Harvesting a second graft from the extensor mechanism for revision ACL reconstruction does not delay return of quadriceps function.

PURPOSE: The purpose of this study was to evaluate whether harvesting a second graft from the ipsilateral extensor mechanism adversely affects clinical outcomes in revision anterior cruciate ligament (ACL) reconstruction. METHODS: A retrospective review of 34 patients undergoing revision anterior cruciate ligament (ACL) reconstruction with either quadriceps tendon (QT) autograft or bone-tendon-bone (BTB) autograft was conducted. Patients with two grafts (BTB+QT) from the extensor mechanism were matched based on age, laterality, and sex to patients who had primary reconstruction with hamstring (HS) autograft followed by revision with either BTB or QT autograft (HS+QT/BTB). Return of quadriceps function was assessed with time to return to jogging in a standardized rehab protocol or time to regain 80% quadriceps strength. Secondary outcomes included International Knee Documentation Committee (IKDC) and Marx scores at 12-month follow-up and return to sport. RESULTS: There were no significant differences in return to jogging or 80% quadriceps strength (HS 149.5 ± 38.2 days, BTB+QT 131.7 ± 40.1 days, n.s.), number able to return to sport (HS 62%, BTB+QT 93%, n.s.), months to return to sport (HS 10.6 ± 1.4, BTB+QT 10.5 ± 2.3, n.s.), return to pre-injury level of competition (HS 62%, BTB+QT 73%, n.s.), or IKDC (HS 77.2 ± 16.4, BTB+QT 74.8 ± 23.9, n.s.) and Marx scores (HS 9.2 ± 5.3, BTB+QT 8.0 ± 3.7, n.s.) at one-year follow-up. CONCLUSION: The main finding of the present study was that outcomes for patients who underwent revision ACL reconstruction with a second extensor mechanism autograft were comparable to those seen for patients who underwent revision ACL reconstruction with extensor mechanism autograft after primary ACL reconstruction with hamstring autograft. By better understanding the consequences of harvesting a second graft from the extensor mechanism, surgeons can better decide what graft to use in revision ACL reconstruction. LEVEL OF EVIDENCE: Level III.

Low posterior tibial slope is associated with increased risk of PCL graft failure.

PURPOSE: To evaluate the effect of posterior tibial slope (PTS) on patient-reported outcomes (PROs) and posterior cruciate ligament (PCL) graft failure after PCL reconstruction. METHODS: Patients undergoing PCL reconstruction with a minimum 2-year follow-up were included in this retrospective cohort study. A chart review was performed to collect patient-, injury-, and surgery-related data. Medial PTS was measured on preoperative lateral radiographs. Validated PROs, including the International Knee Documentation Committee Subjective Knee Form, Knee injury and Osteoarthritis Outcome Score, Lysholm Score, Tegner Activity Scale, and Visual Analogue Scale for pain, were collected at final follow-up. A correlation analysis was conducted to assess the relationship between PTS and PROs. A logistic regression model was performed to evaluate if PTS could predict PCL graft failure. RESULTS: Overall, 79 patients with a mean age of 28.6 ± 11.7 years and a mean follow-up of 5.7 ± 3.3 years were included. After a median time from injury of 4.0 months, isolated and combined PCL reconstruction was performed in 22 (28%) and 57 (72%) patients, respectively. There were no statistically significant differences in PROs and PTS between patients undergoing isolated and combined PCL reconstruction (non-significant [n.s.]). There were no significant correlations between PTS and PROs (n.s.). In total, 14 (18%) patients experienced PCL graft failure after a median time of 17.5 months following PCL reconstruction. Patients with PCL graft failure were found to have statistically significantly lower PTS than patients without graft failure (7.0 ± 2.3° vs. 9.2 ± 3.3°, p < 0.05), while no differences were found in PROs (n.s.). PTS was shown to be a significant predictor of PCL graft failure, with a 1.3-fold increase in the odds of graft failure for each one-degree reduction in PTS (p < 0.05). CONCLUSIONS: This study showed that PTS does not affect PROs after PCL reconstruction, but that PTS represents a surgically modifiable predictor of PCL graft failure. LEVEL OF EVIDENCE: III.

The REVision Using Imaging to Guide Staging and Evaluation (REVISE) in ACL Reconstruction Classification.

Revision anterior cruciate ligament (ACL) procedures are increasing in incidence and possess markedly inferior clinical outcomes (76% satisfaction) and return-to-sports (57%) rates than their primary counterparts. Given their complexity, a universal language is required to identify and communicate the technical challenges faced with revision procedures and guide treatment strategies. The proposed REV: ision using I: maging to guide S: taging and E: valuation (REVISE) ACL (anterior cruciate ligament) Classification can serve as a foundation for this universal language that is feasible and practical with acceptable inter-rater agreement. A focus group of sports medicine fellowship-trained orthopaedic surgeons was assembled to develop a classification to assess femoral/tibial tunnel "usability" (placement, widening, overlap) and guide the revision reconstruction strategy (one-stage vs. two-stage) post-failed ACL reconstruction. Twelve board-certified sports medicine orthopaedic surgeons independently applied the classification to the de-identified computed tomographic (CT) scan data of 10 patients, randomly selected, who failed ACL reconstruction. An interclass correlation coefficient (ICC) was calculated (with 95% confidence intervals) to assess agreement among reviewers concerning the three major classifications of the proposed system. Across surgeons, and on an individual patient basis, there was high internal validity and observed agreement on treatment strategy (one-stage vs. two-stage revision). Reliability testing of the classification using CT scan data demonstrated an ICC (95% confidence interval) of 0.92 (0.80-0.98) suggesting "substantial" agreement between the surgeons across all patients for all elements of the classification. The proposed REVISE ACL Classification, which employs CT scan analysis to both identify technical issues and guide revision ACL treatment strategy (one- or two-stage), constitutes a feasible and practical system with high internal validity, high observed agreement, and substantial inter-rater agreement. Adoption of this classification, both clinically and in research, will help provide a universal language for orthopaedic surgeons to discuss these complex clinical presentations and help standardize an approach to diagnosis and treatment to improve patient outcomes. The Level of Evidence for this study is 3.

Return to Sport After Anterior Cruciate Ligament Injury: Panther Symposium ACL Injury Return to Sport Consensus Group.

BACKGROUND: A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sport and their previous activity level. PURPOSE: The aim of the Panther Symposium ACL Injury Return to Sport Consensus Group was to provide a clear definition of RTS after ACL injury and a description of the RTS continuum as well as provide clinical guidance on RTS testing and decision-making. STUDY DESIGN: Consensus statement. METHODS: An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence. RESULTS: Key points include that RTS is characterized by achievement of the preinjury level of sport and involves a criteria-based progression from return to participation to RTS and, ultimately, return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along an RTS continuum, with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors, and concomitant injuries. CONCLUSION: The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing, and methods for the biological assessment of healing and recovery.

Patellar Fractures After the Harvest of a Quadriceps Tendon Autograft With a Bone Block: A Case Series.

BACKGROUND: The quadriceps tendon is a versatile graft option, and the clinical implications of a quadriceps tendon harvest need to be further defined. PURPOSE: To review surgical considerations for the safe harvest of a quadriceps tendon autograft for anterior cruciate ligament (ACL) reconstruction, with a focus on the risk of patellar fractures. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A series of 57 patients underwent ACL reconstruction with a quadriceps tendon autograft with a patellar bone block from March 2011 to December 2012 at a single institution. Patients who sustained a patellar fracture were identified. The clinical course for each patient was reviewed with International Knee Documentation Committee (IKDC) subjective knee form scores through 2-year follow-up. RESULTS: The incidence of patellar fractures was 3.5% intraoperatively and 8.8% at 2 years. This included 2 intraoperative fractures, 1 fracture during strength testing, and 2 occult fractures detected on computed tomography (CT) performed 6 months postoperatively for research purposes in asymptomatic participants. For the 5 patients with a patellar fracture with 24-month follow-up, the IKDC scores were 91.95, 91.95, 100.00, 100.00, and 64.37. CONCLUSION: Careful consideration of the quadriceps tendon and patellar anatomy is needed to safely harvest the bone plug from the superior pole of the patella. The consequences of a quadriceps tendon autograft harvest, specifically with regard to the risks associated with fractures of the patella during the harvest, demand full consideration. Postoperative imaging with CT may identify abnormalities in patients who are otherwise asymptomatic.

3-Dimensional Printed Models May Be a Useful Tool When Planning Revision Anterior Cruciate Ligament Reconstruction.

PURPOSE: To determine whether using 3-dimensional (3D)-printed models in addition to computed tomography (CT) scans to evaluate the primary femoral and tibial tunnels before revision anterior cruciate ligament (ACL) reconstruction leads to better agreement with the surgical approach than CT alone. METHODS: Fifteen patients who underwent revision ACL reconstruction were retrospectively identified. The mean age was 24.3 years, and 73% were female. Using only CT images, 3 board-certified orthopaedists and 5 sports medicine orthopaedic fellows evaluated whether the existing tibial and femoral tunnels were acceptable for the revision surgery. Subsequently, 3D-printed models were made available in addition to the CT scan, and the same questions were asked. RESULTS: For the attending orthopaedic physicians, adding the 3D-printed models did not have a significant impact on the tibial or femoral tunnel agreement compared with the surgical approach. With the fellow physicians, however, using the 3D-printed models with tibial tunnel evaluation led to a higher agreement rate (76%) compared with CT images alone (63%) (P = .050). Furthermore, with the fellow physicians, there was a higher overall agreement when evaluating both the tibial and femoral tunnels with the addition of 3D-printed models (74%) compared with CT alone (65%) (P = .049). CONCLUSION: Our hypothesis that using 3D-printed models leads to better agreement with the surgical approach was unsupported based on the response of the board-certified orthopaedists. Based on the fellow response, it stands to reason that 3D-printed models may be a useful tool in understanding spatial orientation when planning for revision ACL surgery. LEVEL OF EVIDENCE: IV, retrospective case series.

PATIENT-SPECIFIC AND SURGERY-SPECIFIC FACTORS THAT AFFECT RETURN TO SPORT AFTER ACL RECONSTRUCTION.

CONTEXT: Anterior cruciate ligament (ACL) reconstruction is frequently performed to allow individuals to return to their pre-injury levels of sports participation, however, return to pre-injury level of sport is poor and re-injury rates are unacceptably high. Re-injury is likely associated with the timeframe and guidelines for return to sport (RTS). It is imperative for clinicians to recognize risk factors for re-injury and to ensure that modifiable risk factors are addressed prior to RTS. The purpose of this commentary is to summarize the current literature on the outcomes following return to sport after ACL reconstruction and to outline the biologic and patient-specific factors that should be considered when counseling an athlete on their progression through rehabilitation. EVIDENCE ACQUISITION: A comprehensive literature search was performed to identify RTS criteria and RTS rates after ACL reconstruction with consideration paid to graft healing, anatomic reconstruction, and risk factors for re-injury and revision. Results were screened for relevant original research articles and review articles, from which results were summarized. STUDY DESIGN: Clinical Review of the Literature. RESULTS: Variable RTS rates are presented in the literature due to variable definitions of RTS ranging from a high threshold (return to competition) to low threshold (physician clearance for return to play). Re-injury and contralateral injury rates are greater than the risk for primary ACL injury, which may be related to insufficient RTS guidelines based on time from surgery, which do not allow for proper healing or resolution of post-operative impairments and elimination of risk factors associated with both primary and secondary ACL injuries. CONCLUSIONS: RTS rates to pre-injury level of activity after ACLR are poor and the risk for graft injury or contralateral injury requiring an additional surgery is substantial. Resolving impairments while eliminating movement patterns associated with injury and allowing sufficient time for graft healing likely gives the athlete the best chance to RTS without further injury. Additional research is needed to identify objective imaging and functional testing criteria to improve clinical decision making for RTS after ACLR. LEVEL OF EVIDENCE: Level 5.

Use of a fluoroscopic overlay to assist arthroscopic anterior cruciate ligament reconstruction.

BACKGROUND: A growing body of evidence supports the importance of anatomic tunnel positioning in the success of anterior cruciate ligament (ACL) reconstruction, which stimulates the need for technologies to aid surgeons in achieving accurate anatomic tunnel placement. Intraoperative fluoroscopy is potentially one such technology, while its efficacy and usability have yet to be established. PURPOSE: To investigate the performance of an intraoperative fluoroscopic overlay in guiding tunnel placement during ACL reconstruction. STUDY DESIGN: Controlled laboratory study. METHODS: Twenty cadaveric knees underwent computed tomography (CT) scans and arthroscopic digitization of ACL insertion sites. The outlines of the digitized insertion sites were mapped to the corresponding CT-acquired bone models through a co-registration procedure. Twenty orthopaedic surgeons performed simulated ACL reconstructions, each on a randomly assigned cadaveric knee, first without and then with the aid of a fluoroscopic overlay system. The overlay system displayed on a lateral fluoroscopic image targets points representing the locations of the ACL insertion sites estimated from the literature data. Surgeons were allowed to adjust their tunnel positions under the guidance of the fluoroscopic image. Their initial, intermediate, and final positions were documented and compared with the target points as well as the native insertion sites. RESULTS: Surgeons demonstrated significant (P < .01) improvements in femoral and tibial tunnel placements relative to the target points from an average distance of 3.9 mm to 1.6 mm on the femur and 2.1 mm to 0.9 mm on the tibia. The improvements toward the knee-specific actual insertion sites were significant on the tibial side but not on the femoral side. CONCLUSION: Surgeons can be successfully guided with fluoroscopy to create more consistent femoral and tibial tunnels during ACL reconstruction. More research is warranted to develop better population representations of the locations of natural insertion sites. CLINICAL RELEVANCE: Intraoperative fluoroscopy can be an effective, easy, and safe method for improving tunnel positioning during ACL reconstruction.

Anterior cruciate ligament healing and advances in imaging.

Graft healing and maturation are important considerations during the rehabilitation process. Histologic studies have identified the stages of graft healing following anterior cruciate ligament (ACL) reconstruction. Correlations between histology and radiographic findings have allowed for the development of noninvasive methods to assess graft maturity. Important information regarding graft vascularity and incorporation of the graft to host bone can be obtained from imaging modalities. The role of noninvasive means in the evaluation of patients following ACL reconstruction continues to develop as these powerful tools evolve.

Anatomic anterior cruciate ligament reconstruction with quadriceps tendon autograft.

A multitude of graft options exist including both allograft and autograft sources for reconstruction of the anterior cruciate ligament. With recent concerns regarding the early graft failure and cost-effectiveness of allograft sources, more attention has been directed toward autograft options. However, autograft harvest has been associated with specific morbidity that can result in suboptimal outcomes. The quadriceps tendon is an excellent biomechanical and biologic option.

Biomechanical comparison of 3 methods to repair pectoralis major ruptures.

BACKGROUND: Pectoralis major ruptures are closely associated with weight lifting and participation in sports. The anatomy of the pectoralis major tendon is unique with an elongated thin footprint requiring multiple points of fixation to restore the native anatomy. Multiple options exist for tendon repairs, but the strongest construct has yet to be identified. PURPOSE: The intent of this study was to compare the load to failure of bone trough, cortical button, and suture anchor repairs of the pectoralis major tendon in the extended and abducted position. STUDY DESIGN: Controlled laboratory study. METHODS: Thirty fresh-frozen cadaveric shoulders were divided equally into 3 groups based on the repair technique to be performed. Bone mineral density of the surgical neck of the proximal humerus was assessed before each repair. Bone trough, suture anchor, and cortical button repairs were performed as dictated by computerized randomization. Each specimen was loaded to failure and mode of failure was noted. RESULTS: The majority of failures occurred through the suture used for tendon repair. One specimen in the bone trough group failed via fracture of the proximal humerus. The suture anchor group failed at the implant in 5 of 9 specimens and through the suture in 4 of 9 specimens. Load to failure was greatest in bone trough repairs at 596 N, followed by cortical button at 494 N, and finally suture anchor repairs with 383 N. Load to failure was significantly greater in the bone trough group when compared with suture anchor repairs (P = .007). No correlation was found between bone mineral density and load to failure. CONCLUSION: Bone trough repair of the pectoralis major tendon was stronger than suture anchor repair. CLINICAL RELEVANCE: Identification of the strongest repair may help guide surgical repair.

Allograft anterior cruciate ligament reconstruction: indications, techniques, and outcomes.

The anterior cruciate ligament (ACL) is an important stabilizer of the knee against translational and rotational forces. The goal of anatomic reconstruction of the ACL-deficient knee is to re-create a stable knee that will allow for return to sport and prevent recurrent injury. Multiple graft options exist for ACL reconstruction, and each option has unique advantages and disadvantages. With appropriate patient selection, each graft can be utilized to optimize patient outcomes. Allograft options limit morbidity following ACL reconstruction, but care must be taken with surgical technique and postoperative rehabilitation to allow for graft incorporation. An understanding of the surgical technique and differences between graft options will allow the patient, surgeon, and physical therapist to maximize outcomes following ACL reconstruction.

Individualized anatomic anterior cruciate ligament reconstruction.

Arthroscopic anterior cruciate ligament reconstruction (ACL-R) is a technique that continues to evolve. Good results have been established with respect to reducing anteroposterior laxity. However, these results have come into question because nonanatomic techniques have been ineffective at restoring knee kinematics and raised concerns that abnormal kinematics may impact long-term knee health. Anatomic ACL-R attempts to closely reproduce the patient's individual anatomic characteristics. Measurements of the patient's anatomy help determine graft choice and whether anatomic reconstruction should be performed with a single- or double-bundle technique. The bony landmarks and insertions of the anterior cruciate ligament (ACL) are preserved to assist with anatomic placement of both tibial and femoral tunnels. An anatomic single- or double-bundle reconstruction is performed with a goal of reproducing the characteristics of the native ACL. Long-term outcomes for anatomic ACL reconstruction are unknown. By individualizing ACL-R, we strive to reproduce the patient's native anatomy and restore knee kinematics to improve patient outcomes.

Rotatory knee laxity tests and the pivot shift as tools for ACL treatment algorithm.

UNLABELLED: The goal of anterior cruciate ligament (ACL) reconstruction surgery is to eliminate the pivot shift phenomenon. Different injury mechanisms and injury patterns may lead to specific knee laxity patterns. Computer navigation is helpful for the surgeon during examination under anesthesia. Surgical treatment may have to be altered if high-grade laxity is detected preoperatively for example by utilizing a computer navigation that is a helpful adjunct for surgeons during examination under anesthesia. A typical case for revision ACL reconstruction is presented. This article describes several techniques of laxity assessments. Based on the type and degree of pathologic laxity, a treatment algorithm has been developed. LEVEL OF EVIDENCE: V.