Quadriceps autograft is a viable graft choice for arthroscopic ACL reconstruction in patients over 50 years of age.

PURPOSE: The purpose of this study was to evaluate the patient-reported outcomes, graft failure, quadriceps rupture and sports preference after arthroscopic ACL reconstruction in patients older than 50 years who underwent arthroscopic ACL reconstruction with a quadriceps tendon (QT) autograft. METHODS: Between 2010 and 2020, prospectively collected data were obtained from an institutional database. Patients older than 50 years with primary arthroscopic ACL reconstruction and a minimum of 2 years of follow-up were included. Patients undergoing a revision ACL reconstruction or undergoing a primary ACL reconstruction using a graft other than a QT autograft, and patients with a contralateral knee injury or osteoarthritis (Ahlbäck stage 2 or higher) were excluded. A minimally invasive technique was used for QT autograft harvesting. Patients were evaluated for pre-injury and 2-year follow-up Lysholm knee score, Tegner activity level, Visual Analog Scale (VAS) for pain, graft failure, quadriceps tendon rupture, and return to sport. RESULTS: A total of 57 patients were included in the study. The mean age of the cohort was 54.9 ± 5.2 (range 50-75). Of the 57 reconstructions, 16 (28%) were isolated ACL reconstructions, while 41 (72%) were complex reconstructions (concomitant meniscus, cartilage and/or collateral ligament injuries). At the 2-year follow-up Lysholm knee score, Tegner activity level and VAS for pain improved to pre-injury level and no significant difference was noted between pre-injury and 2-year follow-up functional scores (n.s.). No case of graft failure or quadriceps tendon rupture was reported. No significant difference was noted in the pre-injury and postoperative sports preference (n.s.) and all patients return to their desired sports activity. CONCLUSION: Arthroscopic ACL reconstruction by using QT autograft in highly active older patients provides satisfactory patient-reported functional outcomes and allows recovery of the pre-injury level of activity. QT autograft is a good graft option in patients older than 50 years. LEVEL OF EVIDENCE: Level IV.

No difference in patient reported outcomes, laxity, and failure rate after revision ACL reconstruction with quadriceps tendon compared to hamstring tendon graft: a systematic review and meta-analysis.

PURPOSE: The purpose of this study was to synthesize and quantitatively assess the outcomes of ACL Revision using a quadriceps tendon (QT) graft and to compare them with those of ACL Revisions performed with hamstring tendons (HT) graft. METHODS: A comprehensive search based on the PRISMA protocol was performed across PubMed, Scopus, Embase, and Cochrane Library from inception until February 2022. Clinical studies reporting the outcomes of ACL Revision with QT autograft were included. Subjective and Objective IKDC, Tegner activity level, Lysholm knee score, KOOS score, VAS for pain, knee laxity (KT-1000/2000 arthrometer, Lachman test, and pivot-shift test), and graft failure were assessed. A systematic review and meta-analysis were performed and a quality assessment of the included studies was carried out with the MINORS score. RESULTS: Seven studies met the selection criteria and were included in the systematic review for the qualitative synthesis of data. A pooled mean of all the variables was provided for the 7 studies, while 3 studies included a control group of ACL Revision with HT and were included in a meta-analysis. A total of 420 participants with a mean age of 28.9 ± 10.5 years and a mean postoperative follow-up of 39.3 ± 16.4 months were assessed. Of these, 277 patients underwent ACL Revision with QT and 143 patients underwent ACL Revision with HT. In the QT group, average graft failure was 9.8% compared to 17.4% in the HT group. KOOS Sport and pivot-shift test showed better postoperative outcomes in QT than HT, although it was not statistically significant (p = 0.052). CONCLUSION: The QT autograft was associated with an improved trend of rotatory laxity, PROMs and failure rate compared to HT autograft after revision ACL reconstruction. The QT autograft for revision ACL reconstruction is supported by the current literature. It is a viable graft that should be considered for both primary and revision ACL reconstruction. LEVEL OF EVIDENCE: Level IV.

Total knee arthroplasty improves sports activity and the patient-reported functional outcome at mid-term follow-up.

PURPOSE: The purpose of this study was to assess (1) sports participation and preference for the type of sports activity after TKA, (2) mid-term functional outcome and activity level, (3) correlation of different age groups with activity level and functional outcomes, and (4) mid-term survivorship of the prosthesis. METHODS: A retrospective review of prospectively collected data was performed. 182 patients were included who underwent primary TKA between January 2010 and December 2016. Inclusion criteria were symptomatic knee osteoarthritis, age 50-90 years, and with a minimum of 5-year follow-up after TKA. Patients with rheumatoid arthritis and revision TKA were excluded. Sports participation and sports preference, Oxford Knee Score (OKS), Tegner Activity Level, and Visual Analogue Scale (VAS) for pain were recorded pre- and postoperatively at 6 months, 1 year, 2 years, and 5 years. The patient cohort was subdivided according to age groups; activity levels, patient-reported outcomes, and improvement in knee pain were correlated with these age groups. Kaplan-Meier curves were used to investigate survivorship at a minimum of 5 years. RESULTS: The mean age of the cohort was 75.6 ± 7.2 years (range 52-89). Significant improvement was noted in sports participation (p < 0.003). After TKA, there was no change in the preference for sports and none of the patients had to discontinue their sporting activity. OKS improved significantly at all follow-up time points compared to the preoperative score (p < .0001). Patients' sports and physical activity improved significantly at 1 year compared to the preoperative activity level (p < 0.001). Although the Tegner activity level improved over time, this improvement was not significant (NS), while it was significantly higher in males than in females (p < 0.004). Significant improvement was found in the VAS for pain at all follow-up time points compared to the preoperative score (p < .0001). Survivorship was found to be 100% at a 5-year follow-up. CONCLUSION: After TKA, patients can be able to return to sporting activity or even perform better than before surgery. Maximum improvement was noted in the first post-operative year. The male and younger groups perform better than the female and older groups. Sports and physical activity do not negatively impact survivorship of the knee prosthesis at mid-term follow-up and all patients are encouraged to take up sports participation after their TKA. LEVEL OF EVIDENCE: Level 3.

Revision ACL reconstruction using quadriceps, hamstring and patellar tendon autografts leads to similar functional outcomes but hamstring graft has a higher tendency of graft failure.

PURPOSE: The purpose of this study was to evaluate the differences in the patient-reported functional outcomes, and graft failure in revision ACL reconstruction using quadriceps tendon (QT), Hamstring tendon (HT) and bone-patellar tendon-bone (BPTB) autografts. METHODS: Between 2010 and 2020, 97 patients who underwent revision ACL reconstruction (40 patients received a QT, 26 an HT and 31 a BPTB graft) met the inclusion criteria. Pre-injury and at 2-year postoperatively patients were evaluated for patient-reported functional outcomes; Lysholm knee score, Tegner activity level and VAS (visual analogue scale) for pain; and graft failure. Patient-reported outcomes and graft failure were compared between the QT, HT and BPTB groups. The patients with graft failure were not included for outcome analysis at 2-years of follow-up. RESULTS: All three revision groups with QT, HT and BPTB autograft did not differ significantly in terms of age, sex, time from injury to surgery, concomitant injuries and single-stage or double-stage procedures (n.s.). No significant difference was found in the pre-injury patient-reported outcome; Lysholm knee score, Tegner activity and VAS for pain (n.s.) between the three groups. At the 2-year follow-up functional outcomes improved in all three groups and all the patients returned to pre-injury activity level; however, no significant difference was found in functional outcomes at the 2-year follow-up between the three groups (n.s.). Graft failure occurred in 4 (10%), 5 (19%) and 3 (10%) patients of QT, HT and BPTB groups, respectively. However, the rate of failure did not differ significantly between groups. CONCLUSION: All three autografts (QT, HT and BPTB) demonstrated satisfactory patient-reported outcomes in revision ACL reconstruction. Compared with QT and BPTB grafts, HT graft showed a higher tendency for failure rates. With the increasing incidence of revision ACL reconstruction, surgeons should be aware of all the available graft options. The findings of this study will assist the surgeons in the graft selection for revision ACL reconstruction. LEVEL OF EVIDENCE: Level III.

Quadriceps tendon autograft with or without bone block have comparable clinical outcomes, complications and revision rate for ACL reconstruction: a systematic review.

PURPOSE: The purpose of this systematic review is to report complications, graft failure, fixation methods, rehabilitation protocol, clinical and patient-reported outcomes, and return to sports with the use of quadriceps tendon graft with the bone block (QT-B) and without bone block (QT-S). METHODS: According to the PRISMA guidelines a comprehensive search was performed across PubMed/MEDLINE, Scopus, EMBASE, and Cochrane Library databases from inception until April 2022. Only prospective studies using quadriceps tendon autograft with a minimum of 20 patients were considered for inclusion. The outcome measures extracted from the studies were the KT-1000, Lysholm score, Subjective and Objective IKDC, Tegner, Marx Score, complications, failures and/or revision surgery, and rate of return to sports. Cochrane risk of bias and MINORS tool were used for the risk of bias assessment of all included studies. RESULTS: A total of 13 studies were included, consisting of 5 randomized controlled trials, 6 cohort studies, 1 case-control and 1 case series. A total of 484 patients received QT-S in 6 studies of which 224 (46.2%) were males and 212 (43.8%) females with a mean age of 21.5 ± 7.5 (range 14-58). While 243 patients received QT-B in 7 studies of which 167 (68.7%) were males and 76 (31.3%) females with a mean age of 28.9 ± 4.5 (range: 18-49). The studies analyzed had a mean MINORS score of 14.6 (range, 12-19). Both QT-B and QT-S for ACL reconstruction reported satisfactory results in terms of patient-reported outcome measures. Although, a slightly higher anterior laxity was found with the QT-S than with the QT-B. CONCLUSION: Quadriceps tendon with a bone block (QT-B) or without bone block (QT-S) for ACL reconstruction is supported by current literature. Both grafts are safe and viable options for ACL reconstruction with comparable clinical outcomes, complications and revision rates. LEVEL OF EVIDENCE: Level IV. REGISTRATION: PROSPERO-CRD42022347134; https://www.crd.york.ac.uk/prospero/.

No difference in sports participation and patient-reported functional outcomes between total knee arthroplasty and unicompartmental knee arthroplasty at minimum 2-year follow-up in a matched control study.

PURPOSE: The purpose of this study was to compare (1) sports participation and type of sports activity between TKA and UKA patients; (2) functional outcome and activity level between TKA and UKA; and (3) survivorship of the prosthesis in both the groups. METHODS: Prospectively collected data were obtained from an arthroplasty database to identify patients who underwent primary TKA and UKA. Both the cohorts of TKA and UKA were matched, controlling for age, sex, BMI and preoperative patient-reported outcomes, which include Oxford Knee Score (OKS), Tegner activity level, and visual analog scale (VAS) for pain score. After matching the two groups, 287 TKA and 69 UKA cases were available to be included in the study. Patients were evaluated pre- and postoperatively at 2 years for sports participation and sports preference, patient-reported outcomes, activity levels, and improvement in knee pain. RESULTS: The mean age of the TKA and UKA groups were 75.7 ± 8.1 and 74.2 ± 8.8, respectively. There was no significant difference between the two groups concerning the demographic variables. Significant improvement was noted in the weekly sports participation at the final follow-up compared to preoperative sports participation in both the TKA and UKA groups (p < 0.05). All patients were able to return to their desired sporting activity. No significant difference was noted between the two groups in sports participation preoperatively and postoperatively (p > 0.05). OKS, Tegner activity level and VAS for pain demonstrated a significant improvement from preoperative to 2 years postoperatively (p < 0.05). However, preoperative and postoperative patient-reported outcomes did not differ significantly between the TKA and UKA groups (p > 0.05). No case of revision surgery was found at a 2-year follow-up in both groups. CONCLUSION: Traditionally, in isolated medial compartment osteoarthritis, UKA has been considered to be the procedure with better functional outcomes, but the current study demonstrates that when confounding factors are controlled, both TKA and UKA are effective, and offer similar functional outcomes and result in similar improvement in sports participation. These findings will be helpful to counsel the patients to choose the best suitable operative procedure between UKA and TKA. LEVEL OF EVIDENCE: Level 3.

Multiple revision anterior cruciate ligament reconstruction: not the best but still good.

PURPOSE: Given the paucity of literature on the re-revision of ACL, the current study was undertaken. The purpose of this systematic review was to synthesise and qualitatively assess the currently available evidence in the literature regarding the re-revision of ACL reconstruction (rrACLR). METHODS: A systematic review was conducted based on the PRISMA guidelines. The following search terms were used in the title, abstract and keywords fields: "ACL" or "anterior cruciate ligament" AND "revision" or "multiple" or "repeat". The outcome data extracted from the studies were the Lysholm score, Subjective IKDC, Marx Score, Tegner, Marx Score, KOOS score, radiological changes and the rate of return to sports. Complications, failures and/or revision surgery were also analysed. RESULTS: The cohort consisted of 295 patients [191 (64.7%) men and 104 (35.3%) women] with a mean age of 29.9 ± 2.8 years (range 14-58 years) from 10 studies. The mean postoperative follow-up (reported in all studies except one) was 66.9 ± 44.7 months (range 13-230.4 months). Associated injuries were 103 (34.9%) medial meniscus tears, 57 (19.3%) lateral meniscus tears, 14 (4.7%) combined medial plus lateral meniscus tears, 11 (3.7%) meniscal tears (not specified), 252 (85.4%) cartilage lesions, 6 (2.0%) medial collateral ligament injury and 2 (0.7%) lateral collateral ligament injuries. In 47 (15.9%) patients an extra-articular plasty was performed for the anterolateral ligament. In all studies that reported pre- and post-operative IKDC (subjective and objective) and Lysholm score, there was a significant improvement compared to the pre-operative value (p < 0.05). At the final follow-up, laxity measured with KT-1000 was found to be 2.2 ± 0.6 mm. 31 (10.5%) out of 295 patients returned to their pre-injury activity level. A total of 19 (6.4%) re-ruptures were found, while only 4 (1.4%) complications (all minors) were reported, out of which 2 (0.7%) were superficial infections, 1 (0.3%) cyclops lesion and 1 (0.3%) flexion loss. CONCLUSION: Multiple revisions of anterior cruciate ligament reconstruction allow acceptable clinical results and a good degree of knee stability with a low rate of subsequent new re-ruptures but the possibility of regaining pre-injury sports activity is poor; whenever possible, it is preferred to revise the ligament in one stage. This surgery remains a challenge for orthopaedic surgeons and many doubts persist regarding the ideal grafts, additional extra-articular procedures and techniques to use. LEVEL OF EVIDENCE: IV. STUDY REGISTRATION: PROSPERO-CRD42022352164 ( https://www.crd.york.ac.uk/prospero/ ).

Good results after treatment of RAMP lesions in association with ACL reconstruction: a systematic review.

PURPOSE: This study aimed to systematically evaluate the clinical, functional, and radiological outcomes, complications, and rate of return to sports among patients with RAMP lesion of the medial meniscus encountered during anterior cruciate ligament (ACL) reconstruction. METHODS: A systematic review was conducted based on the PRISMA guidelines. Two independent reviewers searched the PubMed, Scopus, Embase, and Cochrane Library databases using the terms "ACL" or "anterior cruciate ligament," and "RAMP lesion." The outcome measures extracted from the studies were the Short Form-12 (SF-12) in its mental and physical component (MCS and PCS), Lysholm score, Subjective IKDC, Marx Score, WOMAC Score, Tegner, Radiological changes, complications, failures and/or revision surgery, and rate of return to sports. RESULTS: The cohort of patients consisted of 1,243 participants with a mean age of 28.6 ± 2.6. The mean postoperative follow-up was 40.9 ± 6.3 months. A total of 1145 (92.1%) RAMP lesions were repaired with concomitant ACL reconstruction, while only 98 (7.9%) lesions were left untreated (or treated with abrasion only). The Lysholm score was used in 6 studies (in one only at final follow-up), with a significant improvement in all the studies (Lysholmpre 60.03 ± 6.12; Lysholmpost 89.9 ± 5.0). Eight studies out of nine reported Subjective IKDC score, and a significant improvement was noted in all cases (IKDCpre 56.2 ± 5.8. IKDCpost 84.9 ± 3.7). Of 18 (1.4%) complications reported, 15 (1.2%) were related to RAMP/ACL surgery, and of the remaining three (0.2%) two (0.2%) were hematomas and one (0.1%) a contralateral ACL lesion. Of the 106 (8.5%) revision surgeries required, 5 (0.4%) were in non-treated lesions [two (0.2%) ACL re-ruptures and three (0.2%) medial meniscus re-injury]. In treated patients, the revision occurred for the following reasons: 75 (6.0%) meniscectomy, 14 (1.1%) meniscal suture revisions, 11 (0.9%) ACL failures and one (0.1%) arthrolysis. CONCLUSIONS: It is not yet clear if, in all cases of ACL reconstruction in which a medial meniscal RAMP lesion is encountered, the lesion needs to undergo surgical repair. Accordingly, it is recommended that in the repair of all unstable medial meniscal RAMP lesions during an ACL reconstruction in cases associated with a stable RAMP lesion, the surgeon may decide on repair based on the patient profile. LEVEL OF EVIDENCE: Level IV.

In elite athletes with meniscal injuries, always repair the lateral, think about the medial! A systematic review.

PURPOSE: This study aimed to evaluate and compare the time required to return to sports (RTS) after surgery, the rate of revision surgery and the time required for RTS after revision surgery in elite athletes undergoing meniscal repair or partial meniscectomy, particularly analysing the difference between medial and lateral menisci. It was hypothesised that both procedures would entail similar, high rates of RTS, with the lateral meniscus exhibiting higher potential healing postprocedure compared to the medial meniscus. METHODS: A systematic review was conducted based on the PRISMA guidelines. Quality assessment of the systematic review was performed using the AMSTAR-2 checklist. The following search terms were browsed in the title, abstract and keyword fields: 'meniscus' or 'meniscal' AND 'tear,' 'injury' or 'lesion' AND 'professional,' 'elite' or 'high-level' AND 'athletes,' 'sports,' 'sportsman,' 'soccer,' 'basketball,' 'football' or 'handball'. The resulting measures extracted from the studies were the rate of RTS, level of RTS, complications, revision surgery and subsequent RTS, Tegner, International Knee Documentation Committee (IKDC) and Visual Analogue Scale (VAS). RESULTS: In this study, the cohort consisted of 421 patients [415 (98.6%) men and 6 (1.4%) women] with a mean age of 23.0 ± 3.0 years. All patients were elite athletes in wrestling, baseball, soccer, rugby or handball. While 327 (77.7%) patients received partial meniscectomy at a mean age of 23.3 ± 2.6 years, 94 (22.3%) patients received meniscal repair at a mean age of 22.1 ± 4.0 years. After partial meniscectomy, 277 patients (84.7%) returned to their competitive sports activity and 256 (78.3%) returned to their pre-injury activity levels. A total of 12 (3.7%) patients required revision surgery because of persistent pain [5 (1.5%) patients], chondrolysis [2 (0.7%) patients] or both chondrolysis and lateral instability [5 (1.5%) patients]. Ten (83.3%) of the twelve patients had involvement of the lateral meniscus, whereas the location of injury was not specified in the remaining two patients. After revision surgery, all patients (100%) resumed sports activity. However, after meniscal repair, 80 (85.1%) athletes returned to their competitive sports activity and 71 (75.5%) returned to their pre-injury activity levels. A total of 16 (17.0%) patients required partial meniscectomy in cases of persistent pain or suture failure. Of these, 4 (25%) patients involved lateral and medial menisci each and 8 (50%) patients were not specified. After revision surgery, more than 80.0% of the patients (13) resumed sports activity. CONCLUSIONS: In elite athletes with isolated meniscal injury, partial meniscectomy and meniscal suture exhibited similar rates of RTS and return to pre-injury levels. Nonetheless, athletes required more time for RTS after meniscal repair and exhibited an increased rate of revision surgery associated with a reduced rate of RTS after the subsequent surgery. For lateral meniscus tears, meniscectomy was associated with a high rate of revision surgery and risk of chondrolysis, whereas partial medial meniscectomy allowed for rapid RTS but with the potential risk of developing knee osteoarthritis over the years. The findings of this systematic review suggested a suture on the lateral meniscus in elite athletes because of the high healing potential after the procedure, the reduced risk of developing chondrolysis and the high risk of revision surgery after partial meniscectomy. Furthermore, it is important to evaluate several factors while dealing with the medial meniscus. If rapid RTS activity is needed, a hyperselective meniscectomy is recommended; otherwise, a meniscal suture is recommended to avoid accelerated osteoarthritis. LEVEL OF EVIDENCE: Level IV. STUDY REGISTRATION: PROSPERO-CRD42022351979 ( https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=351979 ).

Anterior Knee Pain: State of the Art.

Anterior knee pain (AKP) is one of the most common conditions to bring active young patients to a sports injury clinic. It is a heterogeneous condition related to multiple causative factors. Compared to the general population, there appears to be a higher risk of development of patellofemoral osteoarthritis in patients with AKP. AKP can be detrimental to the patient's quality of life and, in the larger context, significantly burdens the economy with high healthcare costs. This study aims to present a comprehensive evaluation of AKP to improve clinical daily practice. The causes of AKP can be traced not only to structures within and around the knee, but also to factors outside the knee, such as limb malalignment, weakness of specific hip muscle groups, and core and ligamentous laxity. Hence, AKP warrants a pointed evaluation of history and thorough clinical examination, complemented with relevant radiological investigations to identify its origin in the knee and its cause. Conservative management of the condition achieves good results in a majority of patients with AKP. Surgical management becomes necessary only when it is deemed to provide benefit-when the patient has well-characterized structural abnormalities of the knee or limb that correlate with the AKP clinically or in situations where the patient does not obtain significant or sustained relief from symptoms. AKP has a multifactorial etiology. The treatment strategy must be individualized to the patient based on the patient profile and specific cause identified. Hence, treatment of AKP warrants a pointed evaluation of history and thorough clinical examination complemented with relevant radiological investigations to identify the condition's origin and its cause. A holistic approach focused on the patient as a whole will ensure a good clinical outcome, as much as a focus on the joint as the therapeutic target.