the inactivation and replantation of the knee joint. In this study, we aimed to evaluate the feasibility of our surgical approach. METHODS: This is a retrospective case series study. We retrospectively collected the clinical data of patients with sarcoma treated with knee joint inactivation and replantation and analyzed the efficacy of this surgical method. The bone healing and complications in these patients after inactivated autograft replantation were assessed. RESULTS: This study included 16 patients. Fifteen patients had osteosarcoma, and one had Ewing's sarcoma. The average length of the inactivated bone is 20.2 cm (range 13.5-25.3 cm). All the patients underwent internal plate fixation. The average follow-up duration was 30 months (range 8-60 months). Before the data deadline of this study, eight (50%) patients were still alive, and eight (50%) died of sarcoma metastasis. Eight (50%) patients achieved bone healing at the diaphysis site of the inactivated tumor bone, with an average bone healing time of 21.9 months (range, 12-36 months). Five (31%) patients died due to metastases and did not achieve bone healing. Two (12.5%) patients did not achieve bone healing because of infection, and one (6.3%) patient underwent amputation due to tumor recurrence. Ten (62.5%) patients experienced fractures around the joint ends of the inactivated replanted bone, and eight of these ten patients were combined with joint dislocation. CONCLUSION: The incidence of joint deformities after the knee-joint inactivation and replantation is extremely high and is not recommended for use.

Modified osteochondral autograft transplantation for steroid-induced osteonecrosis of femoral head in idiopathic thrombocytopenic purpura: a case report and literature.

Osteochondral autograft transplantation (OAT) has been commonly applied in the knee and ankle while the technique has not yet been a popularity in the femoral head. In this article, we present a 28-year-old female patient, who has a history of 1-year-use of glucocorticoid in the treatment of idiopathic thrombocytopenic purpura, with steroid-induced osteonecrosis of the femoral head (SONFH). She underwent surgical hip dislocation, osteochondroplasty, OAT, and internal fixation. Her Harris Hip Score improved from 64 to 82 in 36 months to follow-up. The case is valuable considering that a single, instead of several, 1.5 cm autograft was harvested from the non-bearing part of the same femoral head. This modification dispensed with the need of surgery for harvesting autograft from knee or ankle and reduced the structural vulnerability brought by the multihole donor part of the femoral head.

Plastic and elastic biomechanical properties of anterior cruciate ligament autografts.

BACKGROUND: Anterior cruciate ligament (ACL) rupture is a common orthopedic injury, occurring in roughly 68.6 per 100,000 persons annually, with the primary treatment option being ACL reconstruction. However, debate remains about the appropriate graft type for restoring the native biomechanical properties of the knee. Furthermore, plastic graft elongation may promote increased knee laxity and instability without rupture. This study aims to investigate the plastic properties of common ACL-R graft options. METHODS: Patellar tendon (PT), hamstring tendon (HT), and quadriceps tendon (QT) grafts were harvested from 11 cadaveric knees (6 male and 5 female) with a mean age of 71(range 55-81). All grafts were mechanically tested under uniaxial tension until failure to determine each graft's elastic and plastic biomechanical properties. RESULTS: Mechanically, the QT graft was the weakest, exhibiting the lowest failure force and the lowest failure stress (QT < HT, p = 0.032). The PT was the stiffest of the grafts, having a significantly higher stiffness (PT > QT, p = 0.0002) and Young's modulus (PT > QT, p = 0.001; PT > HT, p = 0.041). The HT graft had the highest plastic elongation at 4.01 ± 1.32 mm (HT > PT, p = 0.002). The post-yield behavior of the HT tendon shows increased energy storage capabilities with the highest plastic energy storage (HT > QT, p = 0.012) and the highest toughness (HT > QT, p = 0.032). CONCLUSION: Our study agrees with prior studies indicating that the failure load of all grafts is above the requirements for everyday activities. However, grafts may be susceptible to yielding before failure during daily activities. This may result in the eventual loss of functionality for the neo-ACL, resulting in increased knee laxity and instability.

Effectiveness of synthetic versus autologous bone grafts in foot and ankle surgery: a systematic review and meta-analysis.

BACKGROUND: All orthopaedic procedures, comprising foot and ankle surgeries, seemed to show a positive trend, recently. Bone grafts are commonly employed to fix bone abnormalities resulting from trauma, disease, or other medical conditions. This study specifically focuses on reviewing the safety and efficacy of various bone substitutes used exclusively in foot and ankle surgeries, comparing them to autologous bone grafts. METHODS: The systematic search involved scanning electronic databases including PubMed, Scopus, Cochrane online library, and Web of Science, employing terms like 'Bone substitute,' 'synthetic bone graft,' 'Autograft,' and 'Ankle joint.' Inclusion criteria encompassed RCTs, case-control studies, and prospective/retrospective cohorts exploring different bone substitutes in foot and ankle surgeries. Meta-analysis was performed using R software, integrating odds ratios and 95% confidence intervals (CI). Cochrane's Q test assessed heterogeneity. RESULTS: This systematic review analyzed 8 articles involving a total of 894 patients. Out of these, 497 patients received synthetic bone grafts, while 397 patients received autologous bone grafts. Arthrodesis surgery was performed in five studies, and three studies used open reduction techniques. Among the synthetic bone grafts, three studies utilized a combination of recombinant human platelet-derived growth factor BB homodimer (rhPDGF-BB) and beta-tricalcium phosphate (ß-TCP) collagen, while four studies used hydroxyapatite compounds. One study did not provide details in this regard. The meta-analysis revealed similar findings in the occurrence of complications, as well as in both radiological and clinical evaluations, when contrasting autografts with synthetic bone grafts. CONCLUSION: Synthetic bone grafts show promise in achieving comparable outcomes in radiological, clinical, and quality-of-life aspects with fewer complications. However, additional research is necessary to identify the best scenarios for their use and to thoroughly confirm their effectiveness. LEVELS OF EVIDENCE: Level II.

Comparison of knee flexor strength recovery between semitendinosus alone versus semitendinosus with gracilis autograft for ACL reconstruction: a systematic review and meta-analysis.

BACKGROUND: Whether there is a difference in harvesting the semitendinosus tendon alone (S) or in combination with the gracilis tendon (SG) for the recovery of knee flexor strength after anterior cruciate ligament (ACL) reconstruction remains inconclusive. Therefore, this study aimed to assess the recovery of knee flexor strength based on the autograft composition, S or SG autograft at 6, 12, and ≥ 24 months after ACL reconstruction. METHODS: A systematic review and meta-analysis was conducted following the PRISMA guidelines. A comprehensive search was performed encompassing the Cochrane Library, Embase, Medline, PEDRo and AMED databases from inception to January 2023. Inclusion criteria were human clinical trials published in English, comprised of randomized controlled trials (RCTs), longitudinal cohort-, cross-sectional and case-control studies that compared knee flexor strength recovery between S and SG autografts in patients undergoing primary ACL reconstruction. Isokinetic peak torques were summarized for angular velocities of 60°/s, 180°/s, and across all angular velocities, assessed at 6, 12, and ≥ 24 months after ACL reconstruction. A random-effects model was used with standardized mean differences and 95% confidence intervals. Risk of bias was assessed with the RoBANS for non-randomized studies and the Cochrane RoB 2 tool for RCTs. Certainty of evidence was appraised using the GRADE working group methodology. RESULTS: Among the 1,227 patients from the 15 included studies, 604 patients received treatment with S autograft (49%), and 623 received SG autograft (51%). Patients treated with S autograft displayed lesser strength deficits at 6 months across all angular velocities d = -0.25, (95% CI -0.40; -0.10, p = 0.001). Beyond 6 months after ACL reconstruction, no significant difference was observed between autograft compositions. CONCLUSION: The harvest of S autograft for ACL reconstruction yields superior knee flexor strength recovery compared to SG autograft 6 months after ACL reconstruction, irrespective of angular velocity at isokinetic testing. However, the clinical significance of the observed difference in knee flexor strength between autograft compositions at 6 months is questionable, given the very low certainty of evidence and small effect size. There was no significant difference in knee flexor strength recovery between autograft compositions beyond 6 months after ACL reconstruction. TRIAL REGISTRATION: CRD42022286773.

Metal interference screw fixation combinations show high revision rates in primary hamstring tendon ACL reconstruction.

BACKGROUND: Different fixation methods in anterior cruciate ligament reconstruction (ACLR) have been associated with different revision rates, specifically in the early postoperative period. However, most previous research has either grouped together different fixation types or evaluated femoral-sided fixation or tibial-sided fixation separately. Therefore, the purpose of this study was to determine ACL revision rates for specific combinations of femoral and tibial fixation methods within 2 years of primary hamstring tendon autograft ACLR based on data from the Swedish National Knee Ligament Registry (SNKLR). METHODS: Patients that underwent primary hamstring tendon autograft ACLR between 2005 and 2018 in the SNKLR were included. The collected data included patient characteristics (age, sex, body mass index [BMI]), activity at time of injury, surgical information (concomitant injuries, time from injury to surgery, fixation types at the femur and tibia), and subsequent revision ACLR. Revision rate within 2 years of the index procedure was chosen, as ACLR fixation is most likely to contribute to ACLR revision within the first 2 years, during graft maturation. RESULTS: Of the 23,238 included patients undergoing primary hamstring ACLR, 581 (2.5%) underwent revision ACLR within 2 years of the index procedure. Among the combinations used for > 300 patients, the femoral metal interference screw/tibial metal interference screw fixation combination had the highest revision rate followed by metal interference screw/resorbable screw and Endobutton/AO screw fixation combinations, with respective revision rates of 4.0, 3.0, and 3.0%. The lowest revision rate within 2 years of ACLR was found in the Endobutton/metal interference screw with backup Osteosuture fixation combination, used in 433 cases, with a failure rate of 0.9%. CONCLUSION: Different early ACL revision rates were found across different combinations of femoral and tibial fixation devices within 2 years of primary hamstring tendon autograft ACLR. Metal interference screw fixation, particularly when performed on both the femoral and tibial sides, most frequently resulted in revision ACLR. These findings may be helpful for surgeons in selecting appropriate fixation devices for hamstring ACLR. LEVEL OF EVIDENCE: IV.

Presoaking hamstring autograft with vancomycin does not jeopardize its biomechanical properties, including graft elongation, after cyclic loading.

PURPOSE: Presoaking the graft with vancomycin before implantation has been shown to reduce the risk of postoperative infection after anterior cruciate ligament reconstruction (ACLR). However, the effects of presoaking on the graft biomechanical properties remain unclear. This study aimed to determine whether presoaking the graft with vancomycin affects the graft biomechanical properties and length after cyclic loading. METHODS: Ten paired (20 specimens) gracilis and semitendinous tendons were harvested from fresh-frozen human cadaveric specimens. Two tendons were folded in half to make four strands, and the grafts were randomized into the vancomycin and control groups. The graft was exposed to the antibiotic solution for 15 min (5 mg/mL) and prepared by mixing 1 g of vancomycin with 200 mL of normal saline (NaCl 0.9%). The control group was soaked in normal saline for 15 min. The prepared grafts were attached to the actuator of a dynamic tensile-testing machine. All grafts were tested with 3000 cycles of cyclic loading followed by a pull-to-failure. The cyclic loading protocol consisted of position and load control blocks to simulate the graft in vivo in the postoperative phase after ACLR. RESULTS: Presoaking in vancomycin did not jeopardize the biomechanical properties of the graft. In addition, presoaking with vancomycin did not elongate the grafts. No significant differences were found in the mean Young's modulus and the mean total elongation of the graft of the specimen between the vancomycin group and the control group. CONCLUSION: Presoaking the graft with vancomycin jeopardized neither its biomechanical properties nor elongation even after cyclic loading in this in vitro study. It is suggested that vancomycin presoaking could be considered a safe and effective preventive measure for postoperative infections after ACLR. LEVEL OF EVIDENCE: Not applicable.

Females demonstrate lower levels of activity, psychological readiness and strength symmetry after anterior cruciate ligament reconstruction than males, and also recovery of quadriceps strength and hop symmetry is delayed in females undergoing reconstruction with a quadriceps tendon autograft.

PURPOSE: To investigate sex-based recovery differences in patients undergoing anterior cruciate ligament reconstruction (ACLR) with a hamstring (HT) or quadriceps (QT) tendon autograft. METHODS: This study included 97 patients, including 50 females (HT = 25, QT = 25) and 47 males (HT = 24, QT = 23), assessed presurgery and at 12- and 24-month postoperatively via surveys, laxity, isokinetic knee extensor and flexor torque and a 6-hop performance battery. Limb symmetry indices (LSIs) were calculated. Outcomes were compared between males and females, as well as within each graft type. RESULTS: Males reported significantly higher Tegner scores at 12 (p = 0.029) and 24 (p = 0.031) months, Anterior Cruciate Ligament Return to Sport after Injury scores at 12 (p = 0.009) and 24 (p = 0.010) months, and a significantly higher lateral hop LSI at 12 (p = 0.045) months, knee extensor torque LSI at 12 (p = 0.020) months, and knee flexor torque LSI at 12 (p = 0.001) and 24 (p = 0.039) months. Females undergoing ACLR with a QT (vs. HT) graft demonstrated a lower knee extensor torque LSI at 12 (p = 0.006) months, a lower lateral hop LSI at 12 (p = 0.038) months, and a lower medial hop LSI at 12 (p = 0.042) months. CONCLUSIONS: Females reported less activity and psychological readiness, as well as strength symmetry. Furthermore, the recovery of quadriceps strength and hop symmetry was delayed in females (vs. males) undergoing ACLR with a QT graft. A better understanding of these differences will assist in counselling on expectations, determining the most appropriate graft construct and permitting more targeted rehabilitation. LEVEL OF EVIDENCE: Level IV.

Evaluating the quality of systematic reviews of comparative studies in autograft-based anterior cruciate ligament reconstruction using the AMSTAR-2 tool: A systematic umbrella review.

PURPOSE: There remains a lack of consensus around autograft selection in anterior cruciate ligament reconstruction (ACLR), though there is a large body of overlapping systematic reviews and meta-analyses. Systematic reviews and their methodological quality were aimed to be further assessed, using a validated tool known as assessing the methodological quality of systematic reviews (AMSTAR-2). METHODS: MEDLINE, Embase and CENTRAL were searched from inception to 23 April 2023 for systematic reviews (with/without meta-analysis) comparing primary ACLR autografts. A final quality rating from AMSTAR-2 was provided for each study ('critically low', 'low', 'moderate' or 'high' quality). Correlational analyses were conducted for ratings in relation to study characteristics. RESULTS: Two thousand five hundred and ninety-eight studies were screened, and 50 studies were ultimately included. Twenty-four studies (48%) were rated as 'critically low', 17 (34%) as 'low', seven (14%) as 'moderate' and two (4%) as 'high' quality. The least followed domains were reporting on sources of funding (1/50 studies), the impact of risk of bias on results of meta-analyses (11/36 studies) and publication bias (17/36 studies). There was a significant increase in the frequency of studies graded as 'moderate' compared to 'low' or 'critically low' quality over time (p = 0.020). CONCLUSION: The methodological quality of systematic reviews comparing autografts in ACLR is low, with many studies being rated lower due to commonly absent aspects of systematic review methodology such as investigating sources of funding and publication bias. More recent studies were generally more likely to be of higher quality. Authors are advised to consult AMSTAR-2 prior to conducting systematic reviews in ACLR. LEVEL OF EVIDENCE: Level IV.

Risk factors for anteroposterior laxity increase over time in double-bundle anterior cruciate ligament reconstruction using hamstring autografts.

PURPOSE: An anteroposterior (AP) laxity can increase over time after anterior cruciate ligament reconstruction (ACLR) using hamstring tendons; however, the associated risk factors remain unclear. This study aimed to investigate the risk factors of this phenomenon. METHODS: Overall, 151 patients who underwent ACLR using hamstring autografts were recruited. AP laxity was evaluated using Knee Lax 3 arthrometer at 5 months, 1 and 2 years postsurgery. Patients were categorised into groups I (>1 mm increase) and C (<1 mm increase) based on whether they experienced an irreversible increase in AP laxity after 1 or 2 years compared with 5 months. Patient demographics and Knee injury and Osteoarthritis Outcome Score (KOOS) at 2 years postsurgery were compared between groups. RESULTS: Group I (n = 33, 21%) showed a side-to-side difference of 4.6 (3.0-7.2) mm in AP laxity preoperatively and 0.3 (-0.7 to 1.3), 1.1 (0.2-1.9) and 2.4 (1.7-3.2) mm at 5 months, 1 and 2 years postoperatively, while group C (n = 119, 79%) showed 4.3 (2.8-5.7) mm preoperatively and 1.3 (0-1.9), 0.9 (0.1-1.8) and 0.6 (-0.3 to 1.5) mm, respectively. No significant differences were observed in the overall KOOS at 2 years (n.s.). However, group I was older (36 [22-46] vs. 28 [19-39] years; p = 0.044), had longer surgical waiting periods (122 [69-341] vs. 81 [52-136] days; p = 0.041) and lower preoperative Tegner activity scale scores (6 [5-7] vs. 7 [6,7]; p = 0.002). CONCLUSION: While 33 patients (21%) experienced AP laxity increase over time, they had comparable clinical outcomes with group C. LEVEL OF EVIDENCE: Level III.

Femoral tunnel length does not impact outcomes following ACL reconstruction using a single-bundle quadriceps tendon autograft: A systematic review.

PURPOSE: To determine whether femoral tunnel length (FTL) affects clinical or functional outcomes following primary Anterior cruciate ligament reconstruction (ACLR) with single-bundle quadriceps tendon autograft, both with and without a patellar bone block. METHODS: An electronic search of MEDLINE, EMBASE, and Cochrane databases was carried out via OVID. Data pertaining to study characteristics, patient demographics, surgical techniques, femoral tunnel length, and subjective/objective clinical outcomes was abstracted. Studies were stratified into two groups based on FTL; a short femoral tunnel (S-FT) group of ≤25 mm, and a long femoral tunnel (L-FT) group of >25 mm. There was a high degree of heterogeneity between studies, prohibiting meta-analysis. RESULTS: Seven studies comprising 368 total patients with a mean age of 30.3 years (range: 23.4-34 years) were included for analysis. The S-FT group included 126 patients and the L-FT group 242 patients. Both groups demonstrated statistically significant postoperative improvements across both subjective and objective clinical and functional outcomes. Average complication rates were 11.9% (range: 0%-29%) in the S-FT group and 4.5% (range: 1%-14%) in the L-FT group. Ranges of re-rupture rates were 0%-2% and 0%-3% for the S-FT and L-FT groups, respectively (n.s.). CONCLUSION: Both S-FT and L-FT groups demonstrated comparable postoperative outcomes following primary ACLR with single bundle quadriceps tendon autograft. There were slightly superior, although non-significant, outcomes reported with short femoral tunnel length, however, this may have been confounded by the variation in surgical technique used. LEVEL OF EVIDENCE: IV.

MCL augmentation using a peroneus longus split tendon autograft satisfactorily restores knee stability with no impairment in foot function and with a low failure rate for concurrent ACL reconstruction.

PURPOSE: Addressing grade 2 and 3 medial-sided instabilities during anterior cruciate ligament (ACL) reconstruction is crucial to reduce the risk of ACL graft failure. This study introduced a minimally invasive, medial collateral ligament (MCL) augmentation technique using a peroneus longus split tendon autograft, which was fixed to the femoral deep MCL insertion and tibial superficial MCL insertion. METHODS: This prospective, longitudinal, single-centre case series included patients who underwent MCL augmentation concurrent with primary or revision ACL reconstruction due to anteromedial instability. Preoperatively and at 1-year follow-up, clinical examinations, such as rolimeter test of anterior tibial translation and medial instability, knee (International Knee Documentation Committee subjective knee form [IKDC], Lsyholm, Knee Injury and Osteoarthritis Outcome Score [KOOS]) and foot function scores (American Orthopaedic Foot and Ankle Society score [AOFAS]) and complications, were analyzed. RESULTS: Thirty-one patients with a mean follow-up of 13.5 ± 2.6 months and a mean age of 27.8 ± 9.6 years were included. The side-to-side difference for anterior tibial translation significantly improved from preoperative to 1-year follow-up with an ACL reconstruction failure rate of 6.5%. No patient retained a grade 2 or 3 medial instability on valgus stress testing with 30° flexion. Significant improvements from preoperative to 1-year postoperative follow-up were observed in knee function scores: IKDC (48.9 ± 26.9- 71.3 ± 11.5, p < 0.001) and Lysholm (59.9 ± 28.5-80.5 ± 11.2, p = 0.002) as well as KOOS pain, ADL, sport and QoL, each reaching the respective minimal clinically important difference values. The foot function score AOFAS showed no significant impairment (100 ± 0-99.3 ± 2.5, p = 0.250). Complications included cyclops lesions of ACL reconstruction in three patients. CONCLUSION: At 1-year follow-up, MCL augmentation using a peroneus longus split tendon autograft for patients simultaneously undergoing ACL reconstruction satisfactorily restores knee stability, has a low ACL reconstruction failure rate and does not significantly impair foot function. LEVEL OF EVIDENCE: Level IV therapeutic study; case series.

Defining clinically relevant outcome thresholds for pain and function after osteochondral autograft transplantation of the knee.

PURPOSE: To define the minimal clinically important difference (MCID) for measures of pain and function at 2, 5 and 10 years after osteochondral autograft transplantations (OATs). METHODS: Patients undergoing OATs of the knee were identified from a prospectively maintained cartilage surgery registry. Baseline demographic, injury and surgical factors were collected. Patient-reported outcome scores (PROMs) were collected at baseline, 2-, 5- and 10-year follow-up, including the International Knee Documentation Committee (IKDC) score, Knee Outcome Survey Activities of Daily Living Scale (KOS-ADLS), Marx activity scale and Visual Analogue Scale (VAS) for pain. The MCIDs were quantified for each metric utilizing a distribution-based method equivalent to one-half the standard deviation of the mean change in outcome score. The percentage of patients achieving MCID as a function of time was assessed. RESULTS: Of 63 consecutive patients who underwent OATs, 47 (74.6%) patients were eligible for follow-up (surgical date before October 2021) and had fully completed preoperative PROMs. A total of 39 patients (83%) were available for a minimum 2-year follow-up, with a mean (±standard deviation) follow-up of 5.8 ± 3.4 years. The MCIDs were determined to be 9.3 for IKDC, 2.5 for Marx, 7.4 for KOS-ADLS and 12.9 for pain. At 2 years, 78.1% of patients achieved MCID for IKDC, 77.8% for Marx, 75% for KOS-ADLS and 57.9% for pain. These results were generally maintained through 10-year follow-ups, with 75% of patients achieving MCID for IKDC, 80% for Marx, 80% for KOS-ADLS and 69.8% for pain. CONCLUSIONS: The majority of patients achieved a clinically relevant outcome improvement after OATs of the knee, with results sustained through 10-year follow-up. Patients who experience clinically relevant outcome improvement after OATs in the short term continue to experience sustained benefits at longer-term follow-up. These data provide valuable prognostic information when discussing patient candidacy and the expected trajectory of recovery. LEVEL OF EVIDENCE: Level III.

A Comparison of Treatment of OCD Lesions of the Capitellum With Osteochondral Autograft and Allograft Transplantation.

Osteochondritis dissecans (OCD) of the capitellum occurs relatively infrequently but can be found in young overhead-throwing athletes, most commonly in baseball players and gymnasts. Although non-operative management can effectively treat stable lesions, unstable lesions can lead to debilitating symptoms of the elbow and diminished quality of life without surgical intervention. This article reviews methods of treating OCD of the capitellum categorized by stability, size, and patient characteristics, and seeks to familiarize the reader with the appropriate selection of osteochondral allograft versus autograft in treating large, unstable lesions. We complement this review with 3 case examples, each using either an osteochondral autograft or allograft, and discuss the decision-making methodology used in each case.