Three-Dimensional Hinge Axis Orientation Contributes to Simultaneous Alignment Correction in All Three Anatomical Planes in Opening-Wedge High Tibial Osteotomy.

Purpose: To investigate the simultaneous effect of 3-dimensional (3D) hinge axis (HA) orientation on alignment parameters in all 3 anatomical planes in high tibial osteotomy. Methods: A computed tomography-based 3D model of a human tibia/fibula was used to establish a 3D tibial coordinate system based on the tibial mechanical axis. In here, an HA was positioned and an opening-wedge high tibial osteotomy with a rotation angle of 10° over the HA was simulated. HA rotation in the axial plane ranged from 0° to 90° and HA tilt relative to the axial plane ranged from -20° to +20°. The study quantified the simultaneous effect of HA orientation on change of alignment parameters in all anatomical reference planes. Results: HA rotation within the tibial axial plane between orientations perpendicular to the coronal and sagittal planes primarily affected both coronal and sagittal plane alignment, with an inverse relationship between these planes (range: 0°-9.7°); the effect of HA rotation on the change in axial plane alignment was maximally 0.9°. In contrast, HA tilt relative to the tibial axial plane primarily affected axial alignment (maximum change: 6.9°); the effect on change in both coronal and sagittal plane alignment was maximally 0.6°. Conclusions: HA rotation in the tibial axial plane primarily affects sagittal and coronal plane alignment, and HA tilt relative to the tibial axial plane primarily affects axial plane alignment. Clinical Relevance: Integrating 3D HA orientation in malalignment planning and correction offers the potential to minimize unintended corrections in nontargeted planes in uniplanar correction osteotomies and to facilitate intentional multiplanar correction with a single osteotomy.

The Iliotibial Band is the Main Secondary Stabilizer for Anterolateral Rotatory Instability and both a Lemaire Tenodesis and Anterolateral Ligament Reconstruction Can Restore Native Knee Kinematics in the Anterior Cruciate Ligament Reconstructed Knee: A Systematic Review of Biomechanical Cadaveric Studies.

PURPOSE: To obtain a comprehensive overview of comparative biomechanical cadaveric studies investigating the effect of both the iliotibial band (ITB) and anterolateral ligament (ALL) on anterolateral rotatory instability (ALRI) in anterior cruciate ligament (ACL)-injured knees, and the effect of lateral extra-articular tenodesis (LET) versus ALL reconstruction (ALLR) in ACL-reconstructed knees. METHODS: An electronic search was performed in the Embase and MEDLINE databases for the period between January 1, 2010, and October 1, 2022. All sectioning studies comparing the role of both the ITB and ALL on ALRI and all studies comparing the effect of both LET and ALLR were included. Articles were assessed for methodological quality according to the Quality Appraisal for Cadaveric Studies scale. RESULTS: Data of 15 studies were included, representing the mean values of biomechanical data collected from 203 cadaveric specimens, with sample sizes ranging from 10 to 20 specimens. All 6 sectioning studies reported that the ITB acts as a secondary stabilizer to the ACL and helps resist internal knee rotation, whereas in only 2 of 6 sectioning studies the ALL contributed significantly to tibial internal rotation (IR). Most reconstruction studies reported that both a modified Lemaire tenodesis and an ALLR could significantly reduce the residual ALRI in isolated ACL-reconstructed knees and were able to restore IR stability/IR stability during the pivot shift. CONCLUSIONS: The ITB acts as the main secondary stabilizer to the ACL in resisting IR/IR during pivot shift and an anterolateral corner (ALC) reconstruction with either a modified Lemaire tenodesis and ALLR can improve residual knee rotatory laxity in ACL reconstructed knees. CLINICAL RELEVANCE: This systematic review provides insight in the biomechanical function of the ITB and ALL and emphasizes the importance of adding an ALC reconstruction to ACL reconstruction.

[Acute anterior cruciate ligament rupture: repair or reconstruction?] / Acute voorstekruisbandruptuur: vervangen of hechten?

In the case of persistent complaints of instability due to a rupture of the anterior cruciate ligament (ACL), surgical treatment can be opted for, in which reconstruction with a body's own tendon graft (autograft) is the gold standard. New information has created renewed interest in the primary repair of an ACL rupture. Potential advantages of repair of the ACL rupture compared with a reconstruction are the restoration of the complex natural anatomy including the proprioception of the native ACL, and no donor site morbidity. Biomechanical studies show that when suturing an ACL rupture, intra-articular augmentation is important to protect the repaired ACL during healing. Given the results of randomized studies comparing the ACL suture technique including augmentation with the ACL reconstruction, it can be concluded that the nowadays used suture technique in combination with an augmentation could be an alternative treatment to the current gold standard, the ACL reconstruction.

Higher return to pre-injury type of sports after revision anterior ligament reconstruction with lateral extra-articular tenodesis compared to without lateral extra-articular tenodesis.

PURPOSE: To evaluate the rate of return to pre-injury type of sports (RTS type) in patients after revision anterior cruciate ligament reconstruction (ACLR) with lateral extra-articular tenodesis (LET) compared to patients after revision ACLR without LET. METHODS: Seventy-eight patients who underwent revision ACLR with an autologous ipsilateral bone-patellar tendon-bone autograft with and without LET were included at least one year after surgery (mean follow-up: 43.9, SD: 29.2 months). All patients filled in a questionnaire about RTS type, the Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee subjective form (IKDCsubjective), and the Tegner activity score. RESULTS: The RTS type for revision ACLR with LET was 22 of 42 (52%), whereas 11 of 36 (31%) of the patients who underwent revision ACLR without LET returned to the pre-injury type of sport (p = 0.05). No significant differences were found in KOOS subscores, IKDCsubjective, and Tegner activity scores. CONCLUSION: An additional LET increases the rate of RTS type after revision ACLR. LEVEL OF EVIDENCE: III.

Translation, Validity, and Reliability of the Dutch Anterior Cruciate Ligament-Quality of Life Questionnaire.

Background: The Anterior Cruciate Ligament-Quality of Life (ACL-QoL) questionnaire is a valid and reliable injury-specific instrument to assess the impact of an ACL rupture on the daily life of a patient. Purpose: To translate the ACL-QoL into Dutch (ACL-QoL-NL) and to study its psychometric properties in patients with an ACL rupture. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The original ACL-QoL questionnaire was translated from English to Dutch according to international guidelines. The study population consisted of 122 patients with a confirmed ACL rupture who completed the ACL-QoL-NL as well as 4 questionnaires: the International Knee Documentation Committee subjective score, Knee injury and Osteoarthritis Outcome Score, 36-item Short Form Health Survey, and Lysholm Knee Score. We determined the internal consistency, construct validity, and prevalence of floor and ceiling effects of the ACL-QoL-NL total score as well as its 5 subscales. To determine test-retest reliability, we analyzed the data of 68 patients who had a stable knee condition and who completed the ACL-QoL-NL a second time after a 2-week interval. Results: The confirmatory factor analysis showed that the original structure of the ACL-QoL-NL was confirmed, except for 4 of 31 items. Internal consistency of the total scale and all 5 subscales was good. More than 75% of the predefined hypotheses on the correlations between the ACL-QoL-NL and the 4 questionnaires were met, indicating good construct validity. No significant floor or ceiling effects were observed. Test-retest reliability was good, and no systematic bias between test and retest was found. Standard error of measurement for the total score was 4.8 points out of 100, and the smallest detectable changes at the group and individual levels were 1.6 and 13.2 points, respectively. Conclusion: The ACL-QoL-NL questionnaire was successfully translated from English to Dutch and demonstrated good internal consistency, validity, and reliability, with no presence of floor or ceiling effects.

Accuracy, inter- and intrarater reliability, and user-experience of high tibial osteotomy angle measurements for preoperative planning: manual planning PACS versus semi-automatic software programs.

PURPOSE: To compare the accuracy, inter- and intrarater reliability, and user-experience of manual and semi-automatic preoperative leg-alignment measurement planning software for high tibial osteotomy (HTO). METHODS: Thirty patients (31 lower limbs) who underwent a medial opening wedge HTO between 2017 and 2019 were retrospectively included. The mechanical lateral distal femur angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), and planned correction angle were measured on preoperative long-leg full weight-bearing radiographs utilising PACS Jivex Review® v5.2 manual and TraumaCad® v2.4 semi-automatic planning software. Independent measurements were performed by four raters. Two raters repeated the measurements. Accuracy in the standard error of measurement (SEM), inter- and intrarater reliability, and user-experience were analysed. Additionally, measurements errors of more than 3° were remeasured and reanalysed. RESULTS: The SEMs of all measured varus malalignment angles and planned correction angle were within 0.8° of accuracy for both software programs. Measurements utilising the manual software demonstrated moderate interrater intraclass correlation coefficient (ICC)-values for the mLDFA and mMPTA, and an excellent interrater ICC-value for the correction angle (0.810, 0.779, and 0.981, respectively). Measurements utilising the semi-automatic software indicated excellent interrater ICC-values for the mLDFA, mMPTA, and correction angle (0.980, 0.909, and 0.989, respectively). The intrarater reliability varied substantially per angle, presenting excellent intrarater agreements by both raters (ICC >  0.900) for the correction angle in each software program as well as poor-to-excellent ICC-values for the mLDFA (0.282-0.951 and 0.316-0.926) and mMPTA (0.893-0.934 and 0.594-0.941) in both the manual planning and semi-automatic software. Regarding user-experience, semi-automatic software was preferred by two raters, while the other two raters had no distinctive preference. After remeasurement of five outliers, excellent interrater ICC-values were found for the mLDFA (0.913) and mMPTA (0.957). CONCLUSIONS: Semi-automatic software outperforms the manual software when user-experience and outliers are considered. However, both software programs provide similar performance after remeasurement of the human-related erroneous outliers. For clinical practice, both programs can be utilised for HTO planning. LEVEL OF EVIDENCE: Diagnostic study, Level III.

Acute Anterior Cruciate Ligament Rupture: Repair or Reconstruction? Five-Year Results of a Randomized Controlled Clinical Trial.

BACKGROUND: High-level evidence for short-term outcomes of contemporary anterior cruciate ligament (ACL) suture repair (ACLSR) in comparison with those of ACL reconstruction (ACLR) is scarce. High-level evidence for mid- and long-term results is lacking, whereas outcomes of ACLSR in several historical studies were shown to deteriorate at midterm follow-up after initial good short-term outcomes. HYPOTHESIS: Contemporary ACLSR is noninferior to ACLR in the treatment of acute ACL rupture in terms of patient self-reported outcomes at 5 years postoperatively. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 48 patients were enrolled in the study and, after stratification and randomization, underwent either dynamic augmented (DA) ACLSR or anatomic single-bundle ACLR. The primary outcome measure was the International Knee Documentation Committee 2000 (IKDC) subjective score (IKDCs). Furthermore, the Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner Activity Scale score (TAS), visual analog scale score for satisfaction (VASs), IKDC physical examination score (IKDCpe), limb symmetry index for quadriceps (LSIq) and hamstrings (LSIh) strength and jump test battery (LSIj), Kellgren-Lawrence grade of osteoarthritis (OA), and rate of adverse events were recorded. Analyses were based on an intention-to-treat principle. RESULTS: The lower limit of the 2-sided 95% CI for the median IKDCs of the DA ACLSR group (n = 23; 75.9) was lower than the prespecified noninferiority margin (n = 21; 86.6). Therefore, the null hypothesis was rejected. However, the upper limit of the 2-sided 95% CI of the DA ACLSR group (100.0) was higher than the median IKDCs of the ACLR group (96.6), rendering the result for noninferiority inconclusive. No statistical difference was found between groups for median IKDCs (repair, 90.2; reconstruction, 96.6). Furthermore, no statistically significant differences were found for any of the secondary outcome measures for the DA ACLSR compared with the ACLR group: KOOS Symptoms, 92.9 versus 96.4; KOOS Pain, 100 versus 97.2; KOOS Activities of Daily Living, 100 versus 100; KOOS Sport and Recreation, 85.0 versus 100; TAS score, 7.0 versus 6.5; VASs, 9.2 versus 8.7; IKDCpe, 81.8% versus 100%; LSIq, ≥91.6 versus ≥88.2; LSIh, ≥95.1 versus ≥90.7; LSIj, ≥94.2 versus ≥97.6; OA grade 0, 90.9% versus 77.8%; clinical ACL failure rate, 20.8% versus 27.2%; and repeat surgery rate, 37.5% versus 20.0%, respectively. CONCLUSION: It remains inconclusive whether the effectiveness of DA ACLSR is noninferior to that of ACLR in terms of subjective patient-reported outcomes as measured using the IKDCs. Although DA ACLSR may be a viable treatment option for patients with acute ACL rupture, caution must be exercised when considering this treatment for young, active patients, corresponding to the present study population.

Meniscal Tears, Posterolateral and Posteromedial Corner Injuries, Increased Coronal Plane, and Increased Sagittal Plane Tibial Slope All Influence Anterior Cruciate Ligament-Related Knee Kinematics and Increase Forces on the Native and Reconstructed Anterior Cruciate Ligament: A Systematic Review of Cadaveric Studies.

PURPOSE: To obtain a comprehensive list of pathologies that cause increased anterior cruciate ligament (ACL) forces and pathologic knee kinematics to evaluate for in both primary and revision ACL reconstruction to decrease the risk of subsequent graft overload. METHODS: An electronic search was performed in the Embase and MEDLINE databases for the period between January 1, 1990, and December 10, 2020. All articles investigating medial and lateral meniscal injury, (postero)lateral corner injury, (postero)medial corner/medial collateral ligament injury, valgus alignment, varus alignment, and tibial slope in relation to ACL (graft) force and knee kinematics were included. RESULTS: Data of 43 studies were included. The studies reported that high-volume medial and lateral meniscectomies, peripheral meniscus tears, medial meniscus ramp tears, lateral meniscus root tears, posterolateral corner injuries, medial collateral ligament tears, increased tibial slope, and valgus and varus alignment were reported to have a significant impact on ACL (graft) force and related knee kinematics. CONCLUSIONS: This systematic review on biomechanical cadaver studies provides a rationale to systematically identify and treat pathologies in ACL-injured knees, because when undiagnosed or left untreated, these specific concomitant pathologies could lead to ACL graft overload in both primary and revision ACL-reconstructed knees. CLINICAL RELEVANCE: it is necessary that orthopaedic surgeons who treat ACL-injured knees understand the surgically relevant biomechanical consequences of additional pathologies and use this knowledge to optimize treatment in ACL-injured patients.

Repair versus reconstruction for proximal anterior cruciate ligament tears: a study protocol for a prospective multicenter randomized controlled trial.

BACKGROUND: For active patients with a tear of the anterior cruciate ligament (ACL) who would like to return to active level of sports, the current surgical gold standard is reconstruction of the ACL. Recently, there has been renewed interest in repairing the ACL in selected patients with a proximally torn ligament. Repair of the ligament has (potential) advantages over reconstruction of the ligament such as decreased surgical morbidity, faster return of range of motion, and potentially decreased awareness of the knee. Studies comparing both treatments in a prospective randomized method are currently lacking. METHODS: This study is a multicenter prospective block randomized controlled trial. A total of 74 patients with acute proximal isolated ACL tears will be assigned in a 1:1 allocation ratio to either (I) ACL repair using cortical button fixation and additional suture augmentation or (II) ACL reconstruction using an all-inside autologous hamstring graft technique. The primary objective is to assess if ACL repair is non-inferior to ACL reconstruction regarding the subjective International Knee Documentation Committee (IKDC) score at two-years postoperatively. The secondary objectives are to assess if ACL repair is non-inferior with regards to (I) other patient-reported outcomes measures (i.e. Knee Injury and Osteoarthritis Outcome Score, Lysholm score, Forgotten Joint Score, patient satisfaction and pain), (II) objective outcome measures (i.e. failure of repair or graft defined as rerupture or symptomatic instability, reoperation, contralateral injury, and stability using the objective IKDC score and Rollimeter/KT-2000), (III) return to sports assessed by Tegner activity score and the ACL-Return to Sports Index at two-year follow-up, and (IV) long-term osteoarthritis at 10-year follow-up. DISCUSSION: Over the last decade there has been a resurgence of interest in repair of proximally torn ACLs. Several cohort studies have shown encouraging short-term and mid-term results using these techniques, but prospective randomized studies are lacking. Therefore, this randomized controlled trial has been designed to assess whether ACL repair is at least equivalent to the current gold standard of ACL reconstruction in both subjective and objective outcome scores. TRIAL REGISTRATION: Registered at Netherlands Trial Register ( NL9072 ) on 25th of November 2020.

Standard MRI May Not Predict Specific Acute Anterior Cruciate Ligament Rupture Characteristics.

BACKGROUND: There has been renewed interest in the concept of anterior cruciate ligament (ACL) suture repair (ACLSR). Morphologic characteristics of the ruptured ACL remnant play a role in deciding whether a patient is eligible for ACLSR. However, no classification of these characteristics of ACL rupture on magnetic resonance imaging (MRI) scans has yet been compared with intraoperative findings in the context of ACLSR. PURPOSE: To investigate the value of using preoperative MRI to predict specific characteristics of acute complete ACL rupture. STUDY DESIGN: Cohort study (diagnostic); Level of evidence, 2. METHODS: A total of 25 patients were included. Two radiologists classified ACL rupture location and pattern on preoperative 1.5-T MRI scans with a standard sequence; the results were compared with the corresponding findings at arthroscopy conducted by a single surgeon. The agreement between the MRI and surgical findings was calculated using Cohen κ values. Furthermore, the reliability coefficients of the MRI classifications within and between radiologists were calculated. RESULTS: The agreement between MRI classification and arthroscopic findings for ACL rupture location was slight (Cohen κ, 0.016 [radiologist 1] and 0.087 [radiologist 2]), and for ACL rupture pattern, this was poor to slight (Cohen κ, <0 and 0.074). The intraobserver reliability of MRI classification for ACL rupture location was moderate for radiologist 1 and slight for radiologist 2 (Cohen κ, 0.526 and 0.061, respectively), and for ACL rupture pattern, this was slight for radiologist 1 and 2 (Cohen κ, 0.051 and 0.093, respectively). The interobserver reliability of MRI classification for ACL rupture location and pattern was slight between radiologists (Cohen κ, 0.172 and 0.040, respectively). CONCLUSION: In the current study, we found poor to slight agreement between MRI classification and arthroscopic findings of specific ACL rupture characteristics. In addition, the intra- and interobserver reliability for MRI classification of the ACL rupture characteristics was slight to moderate.

Efficacy of Nonaugmented, Static Augmented, and Dynamic Augmented Suture Repair of the Ruptured Anterior Cruciate Ligament: A Systematic Review of the Literature.

BACKGROUND: Anterior cruciate ligament suture repair (ACLSR) was abandoned late last century in favor of anterior cruciate ligament (ACL) reconstruction (ACLR) because of overall disappointing results. However, in recent years there has been renewed and increasing interest in ACLSR for treatment of ACL ruptures. Several contemporary ACLSR techniques are being used, but any difference in effectiveness is unclear. HYPOTHESIS: Contemporary nonaugmented (NA), static augmented (SA), and dynamic augmented (DA) ACLSR leads to (1) comparable outcomes overall and (2) comparable outcomes between proximal third, middle third, and combined ACL rupture locations (a) within and (b) between ACLSR technique categories. STUDY DESIGN: Systematic review. METHODS: An electronic search was performed in the MEDLINE and Embase databases for the period between January 1, 2010, and August 7, 2019. All articles describing clinical and patient-reported outcomes for ACLSR were identified and included, and outcomes for NA, SA, and DA ACLSR categories were compared. RESULTS: A total of 31 articles and 2422 patients were included. The majority of articles (65%) and patients (89%) reported outcomes of DA ACLSR. Overall, there was high heterogeneity in study characteristics and level as well as quality of evidence (19 level 4; 7 level 3; 3 level 2; and 2 level 1). Most studies indicated excellent patient-reported outcomes. Overall, the variability in (and the maximum of) the reported failure rate was high within all ACLSR categories. The variability in (and the maximum of) the reported rate of all other complications was highest for DA ACLSR. Regarding ACL rupture location, the failure rate was highest in proximal ACL ruptures within the SA and DA ACLSR categories; rates of all other reported complications were highest in combined ACL ruptures within the DA ACLSR category. However, no studies in the NA category and only 1 study in the SA ACLSR category evaluated combined ACL ruptures. The majority of studies comparing ACLSR and ACLR found no differences in outcomes. CONCLUSION: The amount of high-quality evidence for contemporary ACLSR is poor. This makes it difficult to interpret differences among ACLSR categories and among ACL rupture locations and, though promising, to establish the role of ACLSR in the treatment of ACL ruptures. More high-quality large randomized clinical trials with longer follow-up comparing ACLSR and ACLR are needed.

Isometric placement of the augmentation braid is not attained reliably in contemporary ACL suture repair.

BACKGROUND: To assess if during arthroscopic braid-augmented ACL suture repair (ACLSR), the actual positions of the augmentation braids' tunnels corresponded with the positions of their intended and targeted isometric points, and to test the hypothesis that there would be no dispersion in actual positions of the augmentation braids' tunnels compared to their intended and targeted isometric points. METHODS: In 12 human cadaveric knees, the positions of the augmentation braids' tunnels and their intended and targeted isometric points relative to a femoral and tibial grid were analysed. Furthermore, vector length between these positions was calculated to assess the accuracy and precision of the augmentation braids' tunnel placement. RESULTS: There was dispersion for all of the augmentation braids' tunnel positions compared to their intended isometric points. The femoral and tibial vector lengths (mean ±â€¯SD (range)) were 2.9 ±â€¯1.0 (1.1-4.1) and 7.1 ±â€¯2.0 (3.2-9.8) mm respectively. CONCLUSION: In augmented ACLSR, with the ruptured ACL in situ, there was dispersion of the positions of the actual small diameter femoral and tibial augmentation braids' tunnels away from their desired isometric points. CLINICAL RELEVANCE: The extent of dispersion of the position of both the femoral and tibial tunnels away from their intended isometric positions may cause cyclic length changes with knee motion. An ACLSR with static braid augmentation will thus be vulnerable to cyclic stretching-out. The difficulty of obtaining an isometric tunnel combination for the small diameter augmentation braid may influence the clinician's choice between non-, static or dynamic augmented ACLSR techniques.

Acute Anterior Cruciate Ligament Rupture: Repair or Reconstruction? Two-Year Results of a Randomized Controlled Clinical Trial.

BACKGROUND: Contemporary anterior cruciate ligament (ACL) suture repair techniques have been subject to renewed interest in recent years. Although several clinical studies have yielded good short-term results, high-quality evidence is lacking in regard to the effectiveness of this treatment compared with ACL reconstruction. HYPOTHESIS: Dynamic augmented ACL suture repair is at least as effective as anatomic single-bundle ACL reconstruction for the treatment of acute ACL rupture in terms of patient self-reported outcomes at 2 years postoperatively. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: After stratification and randomization, 48 patients underwent either dynamic augmented ACL suture repair or ACL reconstruction with a single-bundle, all-inside, semitendinosus technique. The International Knee Documentation Committee (IKDC) subjective score at 2 years postoperatively was the primary outcome measure. Patient-reported outcomes (IKDC subjective score, Knee injury and Osteoarthritis Outcome Score, Tegner score, visual analog scale for satisfaction), clinical outcomes (IKDC physical examination score, leg symmetry index for the quadriceps, hamstrings strength, and jump test battery), and radiological outcomes as well as adverse events including reruptures were recorded. Analyses were based on an intention-to-treat principle. RESULTS: The lower limit for the median IKDC subjective score of the repair group (86.2) fell within the prespecified noninferiority margin, confirming noninferiority of dynamic augmented ACL suture repair compared with ACL reconstruction. No statistical difference was found between groups for median IKDC subjective score (repair, 95.4; reconstruction, 94.3). Overall, 2 reruptures (8.7%) occurred in the dynamic ACL suture repair group and 4 reruptures (19.0%) in the ACL reconstruction group; further, 5 repeat surgeries-other than for revision ACL surgery-took place in 4 patients from the dynamic ACL suture repair group (20.8%) and in 3 patients from the ACL reconstruction group (14.3%). CONCLUSION: Dynamic augmented ACL suture repair is not inferior to ACL reconstruction in terms of subjective patient-reported outcomes as measured with the IKDC subjective score 2 years postoperatively. However, for reasons other than revision ACL surgery due to rerupture, a higher number of related adverse events leading to repeat surgery were seen in the dynamic augmented ACL suture repair group within 2 years postoperatively. CLINICAL RELEVANCE: Dynamic augmented ACL suture repair might be a viable treatment option for patients with an acute ACL rupture. REGISTRATION: NCT02310854 ( ClinicalTrials.gov identifier).

Self-reported functional recovery after reconstruction versus repair in acute anterior cruciate ligament rupture (ROTOR): a randomized controlled clinical trial.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction is today's surgical gold standard for ACL rupture. Although it provides satisfactory results, not all patients return to their previous activity level and moreover, early posttraumatic osteoarthritis is not prevented. As such, a renewed interest has emerged in ACL suture repair combined with dynamic augmentation. Compared to ACL reconstruction, the hypothesized advantages of ACL suture repair are earlier return to sports, reduction of early posttraumatic osteoarthritis and preservation of the patient's native ACL tissue and proprioceptive envelope of the knee. In recent literature, ACL suture repair combined with dynamic augmentation tends to be at least equally effective compared to ACL reconstruction, but no randomized comparative study has yet been conducted. METHODS/DESIGN: This study is a prospective, stratified, block randomized controlled trial. Forty-eight patients with an ACL rupture will be assigned to either a suture repair group with dynamic augmentation and microfracture of the femoral notch, or an ACL reconstruction group with autologous semitendinosis graft and all-inside technique. The primary objective is to investigate the hypothesis that suture repair of a ruptured ACL results in at least equal effectiveness compared with an ACL reconstruction in terms of patient self-reported outcomes (IKDC 2000 subjective scale) 1 year postoperatively. Secondary objectives are to evaluate patient self-reported outcomes (IKDC 2000, KOOS, Tegner, VAS), re-rupture rate, rehabilitation time required for return to daily and sports activities, achieved levels of sports activity, clinimetrics (Rolimeter, LSI, Isoforce) and development of osteoarthritis, at short term (6 weeks, 3, 6 and 9 months and 1 year), midterm (2 and 5 years) and long term (10 years) postoperatively. DISCUSSION: A renewed interest has emerged in ACL suture repair combined with dynamic augmentation in the treatment of ACL rupture. Recent cohort studies show good short- and midterm results for this technique. This randomized controlled trial has been designed to compare the outcome of suture repair of a ruptured ACL, combined with DIS as well as microfracture of the femoral notch, with ACL reconstruction using autologous semitendinosus. TRIAL REGISTRATION: Clinical Trials Register NCT02310854 (retrospectively registered on December 1st, 2014).

Dynamic augmentation restores anterior tibial translation in ACL suture repair: a biomechanical comparison of non-, static and dynamic augmentation techniques.

PURPOSE: There is a lack of objective evidence investigating how previous non-augmented ACL suture repair techniques and contemporary augmentation techniques in ACL suture repair restrain anterior tibial translation (ATT) across the arc of flexion, and after cyclic loading of the knee. The purpose of this work was to test the null hypotheses that there would be no statistically significant difference in ATT after non-, static- and dynamic-augmented ACL suture repair, and they will not restore ATT to normal values across the arc of flexion of the knee after cyclic loading. METHODS: Eleven human cadaveric knees were mounted in a test rig, and knee kinematics from 0° to 90° of flexion were recorded by use of an optical tracking system. Measurements were recorded without load and with 89-N tibial anterior force. The knees were tested in the following states: ACL-intact, ACL-deficient, non-augmented suture repair, static tape augmentation and dynamic augmentation after 10 and 300 loading cycles. RESULTS: Only static tape augmentation and dynamic augmentation restored ATT to values similar to the ACL-intact state directly postoperation, and maintained this after cyclic loading. However, contrary to dynamic augmentation, the ATT after static tape augmentation failed to remain statistically less than for the ACL-deficient state after cyclic loading. Moreover, after cyclic loading, ATT was significantly less with dynamic augmentation when compared to static tape augmentation. CONCLUSION: In contrast to non-augmented ACL suture repair and static tape augmentation, only dynamic augmentation resulted in restoration of ATT values similar to the ACL-intact knee and decreased ATT values when compared to the ACL-deficient knee immediately post-operation and also after cyclic loading, across the arc of flexion, thus allowing the null hypotheses to be rejected. This may assist healing of the ruptured ACL. Therefore, this study would support further clinical evaluation of dynamic augmentation of ACL repair.

Superior return to sports rate after patellar tendon autograft over patellar tendon allograft in revision anterior cruciate ligament reconstruction.

PURPOSE: After revision anterior cruciate ligament reconstruction (ACLR), the rate of return to the pre-injury type of sport (RTS type) is low and graft choice might be an important factor. The aim of this study was to determine whether there is a difference in outcome after revision ACLR using a patellar tendon allograft compared to an ipsilateral patellar tendon autograft. It was hypothesized that the rate of RTS type using an ipsilateral patellar tendon autograft will be superior to using patellar tendon allograft. METHODS: The design is a retrospective cohort study. Inclusion criteria were patients who underwent revision ACLR with a minimum follow-up of 1 year after revision using a patellar allograft or ipsilateral autograft. Primary study parameter was rate of RTS type. Secondary study parameters were RTS level, subscores of the KOOS, the IKDCsubjective, the Tegner score and reasons for no RTS. RESULTS: Eighty-two patients participated in this study (36 allografts and 46 autografts). In patients with a minimum follow-up of 1 year, rate of RTS type was 51.4% for the patellar tendon allograft and 62.8% for the patellar tendon autograft group (n.s.). In patients with a minimum follow-up rate of 2 years, rate of RTS type was 43.3 versus 75.0%, respectively (p = 0.027). No differences in secondary study parameters were found. In patients with a minimum follow-up of 1 year, rate of RTS type was significantly higher (p = 0.025) for patients without anxiety compared to patients who were anxious to perform certain movements. CONCLUSION: After a minimum follow-up of 2 years, rate of RTS type is in favour of using an ipsilateral patellar tendon autograft when compared to using a patellar tendon allograft in patients undergoing revision ACLR; after a minimum follow-up of 1 year, no significant difference was found. In revision ACLR, the results of this study might influence graft choice in favour of autologous graft when the use of an allograft or autograft patellar tendon is considered. LEVEL OF EVIDENCE: III.

Double-Bundle, All-Inside Posterior Cruciate Ligament Reconstruction: A Technique Using 2 Separate Autologous Grafts.

In a double-bundle posterior cruciate ligament reconstruction, several surgical techniques are available. Compared with other techniques, the advantages of the all-inside technique and cortical suspension devices with variable loop length are that shorter grafts can be used, tendons can be quadrupled, and a double-bundle posterior cruciate ligament reconstruction can be performed with autologous grafts. Furthermore, the all-inside technique provides independent outside-in socket reaming and is soft tissue, cortex, and bone sparing because no full diameter tunnels but sockets are created with a small diameter guide pin, which can transform into a retrograde drill. Sockets could however lead to bottoming out of the grafts at the femoral side and subsequent residual laxity. This can be avoided by using 2 separate grafts that are fixed in 2 femoral sockets before they are independently fixed and tensioned in 1 tibial socket in their corresponding flexion angle. In this technical note, we present a double-bundle, all-inside posterior cruciate ligament reconstruction using 2 separate autologous grafts.

The value of tourniquet use for visibility during arthroscopy of the knee: a double-blind, randomized controlled trial.

PURPOSE: To study the value of tourniquet use during routine arthroscopy of the knee. METHODS: In this randomized, double-blind controlled trial, 245 patients were included from April 2005 until March 2007 and randomized into an inflated tourniquet group (n = 137) or a deflated tourniquet group (n = 108). The primary outcome was intraoperative visibility. Secondary outcomes were the need to intraoperatively inflate the tourniquet because impaired vision impeded the procedure, the number of times and reason (impaired vision or debris) for flushing the knee, the duration of the procedure (in minutes), and the surgeon's impression of whether the tourniquet was inflated during the procedure. RESULTS: Intraoperative visibility was statistically significantly better in the group with the inflated tourniquet. In 11 of the 16 cases in which visibility was rated fair/poor (unsatisfactory), the surgeon felt the need to inflate the tourniquet. In all of the cases the tourniquet had not been previously inflated. In all but 1 case the visibility improved to at least to a rating of good. The frequency of flushing the knee intraoperatively was significantly higher in the deflated tourniquet group. The operative time was not significantly different statistically. CONCLUSIONS: The results of this study support our hypothesis that routine arthroscopy of the knee with an inflated tourniquet significantly improves visibility, but it does not shorten operative time. LEVEL OF EVIDENCE: Level I, therapeutic randomized controlled trial.