Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus: part II-surgical strategy.

PURPOSE: The aim of this ESSKA consensus is to give recommendations based on scientific evidence and expert opinion to improve the diagnosis, preoperative planning, indication and surgical strategy in Anterior Cruciate Ligament revision. METHODS: Part 2, presented herein, followed exactly the same methodology as Part 1: the so-called ESSKA formal consensus derived from the Delphi method. Eighteen questions were ultimately asked. The quality of the answers received the following grades of recommendation: Grade A (high level scientific support), Grade B (scientific presumption), Grade C (low level scientific support) or Grade D (expert opinion). All answers were scored from 1 to 9 by the raters. Once a general consensus had been reached between the steering and rating groups, the question-answer sets were submitted to the peer-review group. A final combined meeting of all the members of the consensus was then held to ratify the document. RESULTS: The review of the literature revealed a rather low scientific quality of studies examining the surgical strategy in cases of ACL reconstruction failure. Of the 18 questions, only 1 received a Grade A rating; 5, a Grade B rating; and 9, grades of C or D. The three remaining complex questions received further evaluations for each portion of the question and were looked at in more detail for the following grades: B and D; A, C and D; or A, B, C and D. The mean rating of all questions by the rating group was 8.0 + - 1.1. The questions and recommendations are listed in the article. CONCLUSION: ACL revision surgery, especially the surgical strategy, is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardization. Therefore, this international European consensus project is of great importance and clinical relevance for guiding the management of ACL revision in adults. LEVEL OF EVIDENCE: Level II.

Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus part I-diagnostics and preoperative planning.

PURPOSE: The aim of this ESSKA consensus is to give recommendations based on evidence and expert opinion to improve diagnosis, preoperative planning, indication and surgical strategy in ACL revision. METHODS: The European expert surgeons and scientists were divided into four groups to participate in this consensus. A "literature group" (four surgeons); "steering group" (14 surgeons and scientists); "rating group" (19 surgeons) and finally "peer review group" (51 representatives of the ESSKA-affiliated national societies from 27 countries). The steering group prepared eighteen question-answer sets. The quality of the answers received grades of recommendation ranging from A (high-level scientific support), to B (scientific presumption), C (low level scientific support) or D (expert opinion). These question-answer sets were then evaluated by the rating group. All answers were scored from 1 to 9. The comments of the rating group were incorporated by the steering group and the consensus was submitted to the rating group a second time. Once a general consensus was reached between the steering and rating groups, the question-answer sets were submitted to the peer review group. A final combined meeting of all the members of the consensus was held to ratify the document. RESULTS: The literature review for the diagnosis and preoperative planning of ACL revision revealed a rather low scientific quality. None of the 18 questions was graded A and six received a grade B. The mean rating of all the questions by the rating group was 8.4 ± 0.3. The questions and recommendations are listed below. CONCLUSION: ACL revision surgery is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardisation. Therefore, this international consensus project is of great importance. LEVEL OF EVIDENCE: II.

Comparative Outcomes Occur After Superficial Medial Collateral Ligament Augmented Repair vs Reconstruction: A Prospective Multicenter Randomized Controlled Equivalence Trial.

BACKGROUND: Although previous studies have reported good short-term results for superficial medial collateral ligament (sMCL) reconstruction, whether an augmented MCL repair is clinically equivalent remains unclear. PURPOSE/HYPOTHESIS: The purpose of this study was to compare clinical outcomes between randomized groups that underwent sMCL augmentation repair and sMCL autograft reconstruction. The hypothesis was that there would be no significant differences in objective or subjective outcomes between groups. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Patients were prospectively enrolled between 2013 and 2019 from 3 centers. Grade III sMCL injuries were confirmed via stress radiography. Patients were randomized to anatomic sMCL reconstruction versus augmented repair with surgical treatment, determined after examination under anesthesia confirmed sMCL incompetence. Postoperative visits occurred at 6 weeks and 6 months for repeat evaluation, with repeat stress radiography at final follow-up. Patient-reported outcome measures were obtained pre- and postoperatively at 6 months, 1 year, and final follow-up. The primary outcome measure was side-to-side difference on valgus stress radiographs at a minimum follow-up of 1 year. The two 1-sided t test procedure was used to test clinical equivalence for side-to-side difference in valgus gapping, and the Mann-Whitney U test was used to compare postoperative patient-reported outcome measures between groups. RESULTS: A total of 54 patients were prospectively enrolled into this study. Of these, 50 patients had 6-month stress radiograph data, while 40 had 1-year postoperative valgus stress radiograph data. The mean (SD) patient age was 38.0 years (14.2), and body mass index was 25.0 (3.6). Preoperative valgus stress radiographs demonstrated 3.74 mm (1.1 mm) of increased side-to-side gapping overall, while it was 4.10 mm (1.46 mm) in the MCL augmentation group and 3.42 mm (0.55 mm) in the MCL reconstruction group. Postoperative valgus stress radiographs at an average of 6 months were obtained in 50 patients after surgery, which showed 0.21 mm (0.81 mm) for the MCL augmentation group and 0.19 mm (0.67 mm) for the MCL reconstruction group (P = .940). At final follow-up (minimum 1 year), median (interquartile range) Lysholm scores were significantly higher in the reconstruction group (90 [83-99]) as compared with the repair group (80 [67-92]) (P = .031). Final International Knee Documentation Committee (IKDC) scores were also significantly higher for the reconstruction group (85 [68-89]) versus the repair group (72 [60-78] (P = .039). Postoperative Tegner scores were not significantly different between the repair group (5 [3.5-6]) and the reconstruction group (5.5 [4-7]) (P = .123). Patient satisfaction was also not significantly different between repair (7.5 [5.75-9.25]) and reconstruction groups (9.0 [7-10]) (P = .184). CONCLUSION: This study found no difference in objective outcomes between an sMCL augmentation repair and a complete sMCL reconstruction at 1 year postoperatively, indicating equivalence between these procedures. Patient-reported clinical outcomes favored the reconstruction over a repair. In addition, this study demonstrated that anatomic-based treatment of MCL tears with an early knee motion program had a very low risk of graft attenuation and a low risk of arthrofibrosis.

Full thickness quadriceps tendon grafts with bone had similar material properties to bone-patellar tendon-bone and a four-strand semitendinosus grafts: a biomechanical study.

PURPOSE: Despite increasing interest in utilizing quadriceps tendon (QT) grafts in anterior cruciate ligament reconstruction (ACLR), data on the optimal quadriceps graft thickness are limited. The purpose of this study was to characterize the mechanical properties for the quadriceps tendon, comparing full-thickness (FT) QT grafts with and without bone to a partial-thickness (PT) QT graft, and comparing the three QT grafts to four-stranded semitendinosus (4-SST) and bone-patellar tendon-bone (BTB) grafts and one experimental graft, the two-stranded rectus femoris (RF). METHODS: Forty-eight (n = 48) young cadaveric grafts (mean age 32 ± 6 years) were utilized for testing with N = 8 specimens in each of the following groups; (1) FT QT with bone, (2) FT QT without bone, (3) PT QT without bone, (4) BTB, (5) RF, and (6) 4-SST. Each specimen was harvested and rigidly fixed in custom clamps to a dynamic tensile testing machine for biomechanical evaluation. Graft ultimate load and stiffness were recorded. Independent groups one-factor ANOVAs and Tukey's pairwise comparisons were performed for statistical analyses. RESULTS: FT QT with bone and 4-SST grafts demonstrated similar ultimate loads to BTB grafts (both n.s), whereas PT QT demonstrate statistically significantly lower ultimate loads to BTB grafts (n.s) and 4-SST grafts (n.s). Furthermore, no statistically significant differences were observed between the ultimate loads of FT QT vs. PT QT grafts without bone (n.s) or between FT QT with vs. without bone (n.s). FT QT grafts with bone did not demonstrate statistically significantly greater ultimate loads than PT QT grafts without bone (n.s). The RF graft demonstrated statistically significantly lower ultimate loads to BTB grafts (p < 0.005) and 4-SST grafts (p < 0.014). CONCLUSIONS: Full thickness QT grafts with bone had similar material properties to BTB and a 4-SST grafts, while Partial thickness QT graft without bone had significantly lower material properties than BTB and 4-SST, in a biomechanical setting.

Low surgical routine increases revision rates after quadriceps tendon autograft for anterior cruciate ligament reconstruction: results from the Danish Knee Ligament Reconstruction Registry.

PURPOSE: Recent registry data have demonstrated a higher revision rate of quadriceps tendon (QT) graft compared with hamstring tendon (HT) and patellar tendon (PT) grafts. Clinic routines could be an important factor for revision outcomes. The purpose of this study is to use the Danish Knee Ligament Reconstruction Registry (DKRR) to compare revision rates in patients who have undergone ACLR with QT, HT and PT grafts related to individual clinic surgical routine. METHODS: Data on primary ACLRs entered in the DKRR from 2012 through 2019 were analysed since QT graft usage started in 2012. Revision rates for QT, HT and PT grafts were compared according to clinic activity (0-100 and > 100 procedures). Revision rates for the three autograft cohorts are presented, as well as adjusted revision hazard rates. Instrumented knee stability and pivot-shift tests were performed at a one-year follow-up. RESULT: QT revision rate (6.4%) for low-activity clinics was higher than for high-activity clinics (2.9%) (p = 0.003). The adjusted revision hazard ratio for low-activity clinics was 2.3 (p = 0.01). QT autograft was associated with statistically significant, increased side-to-side laxity at follow-up (1.4 mm) compared with HT and PT autografts (1.0 mm) (p < 0.01), as well as an increased positive pivot-shift rate. CONCLUSION: QT autografts for ACLR were associated with higher revision rates in clinics with lower than 100 procedures performed from 2012 to 2019. QT graft usage is not associated with a high revision rate when routinely performed. Learning curve is an important factor when introducing QT ACLR. LEVEL OF EVIDENCE: Level III.

Quadriceps tendon autograft for anterior cruciate ligament reconstruction is associated with high revision rates: results from the Danish Knee Ligament Registry.

PURPOSE: The quadriceps tendon (QT) has recently gained interest as an anterior cruciate ligament reconstruction (ACLR) autograft. There is a paucity of data from large cohort studies on failures and revision rates after ACLR using the QT graft. The purpose of the present study is to use the Danish Knee Ligament Reconstruction Registry (DKRR) to compare revision rates, objective knee stability and subjective clinical outcomes in patients who have undergone ACLR with QT, hamstring tendon (HT), and patellar tendon (PT) as a graft for ACLR. It was hypothesized that QT autografts would result in similar objective knee stability and revision rates as HT and PT autografts. METHODS: Data on primary ACLRs in the DKRR from 2005 through 2017 were analyzed. Knee injury and Osteoarthritis Outcome Scores (KOOS), Tegner activity scale scores, sagittal knee laxity, pivot-shift tests at 1-year follow-up and revision rates at 2-year follow-up were compared for the three autograft cohorts. RESULTS: A total of 531 QT, 14,213 HT and 1835 PT ACLR were registered in the DKLR between 2005 and 2017. QT autograft was associated with statistically significant increased laxity (1.8 mm) compared to HT autograft (1.5 mm) (p < 0.001) and more positive pivot shift. There was a significant higher revision rate for QT (4.7%), compared to PT (1.5%) and HT (2.3%) autografts at 2-year follow-up (p < 0.002). CONCLUSION: Quadriceps tendon autografts for ACLR was associated with higher revision rates than HT and PT grafts. QT graft was also associated with small increased objective knee laxity and more positive pivot shift than HT and PT grafts. LEVEL OF EVIDENCE: III.

Different Suture Materials for Arthroscopic Transtibial Pull-out Repair of Medial Meniscal Posterior Root Tears: A Human Biomechanical Study.

BACKGROUND: Transtibial pull-out repair of the medial meniscal posterior root (MMPR) has been largely assessed through biomechanical studies. Biomechanically comparing different suture types would further optimize MMPR fixation and affect clinical care. PURPOSE/HYPOTHESIS: The purpose of this study was to determine the optimal suture material for MMPR fixation. It was hypothesized that ultra high-molecular weight polyethylene (UHMWPE) suture tape would be biomechanically superior to UHMWPE suture and standard suture. STUDY DESIGN: Controlled laboratory study. METHODS: The MMPR attachment was divided in 24 human cadaveric knees and randomly assigned to 3 repair groups: UHMWPE suture tape, UHMWPE suture, and standard suture. Specimens were dissected down to the medial meniscus, and the posterior root attachments were sectioned off the tibia. Two-tunnel transtibial pull-out repair with 2 sutures, as determined by the testing group, was performed. The repair constructs were cyclically loaded between 10 and 30 N at 0.5 Hz for 1000 cycles to mimic the forces experienced on the medial meniscus during postoperative rehabilitation. Displacement was recorded at 1, 50, 100, 500, and 1000 cycles. Ultimate failure load, displacement at failure, and load at 3 mm of displacement (clinical failure) were also recorded. RESULTS: UHMWPE suture tape had significantly less displacement of the medial meniscus when compared with standard suture at 1 (-0.22 mm [95% CI, -0.41 to -0.02]; P = .025) and 50 (-0.35 mm [95% CI, -0.67 to -0.03]; P = .029) cycles. There were no other significant differences observed in displacement between groups at any number of cycles. UHMWPE suture tape had significantly less displacement at the time of failure than standard suture (-3.71 mm [95% CI, -7.17 to -0.24]; P = .034). UHMWPE suture tape had a significantly higher load to reach the clinical failure displacement of 3 mm than UHMWPE suture (15.64 N [95% CI, 0.02 to 31.26]; P = .05). There were no significant differences in ultimate failure load between groups. CONCLUSION: The meniscal root repair construct with UHMWPE suture tape may be stronger and less prone to displacement than that with standard suture or UHMWPE suture. CLINICAL RELEVANCE: UHMWPE suture tape may provide better clinical results compared with UHMWPE suture and standard suture.