A Systematic Review of Risk Factors for Anterior Cruciate Ligament Reconstruction Failure.

Although most studies have introduced risk factors related to anterior cruciate ligament reconstruction failure, studies on combinations of high-risk factors are rare. To provide a systematic review of the risk factors of anterior cruciate ligament reconstruction failure to guide surgeons through the decision-making process, an extensive literature search was performed of the Medline, Embase and Cochrane Library databases. Studies published between January 1, 2009, and September 19, 2019, regarding the existing evidence for risk factors of anterior cruciate ligament reconstruction failure or graft failure were included in this review. Study quality was evaluated with the quality index. Ultimately, 66 articles met our criteria. There were 46 cases classified as technical factors, 21 cases as patient-related risk factors, and 14 cases as status of the knee joint. Quality assessment scores ranged from 14 to 24. This systematic review provides a comprehensive summary of the risk factors for anterior cruciate ligament reconstruction failure, including technical factors, patient-related factors, and the factors associated with the status of the knee joint. Emphasis should be placed on avoiding these high-risk combinations or correcting modifiable risk factors during preoperative planning to reduce the rate of graft rupture and anterior cruciate ligament reconstruction failure.

No effect of graft size or body mass index on risk of revision after ACL reconstruction using hamstrings autograft.

PURPOSE: The current study investigated the distribution of hamstrings graft size and body mass index and any potential effect on the risk of revision surgery in a large prospective cohort of patients undergoing ACL reconstruction. More specifically, the aim of the study was to investigate whether larger graft size or smaller BMI would decrease the risk of revision after ACL reconstruction. METHODS: A total of 4029 patients, prospectively registered in the Norwegian Knee Ligament Registry, were included in the study. Univariate Kaplan-Meier survival analyses (with log-rank tests) and the Cox proportional hazard (PH) regression model were applied to compare risk of revision between groups of patients. Mutual adjustment for gender, age, activity at the time of injury and fixation method of the graft was performed. RESULTS: Graft sizes spanned from 5.5 to 11.0 mm and the median of 8.0 mm was reported in 42% of patients in the cohort. BMI was reported from 15 to 57 with a median of 25. 46% of patients were classified as overweight (WHO standards), while 23% of patients were obese. At a median of 2.5 years after surgery, 150 patients had undergone revision surgery. Although certain effects were seen in the unadjusted analyses, neither graft size (diameter) nor patient BMI did affect the risk of undergoing revision surgery in the adjusted analyses. CONCLUSIONS: Graft size and BMI was not found to be independent risk factors for undergoing ACL revision surgery. In contrast to other studies, graft size of 8 mm or larger did not have a better outcome than smaller graft sizes. A relatively large group of overweight patients undergoing ACL surgery reflects the general increase in weight seen in Western societies. Although the current study differs from previous findings, it might indicate that graft diameter is less important than previously stated. LEVEL OF EVIDENCE: Cohort study, II.

Graft Diameter and Graft Type as Predictors of Anterior Cruciate Ligament Revision: A Cohort Study Including 18,425 Patients from the Swedish and Norwegian National Knee Ligament Registries.

BACKGROUND: It is important to investigate and compare graft diameters as well as graft types to identify risk factors for revision after an anterior cruciate ligament (ACL) reconstruction. We performed the current study in order to analyze the early ACL revision rate among patients treated with hamstring tendon (HT) autografts or patellar tendon (PT) autografts of different diameters. Our hypothesis was that an increase in both HT and PT autograft diameters would reduce the risk of early ACL revision. METHODS: This retrospective study was based on prospectively collected data from the national knee ligament registries of Norway and Sweden and included patients who underwent primary ACL reconstruction during the period of 2004 through 2014. The primary end point was the 2-year incidence of ACL revision. The impact of graft type and diameter on the incidence of revision surgery was reported as relative risks (RRs) with 95% confidence intervals (CIs), estimated by using generalized linear models with a binomial distribution and log-link function. RESULTS: Of 58,692 patients identified, a total of 18,425 patients were included in this study. The 2-year rate of ACL revision was 2.10% (PT autografts, 2.63%; HT autografts, 2.08%; RR = 0.93 [95% CI = 0.60 to 1.45]). There was an increased risk of ACL revision among patients treated with HT autografts with a diameter of <8 mm compared with larger HT autografts (RR = 1.25 [95% CI = 1.01 to 1.57]). Patients treated with HT autografts with a diameter of ≥9.0 mm or ≥10.0 mm had a reduced risk of early ACL revision compared with patients treated with PT autografts. CONCLUSIONS: Patients treated with larger-diameter HT autografts had a lower risk of early ACL revision compared with those treated with HT autografts of <8 mm. Patients treated with HT autografts of ≥9 or ≥10 mm had a reduced risk of early ACL revision compared with patients treated with PT autografts. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Small hamstring autograft is defined by a cut-off diameter of 7 mm and not recommended with allograft augmentation in single-bundle ACL reconstruction.

PURPOSE: The present study was to analyze graft failure rates of hamstring tendon (HT) autografts with a cut-off graft diameter of 8 mm or 7 mm, and compare clinical outcomes between augmented small HT with an allograft and non-augmented relatively large HT in single-bundle anterior cruciate ligament reconstruction (ACLR). METHODS: A literature search of PubMed, EMBASE, and the Cochrane Library was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines. Studies to assess graft failure of autologous HT ACLR were reviewed, and graft failure rates with a cut-off graft diameter of 8 mm or 7 mm were further extracted. Clinical comparative studies of ACLR between augmented small HT with an allograft and non-augmented relatively large HT autografts were also included. Results are presented as risk ratio (RR) for binary data and weighted mean difference for continuous data with 95% confidence intervals (CI). RESULTS: Nine studies with 2243 knees were included. Four studies examined the effect of HT autograft diameter on graft failure and five studies assessed clinical outcomes of allograft augmentation to small HT autografts. No significant difference was noted in graft failure with a cut-off diameter of 8 mm. No significant difference was found between diameters > 7 and ≤ 7 mm, but a significant difference was observed between diameters ≥ 7 and < 7 mm (RR = 0.49; 95% CI 0.26-0.92, I2 = 0%, P = 0.03). A trend towards increased risk of graft failure was noted for allograft-augmented HT compared with non-augmented HT autografts (RR = 0.43; 95% CI 0.18-1.02, I2 = 0%), but no significant differences were noted in IKDC, Lysholm, and Tegner scores between these groups. CONCLUSION: The present study did support the use of 7 mm as a reference for cut-off diameter for small HT autografts, but not allograft augmentation to small HT autografts. These findings would guide clinical application of small HT autografts in single-bundle ACLR. LEVEL OF EVIDENCE: IV.

Hamstring Autograft Too Small: How Much Allograft Do You Need to Supplement to a Desired Hybrid Graft Size?

PURPOSE: To determine a simple rule for choosing supplemental allograft size for hybrid anterior cruciate ligament reconstruction using mathematical and cadaveric models. METHODS: Mathematical and cadaveric models were used to determine the rule. The mathematical model required application of the geometric Pythagorean theorem to add areas of circles. Cadaveric semitendinosus and gracilis tendons were combined in multiple quadrupled hamstring size combinations and then sized using standard surgical techniques to confirm the mathematical model. RESULTS: Geometric measurement, not simple addition, of graft diameters was required to determine the final graft size. Direct comparison of cadaveric and mathematical models showed close relations. If a final graft size of 7 mm is desired, an added diameter of all grafts of approximately 9.5 mm is needed. If a final graft size of 8 mm is desired, an added diameter of all grafts of approximately 11 mm is needed. If a final graft size of 9 mm is desired, an added diameter of all grafts of approximately 12.5 mm is needed. If a final graft size of 10 mm is desired, an added graft diameter of approximately 14 mm is needed. Cadaveric hamstring measurements were similar to the mathematical model. CONCLUSIONS: By use of mathematical and cadaveric models, simple rules for determining the additional size of allograft diameter needed to supplement undersized hamstring autograft were created. CLINICAL RELEVANCE: With the increasing availability of allograft types and sizes, surgeons currently have no guidelines on the size of allograft that is required to supplement an undersized hamstring autograft. Simple rules were created for determining the amount of allograft supplementation required for undersized hamstrings and are easily applied to clinical situations.

Association of the Graft Size and Arthrofibrosis in Young Patients After Primary Anterior Cruciate Ligament Reconstruction.

INTRODUCTION: This study investigated the association of graft-related surgical factors and patient characteristics with the odds of arthrofibrosis after primary anterior cruciate ligament reconstruction (ACL-R). METHODS: A retrospective case-control study assessed consecutive patients who underwent primary ACL-R in one tertiary pediatric hospital. Each arthrofibrosis case was matched to three controls for sex, calendar year, and age at the time of ACL-R, as well as the primary surgeon. Conditional multivariable logistic regression assessed the independent association of graft diameter, time from injury to ACL-R, concomitant knee pathologies, and body mass index. RESULTS: Twenty arthrofibrosis cases of 1,121 ACL-R patients (incidence 1.8%) were matched to 60 controls resulting in the mean age of 14.5 years. An increase of 1 mm graft diameter was associated with 3.2-times increased odds of arthrofibrosis. Other variables were not independently associated with arthrofibrosis. CONCLUSION: For young patients, the decision on the graft size must consider the possibility of arthrofibrosis with a larger graft versus reinjury with a smaller graft.

Patient morbidity at the palatal donor site depending on gingival graft dimension.

BACKGROUND: Autogenous gingival grafts are considered the gold standard procedure with proven clinical success when it comes to gingival augmentation. Different graft harvesting procedures have been described in the literature. Understanding which factors might affect the level of discomfort (morbidity) that patients are likely to experience and oral health-related quality of life outcomes in general seems to be crucial. OBJECTIVES: An evaluation of patients' morbidity depending on the free gingival graft (FGG) dimension. MATERIAL AND METHODS: Sixty patients were divided into 3 groups depending on the length of their graft (group L1: ≤10 mm, group L2: 10-20 mm, group L3: ≥20 mm) and into 2 groups depending on the thickness of the graft (group T1: ≤2 mm, group T2: >2 mm). Discomfort at the donor site was evaluated 1 week postoperatively, using a visual analog scale (VAS). RESULTS: With the length of the FGG, the mean VAS scores for pain, bleeding, eating and speaking disorders, stress and interference with social life increased. Analgesic consumption increased with the length of the graft. The thicker the grafts, the less discomfort and pain, and more problems with speaking, stress, daily and work routines occurred; however, without statistical significance. CONCLUSIONS: No differences were demonstrated in the post-operative patients' morbidity between the examined groups; however, pain gradually increased with the FGG length and width.

Graft choice for anatomic anterior cruciate ligament reconstruction: The comparison between thin autograft and thick hybrid graft. An observational study.

Great controversy over the graft choice has been lasted now. This study compared the second-look evaluation and clinical outcomes of anatomic anterior cruciate ligament reconstruction (ACL-R) using a thin autograft versus a thick hybrid graft.Seventy-six patients with complete follow-up data were categorized into the autograft group (N = 34) and hybrid group (N = 42). The Lysholm score, Tegner activity level, International Knee Documentation Committee (IKDC) Knee Evaluation Form, and KT-1000 test were performed before and at follow-up. Results were compared, and further comparisons were made for grafts thicker than 8.5 mm.The hybrid graft was thicker than the autograft (9.10 ±â€Š0.52 vs 8.57 ±â€Š0.48 mm, P < .001). The KT-1000 test, subjective evaluation, and activity level scores increased significantly between pre- and postoperation for all patients (P < .001). No significant differences were, however, found between the 2 groups. Only grafts thicker than 8.5 mm were selected from the autograft (N = 14) and hybrid (N = 34) groups, the Lysholm, IKDC, and KT-1000 test scores were significantly superior for the autograft than the hybrid graft (P = .021, P = .005, and P = .024, respectively).For anatomic ACL-R, a pure autograft is superior to a hybrid graft of the same diameter. The purity of the autograft was more important than the size, and augmenting allografts may be unnecessary.

Use of the 5-Strand Hamstring Autograft Technique in Increasing Graft Size in Anterior Cruciate Ligament Reconstruction.

BACKGROUND: To determine the extent to which a strategy of routinely preparing a 5-strand hamstring autograft would increase graft size in anterior cruciate ligament (ACL) reconstruction. METHODS: A total of 64 patients were enrolled in a prospective randomized controlled study comparing 5-strand and quadrupled semitendinosus-gracilis autografts in single-bundle ACL reconstruction (5-strand group, n = 32; 4-strand group, n = 32). In the 5-strand group, the diameter of the 4-strand construct and the subsequent 5-strand graft used were measured, whereas in the 4-strand group, the diameter of the quadrupled graft used was measured. Quadrupled graft diameter and hamstring tendon lengths were correlated with patient gender, height, weight, and body mass index (BMI). RESULTS: The mean diameter of the final graft used in the 5-strand group was 8.8 ± 0.8 mm, whereas that in the 4-strand group was 7.8 ± 0.7 mm (P < .001). The mean increase in graft size achieved with the use of the 5-strand technique was 1.4 ± 0.3 mm. In the 5-strand group, 24 of 32 (75%) patients had graft diameters exceeding 8 mm compared with 9 of 32 (28%) patients in the 4-strand group (P < .001). Quadrupled graft diameter was significantly correlated with patient height and BMI, whereas the gracilis and semitendinosus lengths were significantly correlated with patient height. CONCLUSIONS: The 5-strand hamstring autograft provides a significantly larger diameter graft compared with the quadrupled hamstring autograft in ACL reconstruction. Graft sizes exceeding 8 mm are achievable in 75% of patients with the routine application of this technique. This is significantly more than that obtained with the standard quadrupled hamstring graft. Hamstring tendon length and quadrupled hamstring graft diameter are also significantly correlated with patient height. LEVEL OF EVIDENCE: Level 1, prospective randomized controlled trial.

Pre-operative ultrasonographic prediction of hamstring autograft size for anterior cruciate ligament reconstruction surgery

Objectives: To evaluate the feasibility of ultrasonographic examination in predicting 4-strand semitendinosus and gracilis tendon (4S-STG) autograft size preoperatively in anterior cruciate ligament reconstruction and to evaluate the use of anthropometric measurement to predict the 4-strand semitendinosus and gracilis tendons (4S-STG) autograft size pre-operatively in anterior cruciate ligament reconstruction. Method: Twenty-seven patients were included in this study conducted from 1st January to 31st December 2013. All patients were skeletally mature and scheduled to undergo primary anterior cruciate ligament reconstruction using 4S-STG autograft. Ultrasonographic examination of semitendinosus and gracilis tendons to measure the cross sectional area was conducted and anthropometric data (weight, height, leg length and thigh circumference) was measured one day prior to surgery. True autograft diameters were measured intraoperatively using closed-hole sizing block in 0.5 mm incremental size. Results: There is a statistically significant correlation between the measured combined cross sectional area (semitendinosus and gracilis tendons) and 4S-STG autograft diameter (p = 0.023). An adequate autograft size (at least 7 mm) can be obtained when the combined cross sectional area is at least 15 mm2. There was no correlation with the anthropometric data except for thigh circumference (p = 0.037). Autograft size of at least 7 mm can be obtained when the thigh circumference is at least 41 mm. Conclusions: Both combined cross sectional area (semitendinosus and gracilis tendons) and thigh circumference can be used to predict an adequate 4S-STG autograft size.

Effect of skin graft thickness on scar development in a porcine burn model.

Animal models provide a way to investigate scar therapies in a controlled environment. It is necessary to produce uniform, reproducible scars with high anatomic and biologic similarity to human scars to better evaluate the efficacy of treatment strategies and to develop new treatments. In this study, scar development and maturation were assessed in a porcine full-thickness burn model with immediate excision and split-thickness autograft coverage. Red Duroc pigs were treated with split-thickness autografts of varying thickness: 0.026in. ("thin") or 0.058in. ("thick"). Additionally, the thin skin grafts were meshed and expanded at 1:1.5 or 1:4 to evaluate the role of skin expansion in scar formation. Overall, the burn-excise-autograft model resulted in thick, raised scars. Treatment with thick split-thickness skin grafts resulted in less contraction and reduced scarring as well as improved biomechanics. Thin skin autograft expansion at a 1:4 ratio tended to result in scars that contracted more with increased scar height compared to the 1:1.5 expansion ratio. All treatment groups showed Matrix Metalloproteinase 2 (MMP2) and Transforming Growth Factor ß1 (TGF-ß1) expression that increased over time and peaked 4 weeks after grafting. Burns treated with thick split-thickness grafts showed decreased expression of pro-inflammatory genes 1 week after grafting, including insulin-like growth factor 1 (IGF-1) and TGF-ß1, compared to wounds treated with thin split-thickness grafts. Overall, the burn-excise-autograft model using split-thickness autograft meshed and expanded to 1:1.5 or 1:4, resulted in thick, raised scars similar in appearance and structure to human hypertrophic scars. This model can be used in future studies to study burn treatment outcomes and new therapies.

Five-Strand Hamstring Autograft Versus Quadruple Hamstring Autograft With Graft Diameters 8.0 Millimeters or More in Anterior Cruciate Ligament Reconstruction: Clinical Outcomes With a Minimum 2-Year Follow-Up.

PURPOSE: To compare the outcomes of 2 groups of patients undergoing anterior cruciate ligament (ACL) reconstruction: the first with a quadrupled semitendinosus gracilis (ST-G) autograft larger than 8 mm diameter and the second with a 5-strand ST-G autograft larger than 8 mm due to an insufficient diameter graft harvesting. METHODS: This was a retrospective study with 70 patients divided into 2 groups. Inclusion criteria included ACL ruptures of less than 3 months, ST-G ACL reconstructions, and final (4-strand or 5-strand) graft size larger than 8 mm. Exclusion criteria included multiligament knee injuries, meniscal or chondral pathology, ACL re-ruptures, inflammatory joint disease, or other procedures in the knee. RESULTS: Group A comprised 33 patients with a quadruple ST-G graft, and group B comprised 37 patients with an insufficient graft diameter (<8 mm) in which a 5-strand graft was used. Mean age in group A was 29.7 (range 17-52) years and in group B was 30.6 (range 13-53) years (P = .78). Average follow-up in group A was 32.2 (range 24-48) months and in group B was 30.35 (range 24-48) months (P = .75). Average graft diameter in group A was 8.5 mm (range 8-10) and in group B when the graft was measured as quadruple was 7.2 mm (range 6.5-7.5) and 9.2 mm (range 8-10) when it was converted to 5-strand (P = .00596). Group A had 3 (9%) re-ruptures, and group B had 2 (5.4%) (P = .55). The average postoperative Lysholm score in group A was 93.3 (range 71-100) and in group B was 97.1 (range 80-100) (P = .79). Mean postoperative International Knee Documentation Committee in group A was 91 (range 75.9-100) and in group B was 96.8 (range 82-100) (P = .18). CONCLUSIONS: In our study, the 5-strand hamstring autograft in ACL reconstruction was clinically comparable with the quadruple autograft larger than 8 mm. The differences in re-rupture and clinical outcomes were not statistically significant between the 2 groups, suggesting that it is a valid option when we have a graft of insufficient diameter. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Prediction of length and diameter of hamstring tendon autografts for knee ligament surgery in Caucasians.

PURPOSE: Prediction of hamstring tendon autograft size facilitates preoperative planning of knee ligament surgery and may reduce the need for allografts in complex knee reconstructions. The aim of this study was to analyse whether length and diameter of hamstring tendon autografts can be predicted preoperatively with anthropometric parameters and patient characteristics. METHODS: In this observational study, 725 consecutive Caucasian patients scheduled for ACL reconstruction were included. Preoperatively gender, age, height and weight were recorded. After harvest, tendon lengths of both gracilis and semitendinosus tendons were measured. Diameter of the final four-strand hamstring autograft was recorded. Relationship between length and diameter of tendon grafts and different anthropometric parameters were assed by linear and logistic regression analyses. RESULTS: Mean lengths of the semitendinosus and gracilis tendon autografts were 28.9 ± 3.1 and 27.7 ± 3.0 cm, respectively. Length of the gracilis and semitendinosus grafts was independently related to patient height. Female gender was correlated with smaller graft diameter. One in nine female patients had a diameter <8 mm. The ratio in men was 1 in 36. CONCLUSION: Hamstring autograft length and size can be predicted in Caucasians. Length of the gracilis and semitendinosus tendons was related to patient height. Smaller graft diameter was related to female gender. LEVEL OF EVIDENCE: II.

Can we predict the size of frequently used autografts in ACL reconstruction?

PURPOSE: This study presents a method to measure the size of quadriceps, patellar tendon and hamstring autografts using preoperative magnetic resonance imaging (MRI). METHODS: Sixty-two subjects with a mean age of 25 ± 10 years who underwent ACL surgery between 2011 and 2014 were included. Patient anthropometric data were recorded for all subjects. During surgery, the respective autograft was harvested and measured using commercially available graft sizers. MRI measurements were performed by two raters, who were blinded to the intra-operative measurements. RESULTS: The inter- and intra-rater reliability was ≥0.8 for all MRI measurements. The intra-class correlation coefficient between the MRI measurement of the graft and the actual size of the harvested graft was 0.639. There were significant correlations between quadriceps tendon thickness and height (r = 0.3, p < 0.03), weight (r = 0.3, p < 0.01), BMI (r = 0.3, p < 0.04) and gender (r = -0.4, p < 0.002) and patellar tendon thickness and height (r = 0.4, p < 0.01), weight (r = 0.3, p < 0.01) and gender (r = -0.4, p < 0.012). CONCLUSION: Preoperative MRI measurements of quadriceps, patellar tendon and hamstring graft size are highly reliable with moderate-to-good accuracy. Significant correlations between patient anthropometric data and the thicknesses of the quadriceps and patellar tendons were observed. Obtaining this information can be useful for preoperative planning and to help counsel patients on appropriate graft choices prior to surgery. LEVEL OF EVIDENCE: III.

Cross-sectional area of hamstring tendon autograft after anatomic triple-bundle ACL reconstruction.

PURPOSE: The purpose was to evaluate the cross-sectional area changes in hamstring tendon autografts up to 5 years after the anatomic triple-bundle anterior cruciate ligament (ACL) reconstruction. METHODS: A total of 178 MRI scans from 139 patients (35 males, 104 females, mean age 30.4 years) with the anatomic triple-bundle ACL reconstructions were obtained to evaluate the cross-sectional area of the ACL grafts. They were classified into seven groups according to the period from reconstruction to MRI evaluation: Group -2 months (m.), Group 3-6 m., Group 7-12 m, Group 1-2 years (y.), Group 2-3 y., Group 3-4 y., and Group 4 y.-. Intra-operatively, the cross-sectional area of the graft was measured directly using a custom-made area micrometre. Post-operatively, the cross-sectional area of the grafts' mid-substance was measured with oblique axial MRI slices perpendicular to the long axis of the grafts using a digital radiology viewing program. The percent increase in the cross-sectional area was calculated by dividing the post-operative cross-sectional area by the intra-operative cross-sectional area. RESULTS: The mean percent increase in the cross-sectional area in Groups -2 m., 3-6 m., 7-12 m., 1-2 y., 2-3 y., 3-4 y., and 4 y.- was 105.7 ± 14.0, 134.9 ± 20.0, 137.3 ± 27.8, 129.4 ± 22.2, 124.1 ± 20.4, 117.8 ± 16.9, and 117.1 ± 17.2 %, respectively. The percent increase in Groups 3-6 m., 7-12 m., and 1-2 y. was significantly greater than in Group -2 m., while that in Group 4 y.- was significantly less than in Group 7-12 m. CONCLUSIONS: The cross-sectional area of the hamstring tendon autografts after the anatomic triple-bundle ACL reconstruction increases over time up to 1 year post-operatively, decreases gradually thereafter, and reaches plateau at around 3 years. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

The Effect of Autologous Hamstring Graft Diameter on the Likelihood for Revision of Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Hamstring autografts for anterior cruciate ligament (ACL) reconstruction (ACLR) have become popular in the past 2 decades; however, it is difficult to predict the diameter of the harvested tendons before surgery. Previous biomechanical studies have suggested that a smaller graft diameter leads to a lower load to failure, but clinical studies looking at various predictors for failure, including graft size, have been inconclusive. PURPOSE: To evaluate the relationship of hamstring graft diameter to ACL revision within a large cohort of patients, while controlling for sex, age, body mass index (BMI), and femoral and tibial fixation type. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A case-control study using patients registered in an ACLR registry was conducted. Revision was used as a marker for graft failure. A case was defined as a patient who underwent primary ACLR with a hamstring autograft that was revised during the study period (April 2006 to September 2012). Three controls, defined as patients who underwent primary ACLR with a hamstring autograft that was not revised, were matched to each of the cases according to age, sex, BMI, and femoral and tibial fixation type. Descriptive characteristics were employed, and conditional logistic regression was conducted to produce estimates of odds ratios and 95% CIs. RESULTS: A total of 124 cases and 367 controls were identified. There were no significant differences between cases and controls in the distribution of sex (52.4% male vs 52.9% male, respectively; P = .932), median age (17.6 years [interquartile range (IQR), 15.9-20.4] vs 17.6 years [IQR, 15.9-20.4], respectively; P = .999), median BMI (23.4 kg/m(2) [IQR, 21.5-26.4] vs 23.4 kg/m(2) [IQR, 21.6-25.8], respectively; P = .954), femoral fixation (P = .459), and tibial fixation (P = .766). The mean (±SD) graft diameter was 7.9 ± 0.75 mm in the cases and 8.1 ± 0.73 mm in the controls. The likelihood of a patient needing revision ACLR in the study cohort was 0.82 times lower (95% CI, 0.68-0.98) for every 0.5-mm increase in the graft diameter from 7.0 to 9.0 mm. CONCLUSION: In this study, within the range of 7.0 to 9.0 mm, there was a 0.82 times lower likelihood of being a revision case with every 0.5-mm incremental increase in graft diameter.

Role of anthropometric data in the prediction of 4-stranded hamstring graft size in anterior cruciate ligament reconstruction.

To evaluate whether pre-operative anthropometric data can predict the optimal diameter and length of hamstring tendon autograft for anterior cruciate ligament (ACL) reconstruction. This was a cohort study that involved 169 patients who underwent single-bundle ACL reconstruction (single surgeon) with 4-stranded MM Gracilis and MM Semi-Tendinosus autografts. Height, weight, body mass index (BMI), gender, race, age and -smoking status were recorded pre-operatively. Intra-operatively, the diameter and functional length of the 4-stranded autograft was recorded. Multiple regression analysis was used to determine the relationship between the anthropometric measurements and the length and diameter of the implanted autografts. The strongest correlation between 4-stranded hamstring autograft diameter was height and weight. This correlation was stronger in females than males. BMI had a moderate correlation with the diameter of the graft in females. Females had a significantly smaller graft both in diameter and length when compared with males. Linear regression models did not show any significant correlation between hamstring autograft length with height and weight (p>0.05). Simple regression analysis demonstrated that height and weight can be used to predict hamstring graft diameter. The following regression equation was obtained for females: Graft diameter=0.012+0.034*Height+0.026*Weight (R2=0.358, p=0.004) The following regression equation was obtained for males: Graft diameter=5.130+0.012*Height+0.007*Weight (R2=0.086, p=0.002). Pre-operative anthropometric data has a positive correlation with the diameter of 4 stranded hamstring autografts but no significant correlation with the length. This data can be utilised to predict the autograft diameter and may be useful for pre-operative planning and patient counseling for graft selection.

Three-Dimensional Cartilage Graft Technique: A Different Management for Nasal Tip Surgery.

PURPOSE: Nasal tip reconstruction is an important component in aesthetic rhinoplasty. Different congenital deformities or acquired disorders (trauma, infection, operations) may affect the nasal tip structure. Additionally, the natural appearance of the nasal tip projection can be lost after rhinoplasty. The lower lateral cartilages are the main structural component of the nasal alae and tip support. Any distortion or failure on the alar cartilages may lead to both functional and aesthetic problems. In this article, the author presents a different method for nasal tip support. PATIENTS AND METHODS: Between 2010 and 2014, a chart review was performed of 64 consecutive primary rhinoplasty patients (29 women, 35 men). Postoperative follow-up period was at least 12 months. None of the patients were secondary patients or no nasal tip surgery was done previously. The patients with secondary rhinoplasty, saddle deformity, revision rhinoplasty, cleft lip nose, and crooked nose were excluded from the study. RESULTS: The three-dimensional pyramid cartilage technique was used in all the patients with the open rhinoplasty approach to ensure the nasal tip projection. Average time was between 4 and 7 minutes for graft harvesting and suturing to the nasal tip in this technique. The follow-up period was between 12 and 48 months. There was a revision procedure in 4 patients because of the distortion of the tip graft and tearing of the graft material. The revision procedure was done for these patients. DISCUSSION: In this article, the author presents "three-dimensional pyramid cartilage technique' as a new and alternative technique for better projection of the nasal tip. This technique also provided the support to nasal tip using only 1 graft material with minimal manipulation, with no donor area morbidity or another cartilage resection except the nasal septum.

MRI volume and signal intensity of ACL graft predict clinical, functional, and patient-oriented outcome measures after ACL reconstruction.

BACKGROUND: Clinical, functional, and patient-oriented outcomes are commonly used to evaluate the efficacy of treatments after anterior cruciate ligament (ACL) injury; however, these evaluation techniques do not directly measure the biomechanical changes that occur with healing. PURPOSE: To determine if the magnetic resonance (MR) image-derived parameters of graft volume and signal intensity (SI), which have been used to predict the biomechanical (ie, structural) properties of the graft in animal models, correlate with commonly used clinical (anteroposterior [AP] knee laxity), functional (1-legged hop), and patient-oriented outcome measures (Knee Injury and Osteoarthritis Outcome Score [KOOS]) in patients 3 and 5 years after ACL reconstruction. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Based on a subset of participants enrolled in an ongoing ACL reconstruction clinical trial, AP knee laxity, 1-legged hop test, and KOOS were assessed at 3- and 5-year follow-up. Three-dimensional, T1-weighted MR images were collected at each visit. Both the volume and median SI of the healing graft were determined and used as predictors in a multiple regression linear model to predict the traditional outcome measures. RESULTS: Graft volume combined with median SI in a multiple linear regression model predicted 1-legged hop test at both the 3- and 5-year follow-up visits (R(2) = 0.40, P = .008 and R(2) = 0.62, P = .003, respectively). Similar results were found at the 5-year follow-up for the KOOS quality of life (R(2) = 0.49, P = .012), sport/function (R(2) = 0.37, P = .048), pain (R(2) = 0.46, P = .017), and symptoms (R(2) = 0.45, P = .021) subscores, although these variables were not significant at 3 years. The multiple linear regression model for AP knee laxity at 5-year follow-up approached significance (R(2) = 0.36, P = .088). CONCLUSION: The MR parameters (volume and median SI) used to predict ex vivo biomechanical properties of the graft in an animal model have the ability to predict clinical or in vivo outcome measures in patients at 3- and 5-year follow-up. CLINICAL RELEVANCE: Results from this study may enhance clinical evaluation of graft health by relating the MR parameters of volume and median SI to traditional outcome measures and could potentially aid researchers in determining the appropriate timing for athletes to return to sport.

Phagocytic function of lower spleen pole and autogenous splenic implants in rats.

PURPOSE: To investigate whether there are differences between the phagocytic function of the remaining lower spleen pole after subtotal splenectomy and autogenous splenic implants. METHODS: Thirty-six male Wistar rats, weighting 364 ± 60g were used. They were subjected to subtotal splenectomy preserving the lower spleen pole and to autogenous splenic implant in the greater omentum. Its viability was assessed microscopically. Phagocytic function was assessed by splenic uptake of the radioisotope-labeled colloid and by macrophages counting. RESULTS: The viability of the autogenous splenic implant and of the lower spleen pole was found in 33 animals, with no difference between them. The weight of the implants was higher than the lower pole of animals from groups G1, G7, G30, G60 and G120. The implants phagocytic function by radioisotope uptake was higher than the lower pole in G7 and G120 groups and it did not differ from the other groups. The number of macrophages was higher in G1, G60, G90 and G120 and did not differ from the other groups. CONCLUSION: Until the 16th week, the phagocytic function was more pronounced in autogenous splenic implants when compared with the lower spleen pole, but it became similar thereafter.