A Comparative Analysis of Quadriceps Tendon, Patellar Tendon Bone Allograft, and Cadaver Graft in Anterior Cruciate Ligament (ACL) Repair and Reconstructive Surgery.

Anterior cruciate ligament (ACL) injuries are a common occurrence among athletes and active individuals, often necessitating surgical intervention for optimal recovery. The choice of graft material for ACL reconstruction remains a topic of debate, with various options available, including quadriceps tendon (QT), patellar tendon bone allograft (PTBA), and cadaver graft (CG). This paper aims to provide an extensive review and comparison of the efficacy, outcomes, and complications associated with these graft types based on recent research. A systematic literature search following PRISMA guidelines was conducted to identify relevant studies published in the past six years. The findings suggest that while each graft type has its advantages and limitations, there is no definitive superior choice. Factors such as patient age, activity level, comorbidities, and surgeon preference should be considered when selecting the most appropriate graft for ACL repair surgery. QT grafts are associated with lower donor-site morbidity compared to patellar tendon grafts. However, QT grafts may have a higher risk of graft rupture and decreased knee flexion strength. PTBA grafts, compared to QT grafts, have a higher risk of donor-site morbidity but a lower risk of graft rupture and improved knee stability. CG grafts have lower donor-site morbidity compared to PTBA grafts but may have a higher risk of graft rupture and decreased knee flexion strength compared to PTBA grafts. In conclusion, the choice of graft material for ACL reconstruction is a complex decision that requires careful consideration of various factors, including patient age, activity level, comorbidities, and surgeon preference. While each graft type has its advantages and limitations, there is no definitive superior choice. Therefore, it is essential to carefully weigh the risks and benefits of each graft type to ensure optimal outcomes for patients undergoing ACL repair surgery.

Clinical Outcomes in Patients Undergoing Anterior Cruciate Ligament Reconstruction With Controlled Accelerated Rehabilitation.

Background An anterior cruciate ligament (ACL) tear is one of the most common sports injuries in the knee region. Currently, anatomical ACL reconstruction with quadrupled hamstring tendon autograft and controlled accelerated rehabilitation is a frequently used treatment approach. This study aims to add to the literature the early and mid-term clinical results of the controlled accelerated rehabilitation program we implemented in our clinic to enable patients to return to their daily activities faster after ACL reconstruction. Methodology In this retrospective study, 51 patients (50 males, 1 female) diagnosed with ACL tear and undergoing ACL reconstruction with quadrupled hamstring tendon graft were included in our study. In the femoral fixation of the graft, the transfix method was used in 22 patients and the Endobutton-CL method was used in 29 patients. A controlled accelerated rehabilitation program developed by Shelbourne was employed with some modifications to the patients. Clinical evaluation of patients was performed using Lysholm, Cincinnati, Tegner, and International Knee Documentation Committee (IKDC) scoring systems. Results The mean postoperative follow-up period was 18.7 months (range = 6-36 months). During the physical examination, Lachman, anterior drawer, and pivot shift, 49 (96%) patients achieved excellent or good results, while only two (5%) patients experienced fair clinical outcomes. On clinical assessment using the Lysholm and IKDC scoring systems, 50 (98%) patients demonstrated excellent or good results, whereas only one (2%) patient showed fair results. Excellent and good outcomes were observed in all patients using the Cincinnati scoring system. We found a significant decrease in Tegner activity score pre-surgery, which significantly increased post-surgery. Conclusions The combination of Endobutton and cross-pin for femoral fixation and staples and interference screw for tibial fixation is thought to be safe in patients undergoing controlled accelerated rehabilitation after ACL reconstruction. The implementation of controlled accelerated rehabilitation enables patients to return to their social lives earlier without resulting in clinically poor outcomes in grafts and implants applied in the early and middle stages.

Return to Sport, Re-injury and Performance After the Anterior Cruciate Ligament Reconstruction: Evaluating the Role of International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) Scoring Systems.

Introduction Anterior cruciate ligament (ACL) tears are common injuries that can considerably impact an individual's quality of life and athletic performance. In these cases, surgical reconstruction of the ligament can be considered to restore stability to the knee. This study aims to investigate the time taken for individuals to return to sport post-ACL reconstruction, assess the rate of re-injury and evaluate the reliability of the International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) scoring systems in predicting a return to sport at the pre-injury level. Methods In this retrospective study, a total of 104 patients who underwent ACL reconstruction between January 2016 and December 2022 by one surgical team at Mater Dei Hospital, Malta were evaluated using a self-administered questionnaire. The questionnaire was based on different components including the sport practised at the time of injury, sport engagement classification, return to sport, the ability to return to pre-injury levels of performance and re-injury. The participants then had to fill in IKDC and KOOS evaluation forms. Results In this study, 73% (n=76) of individuals successfully returned to sport after ACL reconstruction, with no significant difference being found between professional and recreational athletes (Chi-squared=0.00455, p=0.95). After reconstruction, 31.7% (n=33) of participants experienced an ipsilateral or contralateral ACL tear, with those returning to sport within six months showing a fivefold increase in re-injury risk compared to individuals who returned at eight or 12 months, suggesting a significant association between return duration and re-injury. The relationship between scoring systems and return to sport at the pre-injury level of performance was analysed using binary logistic regression, revealing that achieving scores of 85.6 or higher in IKDC or 89 or higher in KOOS meant having a 95% probability of returning to sport at the pre-injury level. Conclusions By considering these scoring systems with other post-operative criteria, clinicians can offer a more customised rehabilitation plan tailored to each patient who undergoes ACL reconstruction.

Functional Outcomes in Anterior Cruciate Ligament (ACL) Reconstruction: A Nine-Month Follow-up Study Using Lysholm Score in a Rural Tertiary Care Center in India.

Introduction The knee joint, an extraordinary feat of biomechanics, is prone to injuries, with the anterior cruciate ligament (ACL) often being a common victim. The intricate coordination of joint movements relies heavily on the ACL's screw-home mechanism, a crucial element for synchronizing knee movement with neighboring joints. Despite its indispensable role, the ACL is susceptible to injury, necessitating surgical intervention. While many patients experience positive outcomes following ACL reconstruction surgeries, a significant proportion face the challenge of procedure failure. The key to success lies in the healing process within the tibial and femoral bone tunnels. The post-ACL reconstruction phase introduces its own set of challenges, particularly in the context of returning to sports (RTS), underscoring the importance of reinstating neuromuscular and motor function. The trajectory of rehabilitation is influenced by factors such as graft healing, patient age, gender, pain levels, and concurrent injuries. Materials and methods This prospective observational study spanned 2.5 years, enrolling 71 patients with diagnosed ACL injuries. Arthroscopic reconstruction utilized hamstring autografts and peroneus longus autografts. A nine-month post-surgery follow-up employed the Lysholm scoring system for comprehensive evaluations. Results Over 2.5 years, 87.3% of male and 12.6% of female participants underwent arthroscopic reconstruction. Lysholm scores revealed 28.1% excellent, 45.0% good, and 26.7% fair outcomes, with no participants in the unsatisfactory range. Lysholm scores demonstrated positive outcomes, indicating the efficacy of arthroscopic reconstruction in enhancing knee function. Findings align with existing literature, emphasizing positive results from ACL reconstruction techniques and specific implants. Comparisons with related studies highlight challenges in standardized return-to-sport guidelines and underscore the need for outcome measure standardization. Conclusion The study contributes nuanced insights into ACL reconstruction outcomes, emphasizing positive functional recovery trends at the nine-month follow-up. Lysholm scores indicate favorable outcomes, supporting the procedure's effectiveness. Consideration of specific implants adds practical value. Despite limitations, this study enriches ACL reconstruction research, promoting advancements in patient care and outcomes. Ongoing research with extended follow-ups and larger cohorts will enhance understanding and refine ACL reconstruction strategies.

High flexion femoral side remnant preservation positioning technique: a new method for positioning the femoral tunnel in anterior cruciate ligament reconstruction.

PURPOSE: The aim of this study is to find a new method for femoral side preservation positioning in anterior cruciate ligament (ACL) reconstruction and test the accuracy and precision of this method. METHOD: Fifty patients with isolated ACL rupture (42 males and 8 females) who underwent single-bundle ACL reconstruction in our hospital between July 2022 and July 2023 were included. The lowest point of the cartilage margin of the lateral wall of the intercontinental fossa and the tibial plateau plumb line at 120° of knee flexion were used as the anatomical landmarks for positioning of the femoral tunnel for ACL reconstruction surgery. Femoral side remnant preservation was performed in all cases. Three-dimensional CT was performed 3 days postoperatively to collect the data, which were analyzed using Mimics 21.0 software. We measured the posterior cortical distance of the femoral condyle at 90° of knee flexion and the vertical distance from the center of the bone tunnel to the cortical extension line behind the femur. All femoral tunnel positions were marked on a 4 × 4 grid and visualized using the quadrant method. RESULTS: Using the new positioning method in 50 knees, the average distance of x was 25.26 ± 2.76% of t and the average distance of y was 23.69 ± 6.19% of h. This is close to the results of previous studies, where x was 24.2 ± 4.0% of t and the average distance of y was 21.6 ± 5.2% of h. Most femoral tunnel positions were located in the same area. The D values were distributed as follows: 60% in the range of 0 to 2 mm, 24% in the range of 2 to 4 mm, and 16% more than 4 mm. The E values were distributed as follows: 80% in the range of 0 to 4 mm and 20% more than 4 mm. CONCLUSION: In arthroscopic ACL reconstruction, the knee was flexed at 120° and the lowest point of the cartilage edge of the lateral wall of the intercondylar fossa and the tibial plateau plumb line were used as anatomical landmarks for the positioning of the femoral bone tunnel, which resulted in more accurate femoral bone tunnel positioning, better reproducibility, and better preservation of the femoral stump compared to traditional positioning methods.

Incidence of Convergence Between Distally and Anteriorly Oriented ALL Femoral Tunnels and ACL Femoral Tunnels in Combined ACL and ALL Reconstruction: 3-Dimensional Computed Tomography Analysis of 227 Patients.

BACKGROUND: Adjusting the direction of the anterolateral ligament (ALL) femoral tunnel is suggested to avoid tunnel convergence during anterior cruciate ligament (ACL) reconstruction. Yet, there has been no in vivo clinical study reporting the effect of changing the direction of the ALL tunnel on the incidence of convergence with the ACL tunnel. PURPOSE: To report the incidence of convergence between the ACL femoral tunnel and a distally and anteriorly directed ALL femoral tunnel and to determine a safe distal angle and anterior angle. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 227 patients undergoing concomitant ALL and anatomic single-bundle ACL reconstruction between January 2020 and December 2022 were retrospectively reviewed. The tunnel convergence rate, angular orientation of the tunnels, and distance between tunnels were obtained using postoperative computed tomography. The patients were grouped based on the direction of the ALL tunnel (transverse vs distal anterior) and the presence of tunnel convergence (convergence vs no convergence). RESULTS: The overall tunnel convergence rate was 53.3% (121/227 patients). Tunnel convergence was observed less frequently in the distal anterior group (33.7%) than in the transverse group (65.2%) (P < .001). The no convergence group showed an ALL tunnel oriented more distally (20.2°± 11.1°) and anteriorly (19.5°± 10.2°) compared with the convergence group (8.7°± 6.5° and 6.9°± 5.3°, respectively) (P = .005 and P = .008, respectively). There were no cases of tunnel convergence for ALL tunnels >24.3° distally and >25.5° anteriorly. There was no difference in the angle of the ACL femoral tunnel between all groups. CONCLUSION: A distally and anteriorly directed ALL femoral tunnel reduced the incidence of convergence with the ACL femoral tunnel. A distal angle >24.3° and an anterior angle >25.5° of an ALL tunnel are suggested to safely avoid convergence with the ACL tunnel.

A lateral extra-articular tenodesis without additional hardware: Surgical technique and biomechanical comparison with an anatomic anterolateral ligament reconstruction in the augmentation of anterior cruciate ligament reconstruction.

BACKGROUND: The aims of this study were to describe a lateral extra-articular tenodesis (LET) using no additional hardware and compare the tibiofemoral kinematics of anterior cruciate ligament (ACL) reconstruction augmented with either the LET or a standard anatomic anterolateral ligament (ALL) reconstruction using intra-tunnel fixation. METHODS: Ten cadaveric knees were mounted on a robotic testing system and underwent a kinematic assessment of anterior tibial translation and internal tibial rotation under a simulated pivot-shift in the following states: ACL-intact, ACL-sectioned, ACL-sectioned/anterolateral complex (ALC)-sectioned, ACL-reconstructed/ALC-sectioned, ACL-reconstructed/ALL-reconstructed, and ACL-reconstructed/LET. For the LET, an iliotibial autograft was passed under the fibular collateral ligament and secured to the femur with the pull sutures of the ACL reconstruction femoral cortical suspensory fixation device, positioned at the distal ridge of Kaplan's fibers. RESULTS: Anterior tibial translation was restored to normal by ACL reconstruction without meaningful benefit of augmentation with LET or ALL. ACL reconstruction restored internal tibial rotation close to normal between 0° and 30°, but increased internal tibial rotation persisted between 45° and 90°. Augmentation of ACL reconstruction with the LET reduced internal rotation close to normal between 45° and 90°, whereas increased internal rotation persisted after ALL reconstruction. CONCLUSION: ACL reconstruction and LET are complementary in controlling tibiofemoral kinematics of knees with a combined ACL and ALC injury: ACL reconstruction restored native tibiofemoral kinematics except for internal rotation at flexion greater than 30°. The increased internal rotation at flexion greater than 30° was restored to normal with an LET, but not with an ALL reconstruction.

Association Between Posterior Tibial Slope and Clinical Outcomes After Isolated Anterior Cruciate Ligament Reconstructions.

Background Increased posterior tibial slope (PTS) is an important risk factor for non-traumatic graft failure and revision surgery after anterior cruciate ligament reconstruction. If a tibial posterior slope is an important factor for graft failure after anterior cruciate ligament reconstruction, does it affect clinical outcomes? This study aimed to evaluate the association between PTS and clinical outcomes after anterior cruciate ligament reconstruction. Material and methods Patients undergoing arthroscopic anterior cruciate ligament reconstruction with hamstring tendons in the clinic were evaluated retrospectively. Inclusion criteria were: patients with at least an 18-month follow-up period who were evaluated with the Tegner Lysholm scoring system, aged between 18 and 40 years, with only an anterior cruciate ligament rupture. PTSs were measured from the lateral radiographs of the knees. The patients were divided into two groups with a PTS of 10° or less. Results The mean Tegner Lysholm score was 86.8 ± 8.9. The mean PTS was 9.7° ± 1.5°. In total, 14 and 15 patients had a PTS of above 10° and below 10°, respectively. The mean age and follow-up time of patients were 28.5 ± 5.3 years and 24.6 ± 7.2 months in the group with a PTS of above 10° and 30.2 ± 5.3 years and 24.2 ± 5.18 months in the group with a PTS of below 10°, respectively. Tegner Lysholm scores were 88.2 ± 8.8 and 85.6 ± 9.1 in the group with values above 10° and below 10°, respectively. Statistically, there was no significant difference between the clinical outcomes of both groups. Conclusion PTS does not affect the clinical outcomes of patients who underwent arthroscopic anterior cruciate ligament reconstruction in the early period.

Online Patient Education Resources for Anterior Cruciate Ligament Reconstruction: An Assessment of the Accuracy and Reliability of Information on the Internet Over the Past Decade.

PURPOSE: The purpose of this study is to evaluate the quality of patient education materials accessible through popular online search engines regarding anterior cruciate ligament (ACL) injuries and anterior cruciate ligament reconstruction (ACLR).  Methods: Two search terms ("ACL surgery" and "ACL reconstruction") were entered into three search engines (Google, Yahoo, and Bing). The quality of information was scored using a novel scoring system developed and overseen by sports medicine orthopedic clinical research fellows and fellowship-trained orthopedic surgeons. Website quality, credibility, and readability were further assessed by the DISCERN score, Journal of the American Medical Association (JAMA) benchmark criteria, and Flesch-Kincaid Reading Grade Level (FKRGL), respectively. The Health On the Net Code of Conduct (HONcode) certification was also utilized to assess the transparency of health information for each website. RESULTS: We evaluated 39 websites. The average score for all websites was 11.2±5.6 out of 28 total points. Six out of the 39 websites (41%) were HONcode certified. The websites that contained HONcode certification had a higher average JAMA benchmark score (3.5±0.7) and DISCERN score (44.6±14.7) when compared to the websites without the certification, 2.2±1.2 and 37.6 ± 15.9 for JAMA and DISCERN, respectively. The mean JAMA benchmark score was 2.7±1.2 (67.5%) for all websites out of a possible four points. The average FKRGL for all 39 websites was 10.0±2.0 (range: 5.4-13). CONCLUSION: The quality of patient education materials accessible on the internet regarding ACL injuries and ACLR can be misleading and directly impact the patient's decision-making process essential to the patient-physician relationship over the past decade. CLINICAL RELEVANCE: The internet can be a helpful online resource, however, surgeon clarification and consultation with qualified healthcare professionals are strongly recommended prior to clinical decision-making regarding potential treatment options.

The Development and Biomechanical Analysis of an Allograft Interference Screw for Anterior Cruciate Ligament Reconstruction.

Graft fixation during cruciate ligament reconstruction using interference screws is a common and frequently used surgical technique. These interference screws are usually made of metal or bioabsorbable materials. This paper describes the development of an allograft interference screw from cortical human bone. During the design of the screw, particular attention was paid to the choice of the screw drive and the screw shape, as well as the thread shape. Based on these parameters, a prototype was designed and manufactured. Subsequently, the first biomechanical tests using a bovine model were performed. The test procedure comprised a torsion test to determine the ultimate failure torque of the screw and the insertion torque during graft fixation, as well as a pull-out test to asses the ultimate failure load of the graft fixation. The results of the biomechanical analysis showed that the mean value of the ultimate failure torque was 2633 Nmm, whereas the mean occurring insertion torque during graft fixation was only 1125 Nmm. The mean ultimate failure load of the graft fixation was approximately 235 N. The results of this work show a good overall performance of the allograft screw compared to conventional screws, and should serve as a starting point for further detailed investigations and studies.

The First Case of Bridge-Enhanced Anterior Cruciate Ligament (ACL) Repair (BEAR) Procedure in Mississippi.

In the past, surgical treatment of anterior cruciate ligament (ACL) tears has mainly involved reconstruction using allografts and autografts. The relatively new FDA-approved bridge-enhanced ACL repair (BEAR) procedure allows the body to use its innate healing properties to help repair the ACL using an absorbable protein-based implant. The procedure is currently being offered by surgeons in 44 states. This case describes the first BEAR procedure performed in the state of Mississippi. A 47-year-old female of normal BMI presented to the orthopedic clinic with a chief complaint of right knee pain. The patient stated that she felt unstable on the injured knee, and the patient had positive anterior drawer and Lachman's tests on physical examination. MRI of the knee one month after injury revealed full-thickness ACL rupture. The patient underwent arthroscopic bridge-enhanced ACL repair in the right knee 43 days after the initial injury. The patient reported positive progress in her healing process at her three-month follow-up, and MRI at the three-month follow-up showed successful repair of the patient's ACL. At six months post-operatively, the patient reported that she is still doing well, and she feels that the stability of her right knee has improved. This case highlights an early trend towards repairs instead of reconstructions in ACL injuries for candidates that meet the following requirements: within 50 days of injury and have an intact tibial stump as recommended by the implant manufacturers.

Anterior Cruciate Ligament Arthroscopic Ligamentoplasty Using the Four-Strand Hamstring Technique.

In this study, we looked at the clinical outcomes of individuals who had a symptomatic torn anterior cruciate ligament and had their anterior cruciate ligament repaired using a four-strand hamstring (4SHS) tendon autograft at least two years later. This is a retrospective study of 34 cases of anterior cruciate ligament arthroscopic reconstruction using the four-strand hamstring graft, collected from Traumatology and Orthopedics at Cheikh Khalifa Hospital in Casablanca, Morocco between January 2017 and January 2021. Different surgeons performed the operations. Physical findings and functional scores were recorded before the follow-up physical examination and surgery; thus, knee radiographs have been evaluated. A six-month rehabilitation program was devised following surgery. The average age of the patients was 30 years, with a male predominance of 94%. Thirty patients (88%) reported negative pivot shift tests and the Lachman test. The average Lysholm score enhanced from 59.3 before surgery to 85.29 at the time of the assessment. Three patients (8.82%) with a positive pivot shift test had no background of extra knee damage. In comparison to the appearance on the preoperative radiographs, no proof of progressive degenerative deterioration was found on the follow-up radiographs. All of the patients, however, had tunnel extension. The tibial tunnel grew on average by 18%, while the femoral tunnel grew on average by 30%. In 88% of patients assessed at least two years after surgery, ligamentoplasty of the anterior cruciate ligament using the four-strand hamstring graft eradicated anterior tibial subluxation. The failure rate was overall 10%. The functional knee scores had greatly improved at the time of the follow-up.

Return to Sport After Anterior Cruciate Ligament Reconstruction Among Physically Active Adults.

An anterior cruciate ligament (ACL) is one of athletes' most severe and frequent knee ligament injuries. The primary function of the ACL is preventing excessive anterior tibial translation, and it limits varus/valgus stress when the knee is in full extension and rotatory movements. Returning to sport after an ACL injury is a crucial aim of ACL reconstruction (ACLR). Multiple factors, modifiable and nonmodifiable, can influence the time to return to sport. This study aimed to discuss factors that affect optimal return-to-play (RTP) timing, symptom recurrence, and long-term consequences of an ACL injury. This is a cross-sectional study involving patients who are following in orthopedic surgery outpatient clinics with a history of ACLR at least six months before surgery and not beyond six years after surgery. Participants received a survey about their sociodemographic data, details of the type and site of injury, and ACL return to sport before and after reconstruction scale. Full data description and testing of dependent variables against participant variables using two-sided tests were performed with a significance level of P ≤ 0.05. The study involved 129 participants, of which the majority were male Bisha residents aged 20 to 29 years. The study found that the right leg was the most commonly injured, with the dominant leg being the most frequently reconstructed due to problems with knee function. Before the injury, most participants ran, cut (quick changes of direction during running), decelerated, and pivoted activities four or more times per month. However, physical activities notably reduced after ACLR. Age and body mass index (BMI) showed statistical significance related to the likelihood of returning to physical activities.  The study found a significant reduction in the frequency of activities such as cutting, deceleration, and running after ACLR. Age was identified as a predictor affecting the likelihood of returning to the sport, with older patients being less likely to return than younger ones.

Dynamics analysis of the anterior cruciate ligament reconstruction surgery based on magnetic resonance imaging.

In clinical practice, anterior cruciate ligament (ACL) rupture is always repaired by the single-beam reconstruction method. Before the surgery, the surgeon made the diagnosis based on medical images, such as CT (computerized tomography) and MR (magnetic resonance) images. However, little is known about how biomechanics governs the biological nature for femoral tunnel position. In the present study, three volunteers' motion trails were captured by six cameras when they were doing squat movement. The medical image can reconstruct the structure of the ligaments and bones and a left knee model was reconstructed by MIMICS by MRI data of DICOM format. Finally, the effects of different femoral tunnel positions on ACL biomechanics were characterized by the inverse dynamic analysis method. The results showed that there were significant differences in the direct mechanical effects of the anterior cruciate ligament at different locations of the femoral tunnel (p < 0.05), the peak stress of ACL in the low tension area was 1097.24 ± 25.55 N, and the peak stress of ACL in the distal femur was 356.81 ± 15.39 N, both of which were much higher than that in the direct fiber area (118.78 ± 20.68 N).

Impact of Occupation on 12-Month Outcomes After Anterior Cruciate Ligament Reconstruction in Male Patients.

Background: The impact of a physically demanding occupation on clinical outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR) is largely unknown. Purpose/Hypothesis: The purpose of this study was to assess the influence of occupation on 12-month outcomes after ACLR in male patients. It was hypothesized that patients undertaking manual work would not only have better functional outcomes in terms of strength and range of motion but also higher rates of joint effusion and greater anterior knee laxity. Study Design: Cohort study; Level of evidence, 3. Methods: From an initial cohort of 1829 patients, we identified 372 eligible patients aged 18 to 30 years who underwent primary ACLR between 2014 and 2017. Based on a preoperative self-assessment, 2 groups were established: patients engaged in heavy manual occupations and those engaged in low-impact occupations. Data were collected from a prospective database including effusion, knee range of motion (using side-to-side difference), anterior knee laxity, limb symmetry index for single hop and triple hop, International Knee Documentation Committee (IKDC) subjective score, and complications up to 12 months. Because of the significantly lower rate of female patients undertaking heavy manual occupations compared to low-impact occupations (12.5% and 40.0%, respectively), data analysis was focused on male patients. Outcome variables were assessed for normality, and statistical comparisons were made between the heavy manual and low-impact groups using either an independent-samples t test or the Mann-Whitney U test. Results: Of 230 male patients, 98 were included in the heavy manual occupation group, and 132 were included in the low-impact occupation group. Patients in the heavy manual occupation group were significantly younger than those in the low-impact occupation group (mean age, 24.1 vs 25.9 years, respectively; P < .005). There was a greater range of active and passive knee flexion in the heavy manual occupation group than in the low-impact occupation group (mean active, 3.38° vs 5.33°, respectively [P = .021]; mean passive, 2.76° vs 5.00°, respectively [P = .005]). There was no difference in effusion, anterior knee laxity, limb symmetry index, IKDC score, return-to-sport rate, or graft rupture rate at 12 months. Conclusion: At 12 months after primary ACLR, male patients engaged in heavy manual occupations had a greater range of knee flexion, with no difference in the effusion rate or anterior knee laxity, compared with those engaged in low-impact occupations.

Anterior cruciate ligament remnant preservation attenuates apoptosis and enhances the regeneration of hamstring tendon graft.

AIMS: The effects of remnant preservation on the anterior cruciate ligament (ACL) and its relationship with the tendon graft remain unclear. We hypothesized that the co-culture of remnant cells and bone marrow stromal cells (BMSCs) decreases apoptosis and enhances the activity of the hamstring tendons and tenocytes, thus aiding ACL reconstruction. METHODS: The ACL remnant, bone marrow, and hamstring tendons were surgically harvested from rabbits. The apoptosis rate, cell proliferation, and expression of types I and III collagen, transforming growth factor-ß (TGF-ß), vascular endothelial growth factor (VEGF), and tenogenic genes (scleraxis (SCX), tenascin C (TNC), and tenomodulin (TNMD)) of the hamstring tendons were compared between the co-culture medium (ACL remnant cells (ACLRCs) and BMSCs co-culture) and control medium (BMSCs-only culture). We also evaluated the apoptosis, cell proliferation, migration, and gene expression of hamstring tenocytes with exposure to co-culture and control media. RESULTS: Compared to BMSCs-only culture medium, the co-culture medium showed substantially decreased early and late apoptosis rates, attenuation of intrinsic and extrinsic apoptotic pathways, and enhanced proliferation of the hamstring tendons and tenocytes. In addition, the expression of collagen synthesis, TGF-ß, VEGF, and tenogenic genes in the hamstring tendons and tenocytes significantly increased in the co-culture medium compared to that in the control medium. CONCLUSION: In the presence of ACLRCs and BMSCs, the hamstring tendons and tenocytes significantly attenuated apoptosis and enhanced the expression of collagen synthesis, TGF-ß, VEGF, and tenogenic genes. This in vitro study suggests that the ACLRCs mixed with BMSCs could aid regeneration of the hamstring tendon graft during ACL reconstruction.Cite this article: Bone Joint Res 2023;12(1):9-21.

A comparison of preoperative scores prior to anterior cruciate ligament reconstruction with optimal preinjury scores and final scores at two-year follow up.

AIMS: The aim of this study was to compare the preinjury functional scores with the postinjury preoperative score and postoperative outcome scores following anterior cruciate ligament (ACL) reconstruction surgery (ACLR). METHODS: We performed a prospective study on patients who underwent primary ACLR by a single surgeon at a single centre between October 2010 and January 2018. Preoperative preinjury scores were collected at time of first assessment after the index injury. Preoperative (pre- and post-injury), one-year, and two-year postoperative functional outcomes were assessed by using the Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm Knee Score, and Tegner Activity Scale. RESULTS: We enrolled 308 males and 263 females of mean age 27 years (19 to 46). The mean preinjury and preoperative post-injury Lysholm Knee Scores were 94 (73 to 100) and 63 (25 to 85), respectively, while the respective mean scores at one and two years postoperatively were 84 (71 to 100) and 89 (71 to 100; p < 0.001). The mean Tegner preinjury and preoperative post-injury scores were 7 (3 to 9) and 3 (0 to 6), respectively, while the respective mean scores at one and two years postoperatively were 6 (1 to 8) and 6 (1 to 9) (p < 0.001). The mean KOOS scores at preinjury versus two years postoperatively were: symptoms (96 vs 84); pain (94 vs 87); activities of daily living (97 vs 91), sports and recreation function (84 vs 71), and quality of life (82 vs 69), respectively (p < 0.001). CONCLUSION: Functional scores improved following ACLR surgery at two years in comparison to preoperative post-injury scores. However, at two-year follow-up, the majority of patients failed to achieve their preinjury scores. The evaluation of ACLR outcomes needs to consider the preinjury scores rather than the immediate preoperative score that is usually collected.Cite this article: Bone Jt Open 2023;4(1):46-52.

High initial graft tension is a post-operative risk factor for high UTE T2* value of the graft 6 months after anterior cruciate ligament reconstruction.

BACKGROUND: To evaluate the risk factor of "ligamentization" using the ultrashort echo time (UTE)-T2* imaging. METHODS: Fifty-nine patients (23 males and 36 females, age of 21.9 ± 10.6 years old) who underwent anterior cruciate ligament (ACL) reconstruction with hamstring tendon were evaluated. The UTE T2* values of the reconstructed ACL at 6 months postoperatively were calculated. Circular regions of interest (5-10 mm2) were set at the proximal, mid-substance, and distal regions of the reconstructed ACL. The UTE T2* values of the entire reconstructed ACL were calculated as the average of these three points. Patients were divided into high (27 knees) and low (32 knees) UTE T2* groups by calculating whether their UTE T2* values were greater than the median of the UTE T2* values of all patients. Risk factors for high UTE T2* values were evaluated. Clinical outcomes were compared between the two groups. RESULTS: There were no significant differences in any measured parameters and clinical outcomes between the two UTE T2* groups. Logistic regression analysis revealed that graft tension was a significant risk factor for patients with high UTE-T2* values (P = 0.047, odds ratio [OR] = 2.285). The UTE-T2* values of the 20 N graft tension using the Tension loc system were significantly lower than those of the 40 N using double-spike plate (DSP) with screws at each site and the 30 N using the Tension loc system at the distal site. CONCLUSIONS: Higher graft tension was an independent risk factor for high UTE T2* values of the reconstructed ACL.

Double-bundle ACL reconstruction versus anatomic single-bundle ACL reconstruction combined with anterolateral ligament reconstruction: a comparative study of clinical outcome.

INTRODUCTION: Recent studies showed increasing evidences of anterolateral ligament (ALL) reconstruction in conjunction with anterior cruciate ligament (ACL) reconstruction that proves to be more superior to the previous double-bundle (DB) ACLR technique especially in improving knee stability in biomechanic studies. However to date, there have been no studies evaluating the functional outcome of DB-ACLR vs single-bundle (SB) with ALL in ACLR. METHODS: A total of 138 patients with ACL deficient knee were enrolled to the study. Double-bundle ACL reconstruction (DB-ACLR) was performed in 75 patients and single-bundle ACL reconstruction with anterolateral ligament reconstruction (SB + ALL) ACLR was performed in 63 patients. Surgical outcomes were compared with The International Knee Documentation Committee Subjective Knee Form (IKDC) and the Kujala score at the 3rd, 6th and 9th month post-operative. RESULTS: The IKDC score in the 3rd and 6th month was superior in the SB + ALL group compared to the DB group. However, this difference was not statistically significant. In the meantime, there were no statistically significant difference between the Kujala Score at the 3rd, 6th, and 9th months consecutively. There were no statistically significant differences in the functional outcomes of DB-ACLR and SB + ALL groups at the 3rd, 6th, and 9th months post-operative period. CONCLUSION: The functional outcome comparison showed non-superiority of SB + ALL group compared to the DB-ACLR group. The patellar pain was less found in DB-ACLR group at 6- and 9-months post-operative period.

Influence of Anaesthesia on Harvesting the Semitendinosus Tendon for Anterior Cruciate Ligament Replacement.

Aim The aim of the study was to investigate if the mode of anesthesia is a relevant factor influencing the length of the semitendinosus tendon harvested for anterior cruciate ligament (ACL) replacement.  Methods Patients undergoing ACL replacement were given the choice between spinal and general anesthesia. If general anesthesia was chosen, a short relaxation period was applied while harvesting the Semitendinosus (ST) tendon. The data for tendon length, the folding factor, and the diameter of the graft were collected. Except for redo procedures and ACL replacement with allograft all patients undergoing an ACL replacement were enrolled. Results Thirty-one patients with general anesthesia (GA) and 14 patients with spinal anesthesia (SA) were examined. The ST tendon length was 29.03 cm ± 2.6 cm in the GA group and 25.4 cm ± 2.70 in the SA group (t value 4.245, p=0.0001). The ST tendon could be quadrupled in 23 patients in the GA and 6 patients in the SA group (χ2=4.13, p=0.04). The graft diameter obtained was 8.53 mm ± 0.62 mm in the GA group and 7.71 mm ± 0.47 mm in the SA group (t value 4.885, p<0.0001). Conclusion General anesthesia with short-time relaxation while harvesting the ST tendon for ACL grafting allows to harvest longer ST tendons and consequently yields better results regarding the graft dimensions and should be offered to patients as a first-choice procedure. There is no other paper published yet, analyzing this relationship and if validated on a larger cohort, this might change clinical practice.