Bone-patellar tendon-bone autograft is associated with a higher rate of return to preinjury levels of performance in high-level athletes than anterior cruciate ligament reconstruction using hamstring autograft.

PURPOSE: Return to preinjury levels of performance (RTP) is the main goal after anterior cruciate ligament reconstruction (ACL-R) for athletes when ACL graft rupture is a career-threatening event. The purpose of this study was to elucidate the associated factors for RTP and subsequent ACL injury after ACL-R using bone-patellar tendon-bone (BPTB) or hamstring (HT) autograft in high-level athletes with a minimum postoperative follow-up of 24 months. METHODS: This retrospective study included 157 patients who had preinjury Tegner activity level of 9 and underwent primary ACL-R using BPTB (average age, 16.9 years; 35 males and 36 females) or HT (average age, 17.2 years; 49 males and 37 females). The mean follow-ups were 33.6 months in BPTB and 44.5 months in HT, respectively. The data were obtained based on routine clinical follow-ups and telephone interviews performed by the surgeon. Multivariate logistic regression analysis was conducted to determine the association of patient variables with RTP and subsequent ACL injury. RESULTS: Ninety-nine patients (63.1%) were able to RTP. The rate of RTP in BPTB (74.6%) was significantly higher than that of HT (53.5%) (p < 0.05). The overall average timing of RTP after ACL-R was 10.0 months while that was significantly earlier in BPTB (9.7 months) than in HT (10.5 months) (p < 0.05). Twenty-three (14.6%) and 21 patients (13.4%) had ACL graft ruptures and ACL injuries in the contralateral knees, respectively. Multivariate analyses showed that BPTB (odds ratio [OR], 2.590; 95% confidence interval [CI], 1.300-5.160; p = 0.007) was associated with a higher potential for RTP after ACL-R. The incidence of ACL graft rupture after ACL-R decreased with BPTB (OR, 0.861; 95% CI, 0.770-0.962; p = 0.009). CONCLUSIONS: The use of BPTB autograft was associated with a higher rate of RTP and a lower incidence of ACL graft rupture compared to ACL-R using HT autograft. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Regional healing trajectory of the patellar tendon after bone-patellar tendon-bone autograft harvest for anterior cruciate ligament reconstruction.

Graft site morbidities after bone-patellar tendon-bone (BPTB) autograft harvest for anterior cruciate ligament reconstruction (ACLR) negatively impacts rehabilitation. The purpose of this study was to establish tendon structural properties 1-month after BPTB autograft harvest compared to the uninvolved patellar tendon, and subsequently to quantify the healing trajectory of the patellar tendon over the course of rehabilitation. Patellar tendon morphology (ultrasound) and mechanical properties (continuous shear wave elastography) from 3 regions of the tendon (medial, lateral, central) were measured in 34 participants at 1 month, 3-4 months, and 6-9 months after ACLR. Mixed models were used to compare tendon structure between limbs at 1 month, and quantify healing over 3 timepoints. The involved patellar tendon had increased cross-sectional area and thickness in all regions 1-month after ACLR. Thickness reduced uniformly over time. Possible tendon elongation was observed and remained stable over time. Tendon viscosity was uniform across the three regions in the involved limb while the medial region had higher viscosity in the uninvolved limb, and shear modulus was elevated in all three regions at 1 month. Viscosity and shear modulus in only the central region reduced over time. Statement of Clinical Significance: The entire patellar tendon, and not just the central third, is altered after graft harvest. Tendon structure starts to normalize over time, but alterations remain especially in the central third at the time athletes are returning to sport. Early rehabilitation consisting of tendon loading protocols may be necessary to optimize biologic healing at the graft site tendon.

The Influence of Platelet-Rich Fibrin on the Healing of Bone Defects after Harvesting Bone-Patellar Tendon-Bone Grafts.

Background and Objectives: A bone-patellar tendon-bone (BTB) autograft in anterior cruciate ligament reconstruction (ACLR) is still considered the gold standard among many orthopedic surgeons, despite anterior knee pain and kneeling pain being associated with bone defects at the harvest site. Bioregenerative products could be used to treat these defects, perhaps improving both the postoperative discomfort and the overall reconstruction. Materials and methods: During a year-long period, 40 patients were enrolled in a pilot study and divided into a study group, in which bone defects were filled with Vivostat® PRF (platelet-rich fibrin), and a standard group, in which bone defects were not filled. The main outcome was a decrease in the height and width of the bone defects, as determined by magnetic resonance imaging on the control exams during the one-year follow-up. The secondary outcomes included an evaluation of kneeling pain, measured with a visual analog scale (VAS), and an evaluation of the subjective knee scores. Results: The application of Vivostat® PRF resulted in a more statistically significant reduction in the width of the defect compared with that of the standard group, especially at 8 and 12 months post operation (p < 0.05). Eight months following the surgery, the study group's anterior knee pain intensity during kneeling was statistically considerably lower than that of the standard group (p < 0.05), and the statistical difference was even more obvious (p < 0.01) at the last follow-up. Each control examination saw a significant decrease in pain intensity in both the groups, with the values at each exam being lower than those from the prior exam (p < 0.01). A comparison of subjective functional test results 12 months post operation with the preoperative ones did not prove a statistically significant difference between the groups. Conclusions: The use of Vivostat® PRF reduces kneeling pain and accelerates the narrowing of bone defects after ACLR with a BTB graft, but without confirmation of its influence on the subjective knee score.

Difference of Knee Strength Recovery Between Revision and Primary ACL Reconstruction.

Different grafting procedures are available to restore knee stability after revision anterior cruciate ligament (ACL) reconstruction. We compared knee strength recovery between ACL revision surgery and primary reconstruction. One hundred and ten patients with ACL revision surgery were matched with 110 patients with primary reconstruction based on the graft procedure. The isokinetic knee strength had been assessed for the first 9 months post-surgery. Knee laxity, function, and activity score were also evaluated. Limb symmetry index for knee extensor and flexor strength was not different at 4-, 6- and 9-months post-surgery between revision surgery and primary reconstruction. These results depended on ipsilateral or contralateral graft choice. Ipsilateral hamstring tendon (HT) and contralateral bone-patellar-tendon-bone (BPTB) graft procedures were similar for a revision of a BPTB graft failure. Contralateral HT procedure was better than ipsilateral BPTB procedure for a revision of a HT graft failure. The early recovery of isokinetic knee strength after ACL revision surgery regardless of the HT or BPTB procedures, was similar to the recovery after primary ACL reconstruction with the same graft technique. These results apparently depended on a temporary quadriceps arthrogenic muscle inhibition and on a persistent donor site morbidity, concerning the new and the previous grafts, respectively.

Preoperative Templating of Bone-Patellar Tendon-Bone Graft for Anterior Cruciate Ligament Reconstruction: A Morphometry-Based Graft Harvest Method.

Background: Knowledge of anatomy and morphometry of the patella and patellar tendon is crucial for the selection of bone-patellar tendon-bone (BTB) graft for anterior cruciate ligament reconstruction. Graft tunnel mismatch in BTB graft especially in patients with patella alta or baja can result in compromised fixation for the bone-to-bone healing. This complication can be avoided by proper templating of graft using parameters measured from magnetic resonance imaging (MRI). The study aimed to derive morphometric data from MRI and predict the suitability of BTB graft preoperatively. Methods: MRI of 1,002 knees was chosen from database after applying the eligibility criteria, which included individuals in the age group of 18-50 years (both sexes) with the intact patella and patellar tendon. Individuals with pathologies of the knee joint and associated structures such as patellar fracture/dislocations, fractures of the distal femur and proximal tibia, and avulsion of the quadriceps tendon or patellar tendon were excluded. For analysis, 1.5 Tesla, proton density, and fat-suppressed sequences of sagittal and axial sections of T2-weighted MRI images were used. Results: Mean age of the 1,002 patients was 35.45 years and there were 290 women and 712 men. Respective measurements were as follows: patella length, width, and thickness, 40.3 mm, 40.2 mm, and 18.6 mm, respectively; patellar tendon length, width, and insertional thickness, 45.2 mm, 27.2 mm, and 5.7 mm, respectively; Insall-Salvati ratio, 1.13; overall graft length, 90.2 mm; and effective tendon length, 26.1 mm. Conclusions: A simple MRI analysis can give us valuable inputs on BTB graft morphometry. The values can also help us with the near-perfect graft harvest. The intraoperative complication of graft tunnel mismatch can be avoided by predicting the overall graft length, effective tendon length, tibial tunnel length, and patellar position using the measured parameters on MRI.

Rectangular bone-patellar tendon bone grafts reduce early graft failure in chronic ACL-Deficient knees.

BACKGROUND: The aim of this study was to assess early graft failure after anterior cruciate ligament (ACL) reconstruction according to chronicity of ACL deficiency (ACLD) and clarify predisposing factors. METHODS: A total of 731 patients who underwent anatomic ACL reconstruction were divided into 3 groups based on chronicity of ACLD: <6 months (Group 1), 6 months to 2 years (Group 2), and >2 years (Group 3). Types of ACL grafts used included single-bundle hamstring tendon (HT), multiple-bundle HT, and rectangular bone-patellar tendon-bone (BTB) grafts. Preoperatively and immediately postoperatively, lateral radiographs in full extension were taken to examine anterior tibial subluxation (ATS). All ACL grafts were evaluated by MRI at 6 months to identify graft failure. The group with the highest failure rate was further examined to compare possible risk factors between the intact and failure subgroups, followed by multivariate logistic regression analysis to identify predisposing factors. RESULTS: Early graft failure on MRI without any episode of postoperative trauma was observed in 7 (1.4%), 2 (1.8%), and 11 (9.2%) patients in Groups 1, 2, and 3, respectively, with a significantly higher rate in Group 3 (P < 0.001). Of the 119 patients in Group 3, significant differences were observed between intact and failure subgroups with regard to surgical procedure (P = 0.03), chondral lesions (P < 0.01), and preoperative ATS (P < 0.01). Multivariate logistic regression analysis revealed that surgical procedures (odds ratio, 3.8; 95%CI, 1.16-12.59) and preoperative ATS (odd ratio, 2.4; 95%CI, 1.26-4.38) were predisposing factors of early graft failure. CONCLUSION: Patients with ACLD for >2 years experienced early graft failure with an incidence rate of 9.2%. Predisposing factors of early graft failure in these patients included the use of single-bundle HT grafts and preoperative ATS. The use of rectangular BTB grafts resulted in a lower graft failure rate. STUDY DESIGN: Case Series.

Biomechanics of hamstring tendon, quadriceps tendon, and bone-patellar tendon-bone grafts for anterior cruciate ligament reconstruction: a cadaveric study.

PURPOSE: The three most commonly used autografts for anterior cruciate ligament reconstruction (ACL) are: bone-patellar tendon-bone (BTB), hamstring tendons (HT), and quadriceps tendon (QT). A cadaveric study was performed to determine if there were any differences in mechanical and structural properties under biomechanical testing. METHODS: Twenty-seven graft specimens were harvested from 9 human cadaveric legs. Mean donor age was 75.2 years (range 53-85 years). Twenty-two specimens (8 HT, 7 QT, and 7 BTB) completed cyclic preconditioning from 50 to 800 N for 200 cycles and a load to failure test at an extension rate of 1 mm/s. Structural and mechanical properties of BTB, HT, and QT grafts were compared using a one-way ANOVA and Tukey's honest significant difference. RESULTS: There was no difference in the ultimate load to failure (N) across all 3 graft types (p = 0.951). Quadriceps tendon demonstrated greater cross-sectional area (mm2) when compared to both HT and BTB (p = 0.001) and was significantly stiffer (N/mm) than HT but not BTB (p = 0.004). Stress (N/mm2) of the HT at ultimate load was greater than QT but not BTB (p = 0.036). Elastic modulus (MPa) of HT was greater than both QT and BTB (p = 0.016). CONCLUSION: There was no difference in the ultimate load to failure of BTB, HT, and QT grafts harvested from the same specimens. All 3 grafts had similar loads to failure with a significant increase in stiffness when compared to the native ACL. Furthermore, QT demonstrated more favourable structural properties compared to HT and BTB with greater cross-sectional area to both HT and BTB and greater stiffness compared to HT.

Clinical Outcomes After Combined ACL and Anterolateral Ligament Reconstruction Versus Isolated ACL Reconstruction With Bone-Patellar Tendon-Bone Grafts: A Matched-Pair Analysis of 2018 Patients From the SANTI Study Group.

BACKGROUND: Bone-patellar tendon-bone (BPTB) autografts are widely considered the standard for anterior cruciate ligament reconstruction (ACLR). PURPOSE/HYPOTHESIS: The aims of this study were to compare the clinical outcomes after ACLR with gold standard BPTB autografts versus combined ACLR + anterolateral ligament reconstruction (ALLR) with hamstring tendon (HT) autografts at medium-term follow-up in a large series of propensity-matched patients. The hypothesis was that combined ACLR + ALLR with HT autografts would result in lower graft rupture rates and non-graft rupture-related reoperation rates. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients undergoing combined ACLR + ALLR using HT autografts between January 2003 and December 2019 were propensity matched in a 1:1 ratio to patients undergoing isolated ACLR using BPTB autografts. At the end of the study period, graft ruptures, contralateral knee injuries, and any other reoperations or complications after the index procedure were identified by a search of a prospective database and a review of medical records. RESULTS: A total of 1009 matched pairs were included. The mean duration of follow-up was 101.3 ± 59.9 months. Patients in the isolated group were >3-fold more likely to have graft failure than those in the combined group (hazard ratio, 3.554 [95% CI, 1.744-7.243]; P = .0005). Patients aged <20 years were at a particularly high risk of graft ruptures compared with patients aged >30 years (hazard ratio, 5.650 [95% CI, 1.834-17.241]; P = .0002). Additionally, there was a significantly higher reoperation rate after isolated ACLR than after combined ACLR + ALLR (20.5% vs 8.9%, respectively; P < .0001). The overall rate of subsequent contralateral ruptures was 9.1% after index surgery (isolated: 10.2%; combined: 8.0%; P = .0934), indicating that the risk profiles for both groups were similar. CONCLUSION: Patients who underwent isolated ACLR with BPTB autografts experienced significantly worse graft survivorship and overall reoperation-free survivorship compared with those who underwent combined ACLR + ALLR with HT autografts. The risk of graft ruptures was >3-fold higher in patients who underwent isolated ACLR using BPTB autografts.

Evolution of the patellar tendon size after Bone-Patelar tendon-Bone ACL reconstruction

Introduction: Bone-patellar tendon-bone (BPTB) autograft is the main treatment choice on complete anterior cruciate ligament (ACL) ruptures. However, high donor-site morbidity has been related to this procedure. A better understanding of the donor-site healing process could help us to decrease donor-site problems. The aim of this study is to describe the evolution of the patellar tendon size during the first year after BPTB procedure.Materials and methods42 consecutive patients underwent ACL reconstruction using BPTB technique in our facilities. We measured the tendon length, width and thickness through musculoskeletal ultrasound before and at 1, 2, 4, 6, 9 and 12 months after the operation. Tendon measurements from the contralateral unaffected tendon were used as a control group. We compared the values between injured and uninjured legs and between pre-op and post-op values.ResultsTendon length decreased significantly in both legs, without any difference between legs at 12 months post-op. Tendon width and thickness of the unaffected limbs showed a tendency to stabilization, while the injured limb showed a significant increase in both values during the first 1-2 months. At 12-months post-op, patellar tendon of the injured limb was significantly wider and thicker than the unaffected contralateral limb.ConclusionHarvesting the central third of the patellar tendon during the BPTB procedure after an ACL injury leads to significant changes in the patellar tendon that can last for up to 12 months after the surgery. Further research must focus on the translation of these findings into clinical signs with longest follow-up periods. (AU)

The effects of initial graft tension on femorotibial relationship following anatomical rectangular tunnel anterior cruciate ligament reconstruction using bone-patellar tendon-bone graft.

BACKGROUND: The purpose of this study was to elucidate the effects of the difference of initial graft tension on the femorotibial relationship on an axial plane and its chronological change following anatomical anterior cruciate ligament (ACL) reconstruction. METHODS: A total of 63 patients who underwent anatomical ACL reconstruction were included in this study. The graft was fixed at full knee extension with manual maximum (higher graft tension; group H) and 80 N (lower graft tension; group L) pulls in 31 and 32 patients, respectively. The femorotibial positional relationship in axial computed tomography at 1 week and 1 year postoperatively were retrospectively evaluated. The side-to-side differences (SSDs) and the amount of changes of SSDs over 1 year were compared between groups. RESULTS: The SSDs of the external rotational angle of the tibia in group H were significantly larger than those in group L at postoperative 1 week (2.7 ± 3.9° vs. 0.3 ± 3.3°; P < 0.01). The amount of internal rotational changes of SSDs of the internal-external rotational angles over 1 year in group H was significantly larger than that in group L (-3.6 ± 3.9° vs. - 0.3 ± 2.7°; P < 0.01). No significant differences were observed on the anterior-posterior translation distance and medial-lateral shift distance. CONCLUSION: The application of higher initial graft tension resulted in excessive external rotation of the tibia to the femur at 1 week postoperatively in anatomical ACL reconstruction, and the excessive early external tibial rotation had resolved over 1 year.

In vivo knee rotational stability 2 years after the ACL reconstruction using a quadriceps tendon graft with bone block and bone-patellar tendon-bone graft.

INTRODUCTION: The aim of this prospective randomised study was to evaluate clinical results and rotational stability at least 2 years after single-bundle anatomic anterior cruciate ligament reconstruction using a quadriceps tendon graft with bone block (BT) and bone-patellar tendon-bone graft (BTB). MATERIALS AND METHODS: In both groups (BT and BTB), 40 patients selected prospectively at random were evaluated. The mean follow-up after the surgery was 28 months (range 24-33 months). A navigation system was used to measure rotational stability of the knee joint. Cincinnati, Lysholm, and IKDC scores and visual analog score (VAS) were used to evaluate clinical results and the non-parametric Wilcoxon test was used for the statistical analysis. RESULTS: After the BT reconstruction, the mean internal rotation of the tibia (IR) was 9.5°. In the contralateral healthy knee joint, IR was 8.6° at average. After the BTB reconstruction, the mean IR was 9.9°. In the contralateral healthy knee joint, IR was 8.7° at average. We did not find any statistically significant difference in IR stability between BT and BTB reconstruction. In terms of clinical results, regarding the VAS, patients perceive significantly more pain after the BTB reconstruction (p < 0.05). Kneeling was reported more difficult and painful after BTB reconstruction. CONCLUSIONS: The BT reconstruction of the ACL provides similar clinical results, less pain, better flexion and the same rotational stability of the knee in comparison with the BTB reconstruction.

Revision Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Graft Combined With Modified Lemaire Technique Versus Hamstring Graft Combined With Anterolateral Ligament Reconstruction: A Clinical Comparative Matched Study With a Mean Follow-up of 5 Years From The SANTI Study Group.

BACKGROUND: Additional lateral extra-articular tenodesis (LET) has recently been correlated with improved clinical outcomes and reduced failure rates in revision anterior cruciate ligament (ACL) reconstruction (ACLR). However, no data are available on clinical outcomes and reoperation after revision ACLR using different LET procedures. PURPOSE: To compare the clinical outcomes of ACL + anterolateral ligament (ALL) reconstruction using hamstring tendon graft (HT-ALL) and a bone-patellar tendon-bone (BPTB) graft + modified Lemaire tenodesis procedure (BPTB-Lemaire) in the setting of revision ACLR and to determine whether ALL reconstruction is associated with an increased rate of adverse outcomes when compared with a modified Lemaire tenodesis procedure. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Descriptive data and clinical outcomes were prospectively collected from patients who underwent revision ACLR with LET between 2009 and 2018 with a minimum follow-up of 2 years. Patients with an HT autograft combined with ALL reconstruction (HT-ALL group) were matched in a 1:1 propensity ratio to patients with a BPTB autograft combined with a modified Lemaire LET procedure (BPTB-Lemaire group). The evaluated parameters included complications and reoperations; knee laxity tests; return to sports; and various scores, including the Lysholm knee score, Tegner activity scale, Anterior Cruciate Ligament Return to Sport After Injury scale, Marx activity rating scale, International Knee Documentation Committee subjective knee evaluation form, and Knee injury and Osteoarthritis Outcome Score. RESULTS: In total, 36 matched pairs were included in the analysis. The mean follow-up durations for the BPTB-Lemaire and HT-ALL groups were 56 ± 35 and 57 ± 23 months, respectively (P = .91). No significant differences were found in graft rupture rate (HT-ALL, 0%; BPTB-Lemaire, 11.1%; P = .13) or reoperations (HT-ALL, 8.3%; BPTB-Lemaire, 22.2%; P = .23). No specific complications with regard to LET were noted in either group. Additionally, there were no significant differences in knee laxity parameters, return to sports, or clinical scores between the groups at the final follow-up, except for the Tegner activity scale score (HT-ALL, 6.4; BPTB-Lemaire, 7.3; P = .03). HT-ALL was associated with a shorter surgical time (41.4 vs 59.8 minutes; P < .0001). CONCLUSION: HT-ALL was at least equivalent, in terms of clinical outcomes, to the more commonly performed procedure, BPTB-Lemaire. Performing ALL reconstruction in the setting of revision ACLR is therefore safe and effective.

Eleccion de injertos en la cirugía de reconstrucción del ligamento cruzado anterior: revisión de conceptos actuales / Anterior cruciate ligament reconstruction. Graft selection. Current Concepts

La ruptura del ligamento cruzado anterior (LCA) es una lesión frecuente en la población general, con una incidencia de hasta 75/100.000 personas por año. Hombres y mujeres jóvenes, involucrados en deportes de contacto y colisión, suelen ser los más afectados. La reconstrucción artroscópica se ha convertido en el estándar de tratamiento, con cerca de doscientos mil procedimientos por año en EEUU. Los injertos se clasifican según sus elementos constituyentes (hueso-tendón-hueso, hueso-tendón o tendón), o el origen del dador (autoinjerto o aloinjerto). A pesar de su alta prevalencia, el injerto ideal sigue siendo motivo de debate en la bibliografía. Consideramos que su elección debe basarse en la experiencia del cirujano con los diferentes injertos y en las características individuales de cada paciente

Anterior cruciate ligament (ACL) tear is a common injury in the general population, with an incidence of up to 75/100,000 annually, affecting mainly men and women involved in contact and collision sports. With nearly 200,000 procedures performed annually in the US, arthroscopic reconstruction has become the standard treatment. Grafts can be classified according to their constituent elements (bone-tendon-bone, bone-tendon or tendon) or the origin of the donor (autograft or allograft). Despite its high prevalence, today the bibliographic debate continues regarding which is the ideal graft. We consider that graft selection should be based on the experience and comfort of the surgeon and the individual patient characteristics

Suture Tape Augmentation Improves the Biomechanical Performance of Bone-Patellar Tendon-Bone Grafts Used for Anterior Cruciate Ligament Reconstruction.

PURPOSE: The purpose of this study was to investigate the time-zero biomechanical properties (stiffness, displacement, and load at failure) of bone-patellar tendon-bone (BTB) grafts used for anterior cruciate ligament (ACL) reconstruction with and without suture tape augmentation as a means to determine the potential clinical benefit of this technique. METHODS: Eight juvenile porcine knees underwent ACL reconstruction with a human cadaveric BTB graft (control). These were compared to 8 juvenile porcine knees that underwent ACL reconstruction with a BTB graft augmented with suture tape. All knees underwent biomechanical testing utilizing a dynamic tensile testing machine. Cyclic loading between 50-250N was performed for 500 cycles at 1 Hz to simulate in vivo ACL loads during the early rehabilitation phase. The grafts were displaced during load-at-failure tensile testing at 20 mm/min. Differences in graft displacement, stiffness, and load at failure for the control and suture tape augmented groups were compared with the Student t-test with a significance level of P < .05. RESULTS: There was no difference in graft displacement between the 2 groups. A 104% higher postcyclic stiffness was noted in the augmented group compared to the controls (augmentation: 261 ± 76 N/mm versus control 128 ± 28 N/mm, P = .002). The mean ultimate load at failure was 57% higher in the augmented group compared to controls (744 ± 219 N vs postcyclic 473 ± 169 N, respectively [P = .015]). There was no difference in mode of failure between the control knees and those augmented with suture tape, with approximately half failing from pull off of the tendon from the bone plug and half with pull out of the bone plug from the tunnel. CONCLUSION: Independent suture tape augmentation of a BTB ACL reconstruction grafts was associated with a 104% increase in graft stiffness and a 57% increase in load at failure compared to nonaugmented BTB grafts. CLINICAL RELEVANCE: In vivo suture tape augmentation of a BTB ACL reconstruction increases graft construct strength and stiffness, which may reduce graft failure in the clinical setting.

Return to Sport Composite Test After Anterior Cruciate Ligament Reconstruction (K-STARTS): Factors Affecting Return to Sport Test Score in a Retrospective Analysis of 676 Patients.

BACKGROUND: Return to sport (RTS) to the preinjury level is the main purpose after anterior cruciate ligament (ACL) reconstruction but the factors affecting the RTS are not completely known. Knee Santy Athletic Return to Sport (K-STARTS) is a composite test designed to assess readiness for RTS after ACL reconstruction. PURPOSE: To determine the key factors that influence K-STARTS scores in a large cohort of patients after ACL reconstruction. STUDY DESIGN: Case-control study. LEVEL OF EVIDENCE: Level 3. METHODS: A retrospective analysis of prospectively collected data was undertaken. All patients who underwent ACL reconstruction surgery between March 2016 and May 2017 and also had a K-STARTS assessment at 6 months postoperatively were included. To identify factors influencing the K-STARTS score, an analysis of variance was performed. Age, sex, sports level, delay between injury and surgery, concomitant lesions, graft type, additional lateral tenodesis procedure, and participation in the RTS program were analyzed to identify factors influencing the K-STARTS score. RESULTS: A total of 676 patients were included in the study. The K-STARTS score was significantly higher in male patients than in female patients (13.9 vs 12.4; P < 0.001), in younger patients (those aged <30 years vs older patients; 14.2 vs 12; P < 0.001), ACL reconstructions performed with hamstring tendon autografts compared with bone-patellar tendon-bone (13.5 vs 13.1; P = 0.03) and in those who completed a specific RTS program in addition to standard rehabilitation, compared with those who did not participate (17.1 vs 13.1; P < 0.001). However, the only factor that significantly influenced the K-STARTS score beyond the minimal detectable change threshold was the completion of the additional RTS program. The preinjury frequency of sports participation, whether the dominant limb was injured, time from injury to surgery, the presence of associated meniscal injuries, and whether a lateral tenodesis was performed did not significantly influence the K-STARTS score. CONCLUSION: Completion of a specific RTS program, in addition to standard rehabilitation, was the most important factor influencing the K-STARTS composite functional and psychological RTS test score at 6 months after ACL reconstruction. CLINICAL RELEVANCE: This study shows that the completion of a specific RTS program affects positively the RTS test score at 6 months after ACL reconstruction.

A cadaveric study of the location and morphology of the central patellar ridge for bone-patellar tendon-bone graft.

INTRODUCTION: The central ridge of the patella is the thickest area of patella and varies among patients. This cadaveric study identified the location and thickness of the bone at the central patella ridge for bone-patellar tendon-bone (BPTB) harvesting. MATERIALS AND METHODS: Fifty cadaveric knees were assessed. First, the morphology, length, width, and location of the central patellar ridge were recorded. Then, we transversely cut the patella 25 mm from the lower pole and measured the thickness of the anterior cortex, cancellous bone, and cartilage from both the mid-patella and the central ridge location. Finally, the depth of the remaining cancellous bone at the mid-patella was compared to the bone at the central ridge. RESULTS: The location of the central-patellar ridge deviated medially from the mid-patella in 46 samples with an average distance of 4.36 ± 1 mm. Only 4 samples deviated laterally. The mean patella length was 41.19 ± 4.73 mm, and the width was 42.8 ± 5.25 mm. After a transverse cut, the remaining cancellous bone was significantly thicker at the central ridge compared to the bone at the mid-patella. CONCLUSIONS: Most of the central patellar ridge deviated medially, approximately 4 mm from the mid-patella. Harvesting the graft from the central ridge would have more remaining bone compared to the mid-patella.

Bioabsorbable interference screws can be used with less tunnel widening in anatomic rectangular tunnel anterior cruciate ligament reconstruction with a bone-patellar-tendon-bone graft.

BACKGROUND: The purpose of this study was to investigate postoperative tunnel widening after rectangular tunnel bone-patellar-tendon-bone graft anterior cruciate ligament reconstruction using newer-generation bioabsorbable interference screws. METHODS: Forty-six patients who had undergone primary rectangular tunnel bone-patellar-tendon-bone graft anterior cruciate ligament reconstruction using MILAGRO bioabsorbable interference screws (DePuy Synthes, Warsaw, IN, USA) for femoral fixation and for whom computed tomography was performed at two weeks and one year postoperatively were included in this prospective study. To assess the tunnel widening, the cross-sectional area of the femoral tunnel aperture (compared between two weeks and one year postoperatively) was assessed using computed tomography. Cyst formation, postoperative screw breakage, screw migration, and graft migration were also evaluated using computed tomography one year postoperatively. RESULTS: Mean tunnel widening was 1.9%, and the cross-sectional area of the femoral tunnel aperture was not significantly different between two weeks and one year postoperatively. Postoperative cyst formation, screw breakage, screw migration, and graft migration were not observed in any patient. CONCLUSIONS: After rectangular tunnel bone-patellar-tendon-bone graft anterior cruciate ligament reconstruction using bioabsorbable interference screws for femoral fixation, tunnel widening was not observed via computed tomography analysis at two weeks and one year postoperatively.

Predicción preoperatoria del diámetro de la plastia autóloga de isquiotibiales en reconstrucción de ligamento cruzado anterior / reoperative prediction of autologous hamstring graft diameter in anterior cruciate ligament reconstruction

ANTECEDENTES Y OBJETIVO: Actualmente no existe un modelo establecido en la práctica clínica que permita predecir de forma fiable este parámetro. El objetivo del estudio fue valorar si existe correlación entre el área total sumada de los tendones recto interno (TRI) y semitendinoso (ST) en estudios preoperatorios de resonancia magnética (RM) y el diámetro intraoperatorio de la plastia. MÉTODOS: Estudio retrospectivo que analizó 89 pacientes intervenidos de reconstrucción de ligamento cruzado anterior con plastia autóloga de isquiotibiales. Las variables analizadas fueron: área en mm2 de ST y TRI en estudio preoperatorio de RM, diámetro intraoperatorio de plastia, edad, sexo, lateralidad de intervención, peso, talla e índice de masa corporal. RESULTADOS: Se halló una correlación fuerte-moderada entre el diámetro final de la plastia y el sumatorio del área total del ST y del TRI (Índice de correlación de Pearson 0,6911; p < 0,001). También se observó que, si la combinación de las áreas mencionadas es de 19mm2 o más, la probabilidad de tener una plastia de diámetro mayor o igual a 8mm es de al menos 91,8%. El análisis de la curva ROC demostró que este método predictivo discrimina correctamente en más del 95,6% de las ocasiones entre obtener una plastia de diámetro mayor o igual de 8mm o no tenerla. La concordancia inter e intraobservador de las mediciones realizadas en RM fue excelente en ambos casos con índices de correlación intraclase intraobservador (CCI) de 0,79 y CCI interobservador de 0,84, CCI 0,77 para tendón ST y TRI respectivamente. CONCLUSIONES: El área total de los tendones ST y TRI (mm2), medida preoperatoriamente en el estudio de RM, se correlaciona con el diámetro final de la plastia y constituye un método fiable y reproducible para predecir el grosor de la plastia autóloga de isquiotibiales. NIVEL DE EVIDENCIA: Cohortes retrospectivo, nivel de evidencia IV. RELEVANCIA CLÍNICA: En la literatura revisada se establece que una plastia menor de 8mm de diámetro se asocia a una mayor probabilidad de rerotura y/o fallo. Pese a ser un factor determinante actualmente no existe un modelo establecido en la práctica clínica que permita predecir de forma fiable el diámetro final de la plastia. Conocer de antemano las probabilidades de que la plastia autóloga de isquiotibiales alcance un diámetro suficiente (igual o mayor a 8mm) permitiría al cirujano ortopédico planificar mejor la intervención y anticipar cuándo se van a tener que utilizar otras alternativas de injerto (utilización de autoinjerto tipo HTH o de aloinjerto, entre otras opciones)

BACKGROUND AND OBJECTIVE: Currently, there is no stablished pre-operative model that helps the orthopaedic surgeon predict the final graft diameter in anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to determine whether there is a correlation between semitendinosus (ST) and gracilis (GT) cross-sectional area (CSA) evaluated pre-operatively in mm2 using magnetic resonance imaging (MRI) and the final intra-operative ST-GT autograft diameter in mm2. METHODS: A retrospective study was designed, 89 patients undergoing ACLR with hamstring autograft participated. We analysed ST-CSA (mm2) and GT-CSA (mm2) using pre-operative MRI, intra-operative autograft diameter, age, sex, side of the injury, weight, height and body mass index (BMI). RESULTS: A moderate-strong correlation was identified between final autograft diameter and ST-GT CSA in MRI (Pearson correlation coefficient .6911 P<.001). We observed that, if the combination of ST-CSA and GT-STA is at least 19mm2, the probability of obtaining an autograft with a diameter greater than or equal to 8mm is 91.8% or more. The ROC curve analysis demonstrated, in this model, that this predictive method on MRI correctly discriminates in over 95.6% of cases between achieving or otherwise an autograft greater than or equal to 8mm during surgery. Intra and interobserver concordance of the MRI measurements were excellent, as shown in the intraobserver intraclass correlation coefficient (CCI) of .79 and the interobserver CCI of .84 and .77 for the ST and GT respectively. CONCLUSIONS: Preoperative determinations of ST-CSA and GT-CSA (mm2) using MRI correlate with the final autograft diameter. This method represents a reliable and reproducible model to predict the hamstring autograft diameter in ACLR. LEVEL OF EVIDENCE: Retrospective cohort study, level IV. CLINICAL RELEVANCE: A review of the available literature reveals a higher risk of ACL failure or re-rupture if the graft is smaller than 8mm in diameter. Despite being an important factor there is no established pre-operative model that predicts the final graft diameter. Knowing beforehand the possibilities of obtaining a hamstring autograft with a diameter greater than or equal to 8mm would help the orthopaedic surgeon to better plan the surgery and to anticipate the need for other graft options (such as bone-patellar-tendon-bone autograft or allografts, amongst other alternatives)

Anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft is associated with higher and earlier return to sports as compared to hamstring tendon graft.

PURPOSE: To study the effect of age, duration of injury, type of graft and concomitant knee injuries on return to sports after anterior cruciate ligament (ACL) reconstruction. METHOD: One-hundred and sixteen athletes underwent ACL reconstruction using either bone-patellar tendon-bone graft (BPTB; n = 58) or semitendinosus-gracilis graft (n = 58), depending upon their random number sequences. Five variables were analyzed in terms of their effect on return to sports-age, type of graft, time interval between injury and surgery, chondral damage and meniscal tears. RESULTS: Fifty-three out of 73 (72.6%) athletes aged between 16 and 25 years and 21/43 (49%) athletes aged between 25 and 40 years returned to sports (p = 0.02). The mean time to return to sports was 9.7 ± 2.1 months and 10.8 ± 1.7 months in athletes aged < 25 years and 25-40 years, respectively (p = 0.04). ACL reconstruction with BPTB graft (43/58) was associated with higher rate of return to sports as compared to hamstring tendon graft (31/58; p = 0.02). The mean duration of return to sports with BPTB and STGPI graft was 9.7 ± 2.0 months and 10.7 ± 2.0 months, respectively (p = 0.02). 29/36 (80.5%) patients operated between 2 and 6 months, 18/29 (62%) operated in < 2 months, and 27/51 (53%) operated after 6 months of injury had returned to sports (p = 0.03). Athletes who were operated within 2 months of the injury were the earliest to return to sports (9.4 ± 2.1 months), followed by those operated within 2-6 months (9.9 ± 1.9 months) and lastly by the ones operated after 6 months of the injury (10.9 ± 2.1 months; p = 0.04). CONCLUSIONS: The rate of return to sports was observed to be higher in athletes younger than 25 years as compared to older athletes (> 25 years). ACL reconstruction with BPTB graft was associated with higher and earlier returns to sports as compared to hamstring graft. The rate of return to sports was highest if surgery was performed between 2 and 6 months after the injury. LEVEL OF EVIDENCE: III.

Length of the Tendon within the Tibial Tunnel Affects Tibial Tunnel Widening following Anatomic Anterior Cruciate Ligament Reconstruction Using a Bone-Patellar Tendon-Bone Graft.

The purpose of this study was to retrospectively investigate the effects of variations in the length of the tendon within the tibial tunnel on tunnel widening (TW) following anatomical anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone (BTB) graft. In total, 68 patients who underwent isolated ACL reconstructions using BTB grafts were included in this study. The patients were divided into two groups according to the length of the tendon within the tibial tunnel: group S (n = 30; tendon length, < 10 mm) and group L (n = 38; tendon length, ≥ 10 mm). Tunnel aperture area was measured using three-dimensional computed tomography (3D CT) at 1 week and 1 year postoperatively, and tibial TW (%) was calculated. The correlation coefficient between the length of the tendon within the tibial tunnel and tibial TW was also calculated. Clinical assessment was performed 1 year postoperatively, corresponding to the period of CT assessment, which involved the evaluation of the Lysholm's score, measurement of anterior knee stability using a KneeLax3 arthrometer, and the pivot-shift test. A weak positive correlation was observed between the length of the tendon within the tibial tunnel and tibial TW (r = 0.270, p = 0.026). Mean tibial tunnel aperture area increased by 19.3 ± 17.4% and 35.8 ± 25.4% in the groups S and L, respectively. TW in the group L was significantly greater than that in the group S (p = 0.004). No significant difference was observed between the two groups in any clinical outcomes. In conclusion, a longer tendinous portion within the tibial tunnel resulted in a greater tibial TW following anatomical ACL reconstructions using a BTB graft.