Comparison of Graft Type and Fixation Method in Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis Based on Randomized Control Studies.

BACKGROUND: The anterior cruciate ligament (ACL) is the most commonly injured ligament in the knee. ACL reconstruction (ACLR) proves the standard for treating this injury. However, graft choice and method of fixation remain a heavily debated topic. This study investigates the following: bone-patellar tendon-bone (BPTB) vs. hamstring tendon (HT) autograft, single-bundle vs. double-bundle hamstring graft, and metal vs. bioabsorbable screws in ACLR. METHODS: A systematic review was performed on PubMed and Google Scholar according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data were collected on patient demographics, complications, and functionality scores including International Knee Documentation Committee (IKDC) and Lysholm scores. A systematic review and meta-analysis were conducted with Review Manager. Outcome measurements were determined using forest plots with significant differences considered p < 0.05. RESULTS: Twenty-five studies were included, accounting for 2,170 patients. No statistically significant difference was appreciated when comparing BPTB to hamstring autografts. Patients who received a double bundle HT autograft exhibited significantly superior outcomes in terms of revision (p = 0.05), failure (p = 0.002), normal pivot shift tests (p = 0.04), and normal IKDC (p = 0.008). When comparing screw types, bioabsorbable screws had a greater Lysholm score (p = 0.01) and lower failure rates for copolymer screws (p = 0.03). CONCLUSION: Overall, the data collected suggested that BPTB and HT autografts display similar postoperative results. However, if an HT autograft is used, the data suggest a double-bundle graft improves both functionality and decreases the possible complications. Finally, bioabsorbable screws prove superior to metal screws when looking at both functionality and failure rates. Further research into the superior graft type is still needed. LEVEL OF EVIDENCE: Level II. See Instructions for Authors for a complete description of levels of evidence.

Anterior Cruciate Ligament Reconstruction with Semitendinosus Tendon Autograft among Paramilitary Patients Undergoing Arthroscopic Surgery in a Tertiary Care Centre.

Introduction: In orthopaedic practice, injuries to the anterior cruciate ligaments occur almost on an epidemic scale, yet it continues to be of interest in orthopaedic surgery whether semitendinosus or gracilis hamstring autografts can be used for better anterior cruciate ligament reconstruction. This study aimed to determine the prevalence of anterior cruciate ligament reconstruction using semitendinosus tendon autografts among paramilitary patients undergoing arthroscopic surgery in a tertiary care centre. Methods: This descriptive cross-sectional study was conducted among paramilitary individuals who had knee injuries and were admitted between 6 february 2020 and 26 January 2022 for arthroscopic surgery after obtaining ethical approval from the Institutional Review Committee. Demographic details and the mode of injury were obtained from the patients. The treating orthopaedic surgeons evaluated the pre- and post-analysis Lysholm Knee Score and Lysholm Knee Scale based on the patient's response. A convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval. Results: Among 166 patients, anterior cruciate ligament reconstruction using a semitendinosus tendon autograft was done in 58 (34.94%) (27.69-42.19, 95% Confidence Interval). Most of the patients in the pre-analysis had mild/periodic limp issues 52 (89.66%), followed by instability during athletics or other severe exertion 43 (74.14%). Conclusions: The prevalence of anterior cruciate ligament injuries in our study is higher than other studies done in similar settings. Keywords: anterior cruciate ligament; grafts; semitendinosus tendon.

Rectangular-Tunnel Anterior Cruciate Ligament Reconstruction Using Quadriceps Tendon-Patellar Bone Autograft Can Reduce Early Donor Site Morbidity While Maintaining Comparable Short-term Clinical Outcomes.

Background: Rectangular tunnel and graft have been recently designed to closely resemble the native anatomy in anterior cruciate ligament reconstruction (ACLR). This study was performed to compare the short-term clinical outcomes between rectangular and round femoral tunnels in ACLR using quadriceps tendon-patellar bone (QTPB) autografts. Methods: A total of 78 patients who underwent primary ACLR with QTPB autografts performed by three senior surgeons and had at least 1 year of postoperative follow-up were retrospectively reviewed. Patients who underwent rectangular tunnel ACLR (n = 40) were compared to those treated with the conventional round tunnel ACLR (n = 38). Outcomes including knee stability, clinical scores, quadriceps strength, associated complications, postoperative knee range of motion, and cross-sectional area of the graft were assessed. Results: Significant improvements in knee stability and clinical scores were observed after surgery in both groups (all p < 0.001). The postoperative measurements of knee stability and clinical scores were not significantly different between the two groups. Knee extension strength deficit at 60°/sec was significantly less in the rectangular tunnel group than in the round tunnel group at postoperative 6 months (41.7% vs. 48.9%, p = 0.032). The cross-sectional area of the partial-thickness QTPB graft was approximately 60% of the full-thickness QTPB graft. Conclusions: In the short-term, rectangular tunnel ACLR was comparable to round tunnel ACLR with QTPB autograft despite the smaller cross-sectional area. Additionally, the rectangular tunnel ACLR allowed partial-thickness grafting technique, which could subsequently reduce early donor site morbidity.

Editorial Commentary: Pedicled Quadriceps Tendon Autograft for Medial Patellofemoral Ligament Reconstruction Eradicates Risk of Saphenous Nerve Injury Seen With Gracilis Autograft. Allograft, When Available, Also Shows Excellent Outcomes.

Comparing a pedicled single-limbed quadriceps tendon (QT) autograft to a matched gracilis autograft (GT) group with bone tunnel anchors for patellar instability, the QT group showed similar outcome yet markedly improved complication rates involving the saphenous nerve and no anterior knee pain. These findings are reassuring for the QT usage as an option to GT autograft. Multiple systematic reviews have clearly shown that allograft medial patellofemoral ligament reconstruction has similar outcomes to autograft and is a viable option. As we have seen in anterior cruciate ligament reconstruction, there has been a march to include the QT into ligament reconstruction of the knee. The evidence is cumulating to support its use for medial patellofemoral complex reconstruction. As we await the verdict of Fulkerson's proposed double-bundle medial patellofemoral ligament and medial quadriceps tendon femoral ligament reconstruction, it appears that either QT autograft or GT allograft will be the go-to procedures of choice. Regardless the type of graft or type of patellar attachment, make sure the femoral side of the medial patellofemoral complex graft gets the most attention.

Anconeus-sparing minimally invasive approach for lateral ulnar collateral ligament reconstruction using a triceps tendon autograft is an effective and safe treatment for chronic posterolateral instability of the elbow.

BACKGROUND: Surgical treatment helps to restore stability of the elbow in patients with posterolateral rotatory instability (PLRI). The anconeus muscle is one of the most important active stabilizers against PLRI. A minimally invasive anconeus-sparing approach for lateral ulnar collateral ligament (LUCL) reconstruction using a triceps tendon autograft has been previously described. The purpose of this study was to evaluate the outcome of this intervention and identify risk factors that influenced the clinical and patient-reported outcomes. METHODS: Sixty-one patients with chronic PLRI and no previous elbow surgery who underwent surgical reconstruction of the LUCL using a triceps tendon autograft in a minimally invasive anconeus-sparing approach during 2012 and 2018 were evaluated. Outcome measures included a clinical examination and the Oxford Elbow Score (OES) and the Mayo Elbow Performance Score (MEPS) questionnaires. Subjective patient outcomes were evaluated with the visual analog scale (VAS) for pain and the Subjective Elbow Value (SEV). Integrity of the common extensor tendons and centering of the radial head were assessed preoperatively on standardized magnetic resonance images (MRIs). RESULTS: Fifty-two patients were available at final follow-up. The mean age of patients was 51 ± 12 years with a mean follow-up of 53 ± 14 months (range 20-76). Clinical examination after surgery (n = 41) showed no clinical signs of instability in 98% of the patients (P < .001) and a nonsignificant improvement in range of motion. OES, MEPS, and VAS scores averaged 40 ± 10 of 48 points, 92 ± 12 of 100 points, and 1 ± 2 points, respectively, all corresponding with good or excellent outcomes. The SEV was 88%, indicating very high satisfaction with the surgery. Only 1 patient had revision surgery due to pain, and there were no reported postoperative complications in this cohort. A radial head subluxation in the MRI correlated significantly with worse postoperative outcomes. CONCLUSIONS: The anconeus-sparing minimally invasive technique for posterolateral stabilization of the elbow using a triceps tendon autograft is an effective and safe treatment for chronic posterolateral instability of the elbow with substantial improvements in elbow function and pain relief with a very low rate of persistent clinical instability.

The effect of harvesting the anterior half of the peroneus longus tendon on foot morphology and gait.

BACKGROUND AND OBJECTIVES: In anterior cruciate ligament reconstruction, the strength of the graft was found to be unsatisfactory usually the anterior half of the peroneus longus tendon was taken for supplementation, but the effect on foot and ankle function and gait in the donor area is unclear. This study aims to explore the changes in the ankle and gait after using the harvested anterior half of the peroneus longus tendon as a reconstruction graft for the anterior cruciate ligament. METHODS: A total of 20 patients, 6 males and 14 females, aged 18 to 44 years, with unilateral anterior cruciate ligament injuries, underwent reconstruction using the harvested anterior half of the peroneus longus tendon as a graft between June 2021 and December 2021. The part on which the anterior half of the peroneus longus tendon was harvested was considered the experimental group, while the contralateral foot was the control group. At the 6-month follow-up, the Lysholm knee score, AOFAS ankle score, and gait-related data (foot length, arch index, arch volume, arch volume index, and gait cycle parameters: percentage of time in each gait phase, step frequency, step length, foot strike angle, and push-off angle) were assessed using a 3D foot scanner and wearable sensors for both groups. RESULTS: All 20 patients completed the six-month follow-up. There were no statistically significant differences between the experimental and control groups regarding knee scores, ankle scores, foot length, arch index, arch volume, arch volume index, step frequency, and step length (P > 0.05). However, there were statistically significant differences between the experimental and control groups in terms of the gait cycle parameters, including the percentage of time in the stance, mid-stance, and push-off phases, as well as foot strike angle and push-off angle (P < 0.05). CONCLUSION: Through our study of the surgical experimental group we have shown that harvesting the anterior half of the peroneus longus tendon does not affect foot morphology and gait parameters; however, it does impact the gait cycle.

Interference Screw versus Cement Fixation in Anterior Cruciate Ligament Soft Tissue Grafts: A Biomechanical Study.

Shortcomings of fixation have been reported as a source of graft failure in anterior cruciate ligament (ACL) reconstruction. While interference screws have long been used as fixation devices for ACL reconstruction, they are not without complications. Previous studies have highlighted the use of bone void filler as a fixation method; however, no biomechanical comparisons using soft tissue grafts with interference screws exist to our knowledge. The purpose of this study is to evaluate the fixation strength of a calcium phosphate cement bone void filler compared with screw fixation in an ACL reconstruction bone replica model with human soft tissue grafts. In total, 10 ACL grafts were constructed using semitendinosus and gracilis tendons harvested from 10 donors. Grafts were affixed with either an 8-10 mm × 23 mm polyether ether ketone interference screw (n = 5) or with approximately 8 mL of calcium phosphate cement (n = 5) into open cell polyurethane blocks. Graft constructs were tested to failure in cyclic loading under displacement control at a rate of 1 mm per second. When compared with screw construct, the cement construct showed a 978% higher load at yield, 228% higher load at failure, 181% higher displacement at yield, 233% higher work at failure, and a 545% higher stiffness. Normalized data for the screw constructs relative to the cement constructs from the same donor showed 14 ± 11% load at yield, 54 ± 38% load at failure, and 172 ± 14% graft elongation. The results of this study indicate that cement fixation of ACL grafts may result in a stronger construct compared with the current standard of fixation with interference screws. This method could potentially reduce the incidence of complications associated with interface screw placement such as bone tunnel widening, screw migration, and screw breakage.

Comparison of Direct Repair Versus Anatomic Graft Reconstruction of the Anterior Talofibular Ligament: A Biomechanical Cadaveric Study.

The goal of our study is to compare the stability of the anatomic reconstruction of the anterior talofibular ligament (ATFL) with direct repair of the ATFL, in a cadaver model. We performed the following techniques in 18 cadaveric ankles: the intact ATFL was cut, after which a direct repair using 2 anchors was performed. The repair was sectioned, and anatomic reconstruction was then performed with a tendon autograft. We measured angular displacement in 3 anatomic planes (axial, coronal, sagittal) for each situation in response to the anterior drawer test (ADT), talar tilt test (TTT) and pivot test (PT), using a specifically constructed arthrometer. The sectioned ATFL was inferior to the intact ATFL in the axial plane with the ADT (p = .012), in the axial plane with the PT (p = .001) and in the axial and coronal planes with the TTT (p = .013 and p = .016, respectively). Direct anatomic repair was inferior to the intact ATFL in the axial plane upon the PT (p = .009). No differences could be found between anatomic graft reconstructions and the intact ATFL with any manoeuver, nor when comparing anatomic graft reconstruction and direct repair with 2 anchors. We were able to conclude that anatomic graft reconstruction of the ATFL reproduces angular stability of the native ligament in a cadaver model. While we could not detect if anatomic graft reconstruction was superior to direct repair, the latter proved to be less stable in the axial plane upon internal rotation (pivot test) versus the intact ATFL.

The trend of allogeneic tendon decellularization: literature review.

Tendon injuries repair is a significant burden for orthopaedic surgeons. Finding a proper graft material to repair tendon is one of the main challenges in orthopaedics, for which the requirement of substitute for tendon repair would be different for each clinical application. Among biological scaffolds, the use of decellularized tendon increasingly represents an interesting approach to treat tendon injuries and several articles have investigated the approaches of tendon decellularization. To understand the outcomes of the the approaches of tendon decellularization on effect of tendon transplantation, a literature review was performed. This review was conducted by searching in Pubmed and Embase and 64 studies were included in this study. The findings revealed that the common approaches to decellularize tendon include chemical, physical, and enzymatic decellularization methods or their combination. With the development of tissue engineering, researchers also put forward new theories such as automatic acellular machine, 3D printing technology to manufacture acellular scaffold.

A prospective randomized controlled study of hamstring and bone-free quadriceps tendons autografts in arthroscopic ACL reconstruction.

INTRODUCTION: Anterior cruciate ligament (ACL) reconstruction is one of the most common surgical procedures worldwide. However, the ideal graft source is still debatable. This study compared hamstring (HT) and bone-free quadriceps (QT) tendon autografts in terms of muscle strength and patient-reported outcomes. METHODS: Between June 2018 and December 2019, 46 patients were enrolled in the study and randomly assigned to one of two groups for the ACL reconstruction surgery-the HT autograft group or the QT autograft group. An experienced examiner performed preoperative and postoperative examinations. The HUMAC NORM isokinetic machine (Computer Sports Medicine International-CSMI, 2004) was used to assess flexor and extensor thigh muscle strength. Both groups received the same surgical technique and fixation method. All patients were examined after three, six, nine, and 12 months. The final evaluations were performed at the 24-month follow-up. Patients' scores on the International Knee Documentation Committee (IKDC) evaluation form and the Lysholm Knee Scoring Scale were used to evaluate patient-reported outcomes. The two groups were also compared in terms of postoperative complications and activity levels. RESULTS: The difference between preoperative and postoperative knee flexor peak torques (FPT) was lower in the QT group than in the HT group. The average difference between preoperative and postoperative knee extensor peak torque (EPT) was higher in the QT group than in the HT group. As a result, the HT group had a lower postoperative H/Q ratio (flexor strength normalized to body mass divided by extensor strength normalized to body mass) than the QT group (p < 0.001). The mean IKDC scores for the HT and QT groups were 90.13 ± 6.99 and 87.12 ± 6.61, respectively. The scores of the two groups postoperatively were close, and both groups showed significant improvement. The average graft size in the QT group was significantly greater than that in the HT group. Saphenous nerve palsy was the most common complication in the HT group (22%). Thigh hematomas were observed in two patients in the QT group and required urgent intervention (12%). CONCLUSION: After ACL reconstruction, we found a significant decrease in strength at the donor sites in both techniques, with similar patient-reported measures and stability outcomes. The H/Q strength ratio was higher in the QT group postoperatively, which may have a protective effect on the reconstructed ligament. Level of Evidence I It is a randomized controlled trial.

Medial Patellofemoral Ligament Reconstruction Using Pedicled Quadriceps Tendon Autograft Yields Similar Clinical and Patient-Reported Outcomes but Less Donor-Site Morbidity Compared With Gracilis Tendon Autograft.

PURPOSE: To compare clinical and patient-reported outcome measures (PROMs) in patients with recurrent patellar dislocation after medial patellofemoral ligament (MPFL) reconstruction using either a gracilis tendon (GT) or quadriceps tendon autograft (QT). METHODS: All MPFL reconstruction performed between 2017 and 2019 were reviewed retrospectively. Only patients with isolated MPFL reconstruction, without any major patellofemoral risk factors and a minimum follow-up of 24 months, were included in the study. Patients were matched with respect to sex, age, and body mass index. All patients were evaluated clinically and using PROMs. RESULTS: A total of 64 patients with an average follow up of 28.7 ± 7.5 months were included in this study. The mean Kujala score (GT: 84.8 ± 12.9, QT: 88.9 ± 10.1), Lysholm score (GT: 89.4 ± 10.2, QT: 88.4 ± 5.0), and visual analog scale score for pain (GT: 1.9 ± 1.8, QT: 1.1 ± 1.3) did not significantly differ between both groups. Tegner activity level was significantly greater (P = .027) in the QT group (5.5 ± 1.9) compared with the GT group (4.6 ± 1.8), but within the minimal clinically important differences. Occasional patellar instability events, but no recurrent dislocation, were reported in 12.5% in the GT group and 6.3% in the QT group (P = .39). Of all patients, 90.6% in the QT and 68.8% in the HT group exceeded the PASS for the Kujala score (P = .06). Significantly more patients (59.4%) treated with GT reported donor-site morbidity in the form of sensitivity deficit at the lower leg compared with those treated with QT (3.1%, P = .001). CONCLUSIONS: GT and QT MPFL reconstruction have comparable PROMs and patellar redislocation rates 2 years' postoperatively. Significantly more patients treated with GT reported lower-leg sensitivity deficit compared with those treated with QT. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

The effect of sterilization and storage on the viscoelastic properties of human tendon allografts - Continued: Storage for 0 to 4 months.

The role of donor-derived tendons, also known as allografts, in anterior cruciate ligament replacement surgeries is steadily increasing. Before surgery, temporary storage and, in most cases, sterilization are essential. It is, thus, crucial to determine how these procedures alter the grafts' biomechanical properties. The purpose of this research was to analyze the effect of different sterilization methods (native, frozen, frozen + 21 kGy gamma irradiation, frozen + 21 kGy electron beam irradiation) and storage durations (0 to 4 months) on the deformation and creep of two tendon types (tibialis anterior, peroneus longus). 80 tibialis anterior and 83 peroneus longus tendons from 51 human cadavers were included. The samples were removed, placed in a radio-cryoprotectant solution, then slowly cooled, sterilized and stored at -80 °C. All groups were subject to 60 s static creep test with 250 N load. Deformation during the loading phase, creep during static loading, and the ratio of these two were evaluated. Deformation at the end of the loading phase and creep consistently exhibited significantly smaller values in the tibialis anterior compared to the peroneus longus type, as well as in electron beam-sterilized grafts as opposed to gamma beam-sterilized ones. Prolonged storage periods (within 0 to 4 months) resulted in a notable increase in these values, particularly in deformation. Based on the experimental data, the tibialis anterior tendon type and sterilization by gamma beam irradiation are better choices for anterior cruciate ligament reconstruction than the peroneus longus and sterilization by electron beam. Increased storage time affects negatively the evaluated mechanical properties.

How to Recognize, Correct, and Avoid Intraoperative Complications During Anterior Cruciate Ligament Reconstructions.

Technical complications are a leading cause of graft failure following anterior cruciate ligament reconstructions. Complications can occur during any phase of the procedure, from graft harvesting to tunnel preparation to graft fixation. Predicting potential causes of technical difficulty and developing strategies to avoid potential pitfalls can limit the number of intraoperative complications. If adverse events do occur intraoperatively, prompt recognition and treatment can lead to favorable outcomes. It is important to discuss strategies to understand potential complications and develop tactics to avoid and correct adverse events that can occur during anterior cruciate ligament reconstruction.

Biomechanical Comparison of Proximal Hamstring Reconstruction Using Distal Hamstring Graft Versus Fascia Lata Graft for Treatment of Chronic Hamstring Injury.

BACKGROUND: Surgical reconstruction using autografts is often required in treating chronic proximal hamstring injuries where the hamstring has retracted >5 cm. There is a paucity of evidence that evaluates reconstructive procedures using the 2 most popular autografts, distal hamstring and fascia lata. PURPOSE: To (1) compare failure load and elongation at failure between the proximal hamstring tendon reconstruction with distal hamstring and fascia lata grafts and (2) compare the stiffness between these reconstructions and the native state. STUDY DESIGN: Controlled laboratory study. METHODS: Seven pairs of human cadaveric hemipelvises (mean age, 60.4 ± 5.0 years; 6 male, 1 female) with no evidence of previous injury or abnormality were dissected to the proximal hamstring origin. Through use of a dynamic tensile testing system, each specimen underwent preconditioning followed by a distraction test to determine the native specimen stiffness. Each pair of specimens was assigned to undergo proximal hamstring reconstruction with distal hamstring and reconstruction with fascia lata. Each specimen then underwent preconditioning followed by pull to failure. The failure load, elongation at failure, mode of failure, and stiffness were determined for each repair. RESULTS: The distal hamstring group exhibited a greater failure load (mean, 334 ± 108 N; P = .031) and higher stiffness (mean, 47.6 ± 16.0 N/mm; P = .009) compared with the fascia lata group (mean, 179 ± 78 N and 23.0 ± 11.2 N/mm, respectively). Although the stiffness of the repair state in the distal hamstring group (mean, 61.4 ± 13.4 N/mm) was not significantly different from that of the native state (mean, 47.6 ± 16.0 N/mm), the stiffness of the repair state in the fascia lata group (mean, 23.0 ± 11.2 N/mm) was significantly lower than that of the native state (mean, 60.1 ± 17.7 N/mm) (P < .0001). The elongation at failure of the distal hamstring graft group (mean, 33.0 ± 6.6 mm) was not significantly different from that of the fascia lata graft group (mean, 29.2 ± 14.9 mm) (P = .58). The most common modes of failure for the distal hamstring group (29% each) were at the repair site, at the graft-muscle interface, and at the muscle, while the most common modes of failure for the fascia lata graft were at the tendon-graft interface. CONCLUSION: The distal hamstring group achieved higher failure load and stiffness than the fascia lata group, and stiffness of the distal hamstring group was not significantly different from that of the native tendon. Elongation at failure was not different between repair techniques. Although distal hamstring graft failure predominantly occurred in 3 distinct locations, failure of the fascia lata repair occurred predominantly at the tendon-graft interface. These cadaveric results suggest that it may be more clinically appropriate to use distal hamstring versus fascia lata for proximal hamstring reconstruction. CLINICAL RELEVANCE: Our time-zero study suggests that the proximal hamstring reconstruction with distal hamstring could be the preferred surgical treatment for chronic hamstring injury over reconstruction with fascia lata. The failure load of reconstruction with distal hamstring was inferior to that of primary suture anchor, suggesting that rehabilitation after reconstruction should not be more aggressive than the standard postoperative rehabilitation protocol for acute repair.

Near complete quadriceps tendon healing 2 years following harvest in anterior cruciate ligament reconstruction.

PURPOSE: Despite the recent increase in the use of quadriceps tendon (QT) autograft in anterior cruciate ligament reconstruction (ACLR); however, there remains a paucity of literature evaluating the postoperative morphology of the QT. The present study aimed to determine the postoperative morphologic change of the QT at a minimum of 2 years following harvesting during ACLR. METHODS: Patients who underwent ACLR with QT autograft and underwent magnetic resonance imaging (MRI) at a minimum of 2 years following harvesting were retrospectively included in the study. The anterior-to-posterior (A-P) thickness, medial-to-lateral (M-L) width, cross-sectional area (CSA), and signal/noise quotient (SNQ) of the QT were assessed at 5 mm, 15 mm, and 30 mm proximal to the superior pole of the patella on MRI. The CSA was adjusted by the angle between the QT and the plane of the axial cut based on a cosine function (adjusted CSA). The A-P thickness, M-L width, adjusted CSA, and SNQ were compared pre- and postoperatively. In addition, defects or scar tissue formation in the harvest site were investigated on postoperative MRI. RESULTS: Thirty patients were recruited for the study. The mean duration between postoperative MRI and surgery was 2.8 ± 1.1 years. The mean A-P thickness was 10.3% and 11.9% larger postoperatively at 5 mm and 15 mm, respectively. The mean M-L width was 7.3% and 6.5% smaller postoperatively at 5 mm and 15 mm, respectively. There were no significant differences in the adjusted CSA between pre- and post-operative states (275.7 ± 71.6 mm2 vs. 286.7 ± 91.8 mm2, n.s.). There was no significant difference in the postoperative change in the SNQ of the QT at all assessment locations. Defect or scar tissue formation at the harvest site was observed in 4 cases (13.3%), and 5 cases (16.6%), respectively. CONCLUSION: At a minimum of 2 years following QT harvest during ACLR, the QT became slightly thicker and narrower (approximately 11% and 7%, respectively). While the current study demonstrates that QT re-harvesting can be considered due to nearly normalized tendon morphology, future histological and biomechanical studies are required to determine the re-harvesting potential of the QT. LEVEL OF EVIDENCE: IV.

Role of Quadriceps Tendon Autograft in Primary and Revision Anterior Cruciate Ligament Reconstruction.

¼ The quadriceps tendon (QT) autograft is becoming increasingly popular in both primary and revision anterior cruciate ligament reconstruction (ACLR).¼ The biomechanical properties of the QT are similar to those of the native ACL, the hamstring tendon (HT), and bone-patellar tendon-bone (BTB) autografts.¼ QT autograft allows surgeons to be flexible with their graft size and reconstruction technique.¼ The QT autograft performs in a similar fashion to the BTB and HT autografts, with excellent patient-reported outcomes, consistent postoperative knee stability, and low rates of postoperative complications including graft failure and donor site morbidity.¼ There are emerging data that the QT autograft is a viable option in revision ACLR.

Tubularization of Bone-Tendon-Bone Grafts: Effects on Mechanical Strength and Postoperative Knee Stability in Anterior Cruciate Ligament Reconstruction.

Background and Objectives: The study addresses a significant limitation in applying bone-patellar tendon-bone (BTB) grafts in anterior cruciate ligament (ACL) surgery. By exploring the tubularization of grafts, the study extends the understanding of this surgical technique. The dual approach of the study-focusing on biomechanical properties using an animal model and postoperative outcomes in humans-offers a comprehensive perspective. Materials and Methods: The experimental cohort encompassed ten pairs of fresh porcine bone-tendon-bone grafts. One graft in each pair underwent modification through sutures that transformed the flat graft into a cylindrical structure. Testing determined the force required for the modified graft to rupture mechanically, expressed as N/mm2, compared to conventionally prepared bone-tendon-bone grafts. The second phase of the research involved a prospective randomized clinical trial comprising 120 patients undergoing operative ACL reconstruction. For half the cases, grafts were tubularized using a random selection process. Clinical evaluations preoperatively and 12 months postoperatively employed the Tegner, Lysholm, and IKDC scoring scales for knee assessment. Results: Experiments showed that ligaments made using the tubularized surgical technique have statistically significantly higher values of measured force and higher maximum elongation values than ligaments made using the classical method. The clinical study concluded that there was no significant difference between the two groups of patients in the average score on the Tegner, Lysholm, and IKDC scales before and after surgery. Conclusions: The study results showed that suturing the graft does not negatively affect its biomechanical properties, and tubularization significantly increases the values of force required to cause rupture and the values of maximum elongation during rupture. Given the possibility of the one-year follow-up period being insufficient, future investigations should extend this period to acquire objective functional insights post-surgery.

Surgical treatment of chronic proximal patellar tendon tears grades 3 and 4 using augmentation with quadriceps tendon-bone graft.

BACKGROUND: Chronic proximal patellar tendinosis with partial tendon tears represents a multifactorial overuse injury. Several surgical techniques have been described with various outcomes and the return to sports may fail. HYPOTHESIS: Reconstruction of the proximal patellar tendon with augmentation using a quadriceps tendon-bone (QTB) graft improves knee function in patients presenting with proximal patellar tendinosis and partial tendon tears. METHODS: Forty-seven patients (32 males, 15 females) with chronic proximal patellar tendinosis and tendon tears grade 3 and 4 were treated between 1992 and 2018. Patients were evaluated retrospectively using the Popkin-Golman (PG) MRI grading system and the removed tendon parts. The Tegner Activity Scale (TAS) and the Numerical Rating Scale (NRS) for pain were used as outcome measures before surgery and at follow up. Complete data were available in 100% of cases at 6 months follow up, and fifteen of them at later follow up. RESULTS: The average follow up was 1.5 years (range, 0.5-16). The TAS improved from a mean preoperative score of 3.7 to a mean postoperative score of 9.1. The median NRS status decreased from an average of 6.4 to 1.1. Two patients needed additional arthroscopic scar tissue removal. CONCLUSION: Reconstruction of proximal patellar tendon tears grades 3 and 4 with augmentation using a QTB graft is a valuable surgical salvage procedure in chronic cases. It improves knee function and yields good to excellent results in most cases including high level athletes. The use of MRI with the PG classification of tendon tears is highly recommended. LEVEL OF EVIDENCE: Therapeutic case series, Level IV.

Quadriceps tendon autograft has similar clinical outcomes when compared to hamstring tendon and bone-patellar tendon-bone autografts for revision ACL reconstruction: a systematic review and meta-analysis.

PURPOSE: Research regarding revision anterior cruciate ligament reconstruction (RACLR) with quadriceps tendon (QT) autografts is lacking. The purpose of this study was to perform a systematic review and meta-analysis of RACLR with QT and compare its patient outcomes to RACLR with hamstring tendon (HT) and bone-patellar tendon-bone (BTB) autografts. METHODS: Adhering to PRISMA guidelines, a search for studies using QT in RACLR was performed within PubMed, Scopus, and CINAHL from database date of inception through December 26, 2022. Primary outcomes sought included: failure rate, Lysholm scores, International Knee Documentation Committee (IKDC) scores, IKDC grades, arthrometric knee side-to-side differences (STSD), pivot shift grade, donor site morbidity, return to sport, visual analog scale (VAS) pain scores. RESULTS: Nine studies were included consisting of 606 RACLR: 349 QT, 169 HT, and 88 BTB. Overall failure rates were 7.6% QT, 13.3% HT, and 8.7% BTB. Mean weighted Lysholm scores were 85.8 ± 3.8 QT, 82.5 ± 3.8 HT and 86.6 ± 4.5 BTB. IKDC average scores were 82.3 ± 1.6 QT, 80.1 ± 1.7 HT, and 81.7 ± 5.5BTB. Combined rates of IKDC A/B grades were 88.4% and 80.0% for QT and HT, respectively. VAS average scores were 0.9 ± 1.1 QT, 1.4 ± 0.2 HT, and 0.7 ± 0.8 for BTB. Side-to-side difference was reported for QT and HT with average values of 1.7 ± 0.6 mm and 2.1 ± 0.5 mm, respectively. Grade 0 or 1 pivot shifts were reported in 96.2% of QT patients and 91.3% of HT. Donor site morbidity, only reported for QT and HT, was 14.6 ± 9.7% and 23.6 ± 14.1%, respectively. QT resulted in a mean Tegner score of 5.9 ± 1.5 versus HT 5.7 ± 1.5. Rate of return to pivoting sports was 38.0% QT, 48.6% HT, and 76.9% BTB. Across all outcomes, there was no significant difference when comparing QT to HT, QT to BTB, and QT compared to HT and BTB combined. CONCLUSIONS: RACLR with QT yields satisfactory patient reported outcomes, satisfactory improvement in knee laxity, expected return to sport rates, and has an overall 7.6% failure rate. Outcomes are comparative to those of HT and BTB making it an acceptable graft choice for RACLR. Surgeons should consider using QT autograft for RACLR, especially when other autografts are unavailable. LEVEL OF EVIDENCE: IV.

Reconstruction of medial patellofemoral ligament with adductor magnus tendon for recurrent patellar dislocation in children: a retrospective comparative cohort study.

BACKGROUND: The purpose of current retrospective study was to explore the outcomes of using the adductor magnus tendon to reconstruct the medial patellofemoral ligament in the treatment of recurrent patellar dislocation in children. METHOD: Thirty-two children with recurrent patellar dislocation were selected. Sixteen cases in the conservative group, seven males and nine females, with an average age of 11.81 ± 1.28 years; sixteen cases in the surgical group, eight males and eight females, with an average age of 11.56 ± 1.15 years. All patients had no surgery history. The IS index (> 1.2), Q angle (> 20°) and tibial tubercle-femoral trochlear groove (TT-TG) distance (> 20 mm) were measured by X-ray and MRI. The conservative group was treated with closed reduction and a brace, and the surgical group received surgical treatment. Two years after surgery, congruence angle (CA) (- 6° to 6°) and lateral patellofemoral angle (LPFA) (7.7°-18.7°) were measured by X-ray image and all children were evaluated based on Kujala and Lysholm scores. The re-dislocation rate was recorded. Analysis was performed by t test and chi-square with the statistical SPSS software. P < 0.05 was considered a statistically significant difference. Furthermore, we measured the length (mm) of the adductor tendon and MPFL in three knee cadaveric specimens, and also observed the positional relationship between the two structures. RESULT: There were no significant differences in sex, age, injury site between groups (P > 0.05). Patients in the two groups were followed up for 2 years in average. Among the 16 cases in the conservative group, 7 cases (43.75%) had recurrence of patellar dislocation, while none of recurrence in the surgical group (P < 0.05). The Lysholm score of the surgical group (94.63 ± 8.99) was significantly better than that of the conservative group (79.31 ± 18.90), and the Kujala score of the surgery group (95.25 ± 10.32) was also significantly better than that of the conservative group (77.06° ± 14.34°) (P < 0.05). The CA and LPFA of the two groups of patients after treatment were significantly recovered. The CA (- 5.81° ± 7.90°) in the surgical group was significantly better than that in the conservative group (20.94° ± 8.21°), and the LPFA (6.44° ± 3.22°) was also significantly better than that in the conservative group (- 9.18 ± 11.08), and the difference is statistically significant (P < 0.05). We found it through autopsy that adductor magnus tendon was 124.33 ± 1.53 mm long, MPFL was 48.67 ± 2.08 mm, and the femoral insertion of the adductor magnus tendon was adjacent to the MPFL femoral insertion. CONCLUSION: Reconstruction of Medial patellofemoral ligament with the adductor magnus tendon, fixing with PEEK suture anchors on the patellar side, can achieve satisfactory results in the treatment of children with recurrent patellar dislocation. Compared with conservative treatment, the rate of recurrence is lower and the stability of the patella is better.