Tendon cross-sectional area on magnetic resonance imaging and anthropometric characteristics can be used to predict insufficient four-strand hamstring autograft diameter in anterior cruciate ligament reconstruction: A systematic review.

PURPOSE: To evaluate the utility of semitendinosus tendon (ST) and gracilis tendon (GT) cross-sectional area (CSA) on magnetic resonance imaging (MRI) and anthropometric characteristics in preoperative estimation of graft diameter in patients undergoing anterior cruciate ligament reconstruction (ACLR) with four-strand hamstring autografts. METHODS: Three databases were searched on 29 August 2023. The authors adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and R-AMSTAR (Revised Assessment of Multiple Systematic Review) guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, anthropometric characteristics, imaging techniques, tendon CSA, correlation coefficients, sensitivities, specificities, regression models and cutoffs for predicting intraoperative graft diameters above 8 mm were recorded. RESULTS: Forty-six studies comprising 4140 patients were included. Twelve of 19 (63.2%) studies reporting on ST + GT CSA found a moderate to very high correlation with intraoperative graft diameter. Five of 10 (50%) and one of seven (14.3%) studies reporting on ST CSA and GT CSA, respectively, found a moderate to high correlation with intraoperative graft diameter. Cutoffs of ST + GT CSA for predicting graft diameters above 8 mm ranged from 15.8 to 31.2 mm2. Nine of 35 (25.7%) studies that reported on height found a moderate to very high correlation with graft diameter. Seven of 33 (21.2%) studies reporting on weight found a moderate correlation with graft diameter. CONCLUSION: Of the MRI parameters assessed, ST + GT CSA was the most reliable predictor of graft diameter. However, cutoffs, sensitivities, and specificities for predicting diameters above 8 mm were highly variable. Anthropometric characteristics in general were less predictive of graft diameter than MRI parameters. This information can be used by clinicians to predict patients at risk for ACLR failure due to insufficient graft size. LEVEL OF EVIDENCE: Level IV.

Investigating the magnetic resonance imaging cross-section area that best correlates with intraoperative hamstring autograft size.

OBJECTIVE: This study aimed to find out the level of the gracilis and semitendinosus tendons that would provide the closest information about the size of the quadruple-stranded hamstring autograft using magnetic resonance images before anterior cruciate ligament reconstruction. METHODS: Ninety-six patients (44 males, 52 females) who underwent anterior cruciate ligament reconstruction with quadruple hamstring tendon autografts between January 2015 and March 2020 were retrospectively analyzed. The cross-sectional areas of the gracilis and the semitendinosus tendons at 6 different levels (pes anserinus insertion site, tibial tuberosity, fibular head, tibial plateau, and the proximal insertion sites of the anterior cruciate ligament and the medial collateral ligament were measured on the magnetic resonance images. In addition, the harvested hamstring tendons were measured together (quadrupled) using a standardized graft-sizing block. RESULTS: There was no significant difference between genders in terms of the tendon sizes measured in all levels using magnetic resonance images. There was a strong correlation between the graft size and the measurements made at the tibial plateau level (P < .0001, r=0.590). CONCLUSION: Intraoperative quadruple hamstring tendon sizes were most correlated with the magnetic resonance image measurements at the tibial plateau level. To use a hamstring autograft with a diameter of at least 8 mm for anterior cruciate ligament reconstruction, the total area of the 2 tendons should be at least 18.11 mm2 in the magnetic resonance image measurements made at the tibial plateau level. LEVEL OF EVIDENCE: Level IV, Diagnostic Study.

A case report: anatomical translocation in tibial insertion of semitendinosus tendon after tibial lengthening.

BACKGROUND: There is the most common method for arthroscopic anterior cruciate ligament (ACL) reconstruction by using the semitendinosus and gracilis tendons and single-tunnel technique. However, anatomic translocation of hamstring tendon attachment is very rare. CASE PRESENTATION: A 45-year-old male who need to receive right knee ACL reconstruction due to sprain injury while playing table tennis was found to have a translocation at tibial attachment of semitendinosus tendon. The tibial insertion of left semitendinosus was then explored by ultrasound and found to be identical to the contralateral limb. The patient has a history of bilateral tibial lengthening. CONCLUSIONS: This is the first case as far as we know that reported anatomic translocation of the tibial attachment of the hamstring tendon after tibial lengthening. Surgeons should be aware of this specific situation when hamstring tendon need to be harvested to avoid unnecessary complications.

Influence of Age on Signal Intensity of Magnetic Resonance Imaging and Clinical Outcomes in Double-Bundle Anterior Cruciate Ligament Reconstruction: Comparisons Among Different Age Groups.

BACKGROUND: Thus far, the clinical results of anterior cruciate ligament (ACL) reconstruction have been observed to be comparable between young and older patients. In contrast, age-related changes in the structural and mechanical properties of tendons used for autografts have been described. However, age-related changes associated with graft maturation remain poorly understood. HYPOTHESES: The hypotheses of this study were that (1) clinical outcomes after ACL reconstruction would be comparable between younger and relatively older patients and (2) younger patients would show lower signal intensity changes on magnetic resonance imaging scans indicative of graft maturation that would be better than that in relatively older patients. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We retrospectively evaluated 236 patients who underwent double-bundle ACL reconstruction via the outside-in technique using hamstring autograft between January 2012 and December 2015. The patients were categorized by age into 3 groups: <20 years old, 20 to 39 years old, and ≥40 years old. Clinical outcomes were evaluated using the subjective International Knee Documentation Committee (IKDC) score, Tegner activity scale, Lysholm score, and objective assessment of joint laxity 24 months after surgery. In addition, graft maturation was evaluated using magnetic resonance imaging-derived measures of the signal intensity ratio (SIR) at 3, 6, 12, and 24 months postoperatively. Clinical outcomes and graft maturation were compared among the 3 groups. RESULTS: The SIR of both bundles increased from 3 months to 12 months and decreased by 24 months, showing the same tendency in all groups. No significant difference was found in the SIR among the 3 groups at any time point (P > .05). The IKDC score was significantly lower in the ≥40-year group than in the <20-year group (P < .01). In contrast, no significant differences were noted in other clinical outcomes. CONCLUSION: Patients aged ≥40 years exhibited lower IKDC scores compared with younger patients, although the results of graft maturation were comparable.

MRI Signal Intensity of Quadriceps Tendon Autograft and Hamstring Tendon Autograft 1 Year After Anterior Cruciate Ligament Reconstruction in Adolescent Athletes.

BACKGROUND: Hamstring tendon autograft (HTA) is a common graft choice for anterior cruciate ligament (ACL) reconstruction (ACLR) in skeletally immature patients. Recently, the use of quadriceps tendon autograft (QTA) has shown superior preliminary outcomes in this population. PURPOSE: To evaluate graft maturity by comparing magnetic resonance imaging (MRI) signal intensity of HTA versus QTA used in primary ACLR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All patients under the age of 18 years who underwent a primary ACLR by the senior authors using either an HTA or a QTA were retrospectively reviewed. A total of 70 skeletally immature patients (37 in the HTA group and 33 in the QTA group) with an available MRI at 6 and 12 months postoperatively were included. Signal intensity ratio (SIR) was measured on sagittal MRI by averaging the signal at 3 regions of interest along the ACL graft and dividing by the signal of the tibial footprint of the posterior cruciate ligament. Statistical analysis was performed to determine interrater reliability and differences between time points and groups. RESULTS: Age, sex, and type of surgery were not associated with any differences in SIR. There was no significant difference in SIR between groups on the 6-month MRI. However, the SIR of the QTA group was significantly less than in the HTA group on the 12-month MRI (2.33 vs 2.72, respectively; P = .028). Within the HTA group, there was no significant difference in SIR at either MRI time point. In the QTA group, there was a significant decrease in SIR between the 6-month and 12-month postoperative MRI (2.70 vs 2.33, respectively; P = .045). CONCLUSION: These findings suggest improved graft maturation, remodeling, and structural integrity of the QTA compared with the HTA between 6 and 12 months postoperatively. This provides evidence that, at 1 year postoperatively, QTA may have a superior rate of incorporation and synovialization as compared with the HTA.

Reliability of Distal Hamstring Tendon Length and Cross-sectional Area Using 3-D Freehand Ultrasound.

The objective of this study was to investigate the reliability of distal hamstring tendon morphology using freehand 3-D ultrasound (US). Freehand 3-D US scans were acquired for 16 young males and females, in two sessions, spaced a week apart. The length, volume, cross-sectional area (CSA) and echo intensity (EI) of the semitendinosus (ST), biceps femoris long and short head and semimembranosus (SM) tendons were acquired. Measurements of the CSA and EI were obtained from three sites along each tendon. The intra-class correlation coefficients ranged from 0.88-0.99 of the examined variables, indicating high test-retest reliability. In addition, the minimal detectable change (MDC) ranged from 0.255-3.766 mm (MDC% of the mean: 0.406%-12.558%) for hamstring tendon length, from 0.036-0.077 mL (MDC%: 1.548%-3.178%) for tendon volume, from 0.512-1.948 mm2 (MDC%: 0.702%-3.586%) for CSA and from 0.898-2.586 au (MDC%: 1.145%-3.325%) for EI. Of the four hamstring tendons, ST had the greatest length (141.587 ± 10.701 mm) and EI (94.637 ± 5.536 au), while SM had the greatest volume (3.056 ± 0.421 mL) and CSA (115.277 ± 16.442 mm2) relative to other tendons. Freehand 3-D US appears to be a reliable tool for the evaluation of hamstring distal tendon morphology; hence, its use for in vivo evaluation of tendon properties is promising.

Good Interrater Reliability for Standardized MRI Assessment of Tendon Discontinuity and Tendon Retraction in Acute Proximal Full-Thickness Hamstring Tendon Injury.

BACKGROUND: Proximal full-thickness free hamstring tendon injury (ie, tendon avulsion or rupture) is a severe injury. Treatment decision making relies on clinical factors and magnetic resonance imaging (MRI) variables; it specifically relies on which tendons are injured as well as the extent of tendon retraction. According to a worldwide evaluation of current practice, discontinuity of both proximal tendons and retraction of >2 cm are used as surgical indications. However, both the diagnosis and the use of MRI variables in decision making may be fraught with uncertainty in clinical practice. A reliable standardized MRI assessment is required. PURPOSE: To propose an MRI assessment for acute proximal full-thickness free hamstring tendon injury and to evaluate its interater reliability. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: We included 40 MRI scans of patients with acute (≤4 weeks of injury) proximal full-thickness free hamstring tendon injury. Three musculoskeletal radiologists assessed proximal full-thickness free hamstring tendon discontinuity using the novel "dropped ice cream sign" and tendon retraction (in mm). Quantification of tendon retraction (in mm) was performed using 2 different methods: (1) a direct (ie, shortest distance between the center of the hamstring origin and the tendon stump) method and (2) a combined craniocaudal/mediolateral measurement method. Absolute and relative interrater reliability were calculated. RESULTS: We found an almost perfect interrater agreement (kappa = 0.87) for assessment of full-thickness tendon discontinuity using the dropped ice cream sign. Interrater agreement for the direct and craniocaudal retraction measurements was good for both the conjoint (intraclass correlation coefficient [ICC], 0.88 and 0.83) and the semimembranosus tendons (ICC, 0.81 and 0.79). The mediolateral retraction measurement yielded only moderate to poor reliability for the conjoint (ICC, 0.53) and semimembranosus tendons (ICC, 0.41). CONCLUSION: The standardized MRI assessment to identify proximal hamstring tendon discontinuity and quantify tendon retraction is reliable. We recommend using the novel dropped ice cream sign and the direct retraction measurement in clinical practice and research.

Effect of Modified Lemaire Anterolateral Extra-articular Tenodesis on the Magnetic Resonance Imaging Maturity Signal of Anterior Cruciate Ligament Hamstring Graft.

BACKGROUND: Lateral extra-articular tenodesis (LET) is one of the most widely used procedures to restore anterolateral stability. Clinical outcomes after the addition of LET to anterior cruciate ligament (ACL) reconstruction (ACLR) have been widely investigated; however, the potential influence of LET on the ACL ligamentization process has not been examined. PURPOSE/HYPOTHESIS: The purpose was to use 10-month postoperative magnetic resonance imaging (MRI) scans to determine whether the maturity of grafts after hamstring autograft ACLR was affected by concomitant LET. The hypothesis was that when modified Lemaire lateral extra-articular tenodesis (MLLET) was performed, the MRI parameters of ACL graft maturity would be modified. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The study included patients treated between December 2017 and December 2018 who had undergone anatomic 3-strand hamstring tendon autograft ACLR, with or without concomitant MLLET, and had undergone MRI 10 months postoperatively. Thus, the study included 30 patients who had isolated ACLR and 22 patients who had ACLR plus MLLET. The 2 groups were comparable based on all criteria analyzed. To evaluate graft maturity, the signal-to-noise quotient (SNQ) was measured in 3 regions of interest of the proximal, midsubstance, and distal ACL graft. Lower SNQ ratios indicate less water content and, theoretically, better maturity and healing of the graft. RESULTS: The mean ± SD for SNQ was 4.62 ± 4.29 (range, 3.12-6.19) in the isolated ACLR group and 7.59 ± 4.68 (range, 4.38-8.04) in the ACLR plus MLLET group (P = .012). Upon comparing the mean values of the 3 portions between the 2 groups, we found a significant difference between the 2 groups for the proximal and middle portions (P = .007 and P = .049, respectively) but no difference in the distal portion (P = .369). CONCLUSION: At the 10-month follow-up, hamstring tendon autografts for anatomic ACLR with MLLET did not show the same MRI signal intensity compared with isolated hamstring anatomic ACLR.

Predicting Autologous Hamstring Graft Diameter in the Pediatric Population Using Preoperative Magnetic Resonance Imaging and Demographic Data.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction before 18 years of age has been linked with an increased risk for failure when the graft diameter is <8 mm. PURPOSE/HYPOTHESIS: The purpose of this study was to determine whether autologous hamstring graft size can be reliably predicted with the use of preoperative magnetic resonance imaging (MRI) measurements. We hypothesized that the average of multiple axial cross-sectional area MRI measurements for the semitendinosus tendon and gracilis tendon would alone accurately predict graft diameter. Additionally, factoring in specific demographic data to the MRI cross-sectional areas would provide a synergistic effect to the accuracy of graft diameter predictions. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: We retrospectively reviewed 51 pediatric patients undergoing ACL reconstructions (age <18 years) performed using either a quadruple-strand semitendinosus tendon or combined double-bundle semitendinosus tendon-gracilis tendon autograft. Preoperative axial MRI scans at multiple points along the craniocaudal axis-specifically, at the level of the joint line, 3 cm cephalad to the medial tibial plateau, and 5 cm cephalad to the medial tibial plateau-were used to determine the combined cross-sectional area of the semitendinosus and gracilis tendons. The MRI measurements were analyzed using Pearson correlation as well as regression analysis to evaluate strength of correlation between measurements. Binomial linear regression was used to analyze the same predictive variables assessed by multiple regression. RESULTS: The predicted graft diameter was within 0.5 mm of the intraoperative graft size in 37 of 51 (72.5%) patients and within 1 mm of the intraoperative graft size in 49 of 51 (96.1%). With the addition of demographics, the accuracy of predictions increased to 78.4% within 0.5 mm and 98% within 1 mm of the actual graft size. Additionally, 38 of 42 patients whose true graft diameter was ≥8 mm were correctly classified, giving a sensitivity of 90.4%. For those whose true graft diameter was <8 mm, 8 of 9 patients were correctly classified; therefore, the specificity was 88.9%. CONCLUSION: The results of our study suggest that taking the average of multiple preoperative MRI measurements can be used to accurately predict autologous hamstring graft size when approaching pediatric patients undergoing ACL reconstruction.

Biceps Femoris Compensates for Semitendinosus After Anterior Cruciate Ligament Reconstruction With a Hamstring Autograft: A Muscle Functional Magnetic Resonance Imaging Study in Male Soccer Players.

BACKGROUND: Rates of reinjury, return to play (RTP) at the preinjury level, and hamstring strain injuries in male soccer players after anterior cruciate ligament reconstruction (ACLR) remain unsatisfactory, due to multifactorial causes. Recent insights on intramuscular hamstring coordination revealed the semitendinosus (ST) to be of crucial importance for hamstring functioning, especially during heavy eccentric hamstring loading. Scientific evidence on the consequences of ST tendon harvest for ACLR is scarce and inconsistent. This study intended to investigate the repercussions of ST harvest for ACLR on hamstring muscle function. HYPOTHESIS: Harvest of the ST tendon for ACLR was expected to have a significant influence on hamstring muscle activation patterns during eccentric exercises, evaluated at RTP in a population of male soccer athletes. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 30 male soccer players with a history of ACLR who were cleared for RTP and 30 healthy controls were allocated to this study during the 2018-2019 soccer season. The influence of ACLR on hamstring muscle activation patterns was assessed by comparing the change in T2 relaxation times [ΔT2 (%) = post-exercise-T2pre-exerciseT2pre-exercise] of the hamstring muscle tissue before and after an eccentric hamstring loading task between athletes with and without a recent history of ACLR through use of muscle functional magnetic resonance imaging, induced by an eccentric hamstring loading task between scans. RESULTS: Significantly higher exercise-related activity was observed in the biceps femoris (BF) of athletes after ACLR compared with uninjured control athletes (13.92% vs 8.48%; P = .003), whereas the ST had significantly lower activity (19.97% vs 25.32%; P = .049). Significant differences were also established in a within-group comparison of the operated versus the contralateral leg in the ACLR group (operated vs nonoperated leg: 14.54% vs 11.63% for BF [P = .000], 17.31% vs 22.37% for ST [P = .000], and 15.64% vs 13.54% for semimembranosus [SM] [P = .014]). Neither the muscle activity of SM and gracilis muscles nor total posterior thigh muscle activity (sum of exercise-related ΔT2 of the BF, ST, and SM muscles) presented any differences in individuals who had undergone ACLR with an ST tendon autograft compared with healthy controls. CONCLUSION: These findings indicate that ACLR with a ST tendon autograft might notably influence the function of the hamstring muscles and, in particular, their hierarchic dimensions under fatiguing loading circumstances, with increases in relative BF activity contribution and decreases in relative ST activity after ACLR. This between-group difference in hamstring muscle activation pattern suggests that the BF partly compensates for deficient ST function in eccentric loading. These alterations might have implications for athletic performance and injury risk and should probably be considered in rehabilitation and hamstring injury prevention after ACLR with a ST tendon autograft.

Magnetic Resonance Imaging 1 Year After Hamstring Autograft Anterior Cruciate Ligament Reconstruction Can Identify Those at Higher Risk of Graft Failure: An Analysis of 250 Cases.

BACKGROUND: There is currently no analysis of 1-year postoperative magnetic resonance imaging (MRI) that reproducibly evaluates the graft of a hamstring autograft anterior cruciate ligament reconstruction (ACLR) and helps to identify who is at a higher risk of graft rupture upon return to pivoting sports. PURPOSE: To ascertain whether a novel MRI analysis of ACLR at 1 year postoperatively can be used to predict graft rupture, sporting level, and clinical outcome at a 1-year and minimum 2-year follow-up. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Graft healing and integration after hamstring autograft ACLR were evaluated using the MRI signal intensity ratio at multiple areas using oblique reconstructions both parallel and perpendicular to the graft and tunnel apertures. Clinical outcomes were assessment of side-to-side laxity and International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Lysholm, and Tegner activity level scores at 1 year. Repeat outcome measures and detection of graft rupture were evaluated at a minimum of 2 years. RESULTS: A total of 250 patients (42.4% female) underwent MRI analysis at 1 year, and assessment of 211 patients between 1 year and the final follow-up (range, 24-36 months) detected 9 graft ruptures (4.3%; 5 in female patients). A significant predictor for graft rupture was a high signal parallel to the proximal intra-articular graft and perpendicular to the femoral tunnel aperture (P = .032 and P = .049, respectively), with each proximal graft signal intensity ratio (SIR) increase by 1 corresponding to a 40% increased risk of graft rupture. A cutoff SIR of 4 had a sensitivity and specificity of 66% and 77%, respectively, in the proximal graft and 88% and 60% in the femoral aperture. In all patients, graft signal adjacent to and within the tibial tunnel aperture, and in the mid intra-articular portion, was significantly lower than that for the femoral aperture (P < .001). A significant correlation was seen between the appearance of higher graft signal on MRI and those patients achieving top sporting levels by 1 year. CONCLUSION: ACLR graft rupture after 1 year is associated with MRI appearances of high graft signal adjacent to and within the femoral tunnel aperture. Patients with aspirations of quickly returning to a high sporting level may benefit from MRI analysis of graft signal. Graft signal was highest at the femoral tunnel aperture, adding further radiographic evidence that the rate-limiting step to graft healing occurs proximally.

Reliability of MRI in Acute Full-thickness Proximal Hamstring Tendon Avulsion in Clinical Practice.

In clinically suspected acute full-thickness proximal hamstring tendon avulsions, MRI is the gold standard for evaluating the extent of the injury. MRI variables such as full-thickness free tendon discontinuity, extent of tendon retraction (>20 mm), and continuity of the sacrotuberous ligament with the conjoint tendon (STL-CT) are used in treatment decision-making. The objective was to assess the intra- and inter-rater reliability of these relevant MRI variables after acute full-thickness proximal hamstring tendon avulsion. Three musculoskeletal radiologists assessed MRIs of 40 patients with an acute full-thickness proximal hamstring tendon avulsion. MRI variables included assessment of free tendon discontinuity and continuity of the STL-CT and extent of tendon retraction. Absolute and relative intra- and inter-rater reliability were calculated. Intra- and inter-rater reliability for the assessment of tendon discontinuity was substantial (Kappa [ĸ]=0.78;0.77). For the retraction measurement of the conjoint and semimembranosus tendons, intra-rater reliability was moderate and poor (Intraclass correlation coefficient (ICC)=0.74;0.45), inter-rater reliability was moderate (ICC=0.73;0.57). Intra- and inter-rater reliability of the STL-CT continuity assessment was substantial and fair (ĸ=0.74;0.31). In conclusion, MRI assessment for full-thickness free tendon discontinuity is reliable. However, assessment of extent of tendon retraction and STL-CT continuity is not reliable enough to guide the treatment decision-making process.

A Simple Method to Reduce the Incidence of Cyclops Lesion after Anterior Cruciate Ligament Reconstruction.

The purpose of this study is to determine the influence of debridement in and around the bone tunnels on the prevalence of cyclops lesion (CL), after anterior cruciate ligament reconstruction (ACLR) with hamstring grafts. Our hypothesis was that bone tunnel debridement during ACLR would reduce the prevalence of CL. Methods for debridement in and around the bone tunnels after tunnel drilling were standardized and applied to 38 knees undergoing double-bundle ACLR between 2011 and 2014, Group A (debridement group). Group B (nondebridement group) included 56 knees in which bone tunnel debridement was not performed. Postoperative MRI was performed to evaluate the presence of CL and the following three criteria: (1) the intercondylar site of CL (grade 1-3), depending on its anterior extent along the femoral condyle; (2) posterior bowing of the ACL graft; and (3) the positional relationship between the frontmost fiber of ACL graft and Blumensaat's line. If CL caused loss of extension or pain or discomfort during knee extension, it was defined as symptomatic CL (SCL). CL was detected in 8 cases (21.1%) in Group A and 26 cases (46.4%) in Group B. The prevalence of CL was significantly lower in Group A than in Group B (p = 0.010), and the risk ratio of CL was 0.31 (95% confidence interval: 0.12-0.79). Furthermore, 10 patients in Group B had SCL, compared with none in Group A (p = 0.004). In Group A, the intercondylar site of CL was grade 1 in all cases, while in Group B, the CL grades were 1 (n = 17), 2 (n = 7), 3 (n = 2) (p = 0.008). There were no cases of posterior bowing of the ACL in Group A, but six cases in Group B (p = 0.023). Debridement in and around the bone tunnel is a simple and effective method of preventing CL and SCL after ACLR. The level of evidence for the study is 3.

Predictive Factors for Hamstring Autograft Diameter in Anterior Cruciate Ligament Reconstruction.

Multiple studies found hamstring tendon (HT) autograft diameter to be a risk factor for anterior cruciate ligament (ACL) reconstruction failure. This study aimed to determine which preoperative measurements are associated with HT autograft diameter in ACL reconstruction by directly comparing patient characteristics and cross-sectional area (CSA) measurement of the semitendinosus and gracilis tendon on magnetic resonance imaging (MRI). Fifty-three patients with a primary ACL reconstruction with a four-stranded HT autograft were included in this study. Preoperatively we recorded length, weight, thigh circumference, gender, age, preinjury Tegner activity score, and CSA of the semitendinosus and gracilis tendon on MRI. Total CSA on MRI, weight, height, gender, and thigh circumference were all significantly correlated with HT autograft diameter (p < 0.05). A multiple linear regression model with CSA measurement of the HTs on MRI, weight, and height showed the most explained variance of HT autograft diameter (adjusted R 2 = 44%). A regression equation was derived for an estimation of the expected intraoperative HT autograft diameter: 1.2508 + 0.0400 × total CSA (mm2) + 0.0100 × weight (kg) + 0.0296 × length (cm). The Bland and Altman analysis indicated a 95% limit of agreement of ± 1.14 mm and an error correlation of r = 0.47. Smaller CSA of the semitendinosus and gracilis tendon on MRI, shorter stature, lower weight, smaller thigh circumference, and female gender are associated with a smaller four-stranded HT autograft diameter in ACL reconstruction. Multiple linear regression analysis indicated that the combination of MRI CSA measurement, weight, and height is the strongest predictor.

Musculoskeletal abnormalities in a large international cohort of boys with 49,XXXXY.

49,XXXXY is the rarest X and Y chromosomal variation, with an incidence of 1 in 80,000-100,000 live male births and has been associated with numerous musculoskeletal abnormalities. Data was collected from an international cohort of boys with 49,XXXXY over 10 years. Children were evaluated by a multidisciplinary team consisting of a pediatric orthopedist, a neurogeneticist, a neurodevelopmentalist, and two physical therapists. Increased rates of torticollis (32.4%), hamstring tightness (42%), radioulnar synostosis (67.6%), pes planus (65.2%), and other foot abnormalities (86.9%) were observed. Several anomalies increased with age, specifically hamstring tightness, kyphosis, and scoliosis. The elucidation of the orthopedic profile of this population is necessary in order to provide healthcare providers with current medical information. This research further supports the necessity for the comprehensive multidisciplinary treatment of boys with 49,XXXXY.

Hamstring grafts for anterior cruciate ligament reconstruction show better magnetic resonance features when tibial insertion is preserved.

PURPOSE: Comparing the MRI features of the grafts between a group of patients treated with an over-the-top anterior cruciate ligament reconstruction technique that preserves the hamstring attachment and a control group with a classical reconstruction technique. METHODS: Patients were assigned to a standard reconstruction technique or an Over-the-top plus lateral plasty technique. All patients underwent preoperative, 4-months and 18-months MRI; together with a clinical evaluation with KOOS and KT1000 laxity assessment. MRI study involved different parameters: the "Graft" was evaluated with the continuity, Howell Grading system, presence of liquid and signal noise quotient. The "Tibial Tunnel" was evaluated with the signal noise quotient, presence of edema or liquid and tunnel widening. All points assigned to each parameter formed a composite score ranging from 0-10. Tunnel and graft positioning were evaluated. RESULTS: At 18-month 20 MRIs (10 each group) were available, demographics were not significantly different between groups. The non-detached group showed significantly less liquid within the graft at 4-months (p = 0.008) and 18-months (p = 0.028), the tunnel was significantly smaller (p < 0.05) and less enlarged at both follow-ups (p < 0.05), signal noise quotient of the intra-tunnel graft was lower at 18-months (p < 0.05). The total score of the non-detached group saw a significant improvement at 4-months (p = 0.006) that remained stable at 18-months (n.s.). CONCLUSIONS: Hamstring grafts, which tibial insertions were preserved, showed better MRI features at 4-and 18-months follow-up, especially in terms of liquid effusion, tunnel enlargement and signal noise quotient. LEVEL OF EVIDENCE: IV.

Sonographic Evaluation of the Optimal Needle Insertion Site in the Biceps Femoris Short Head.

OBJECTIVE: The aim of the study was to identify the optimal needle placement for electromyographic examination of the biceps femoris short head muscle in relation to the biceps femoris long head tendon through sonographic evaluation. DESIGN: This cross-sectional observational study involved 36 lower limbs of 18 healthy volunteers. The distances and angles indicating the relationships between the common fibular nerve and the medial or lateral border of the biceps femoris long head tendon were measured at 5 and 7 cm proximal to the tip of the fibular head (P1 and P2, respectively) using ultrasonography. RESULTS: The median values of the distance between the biceps femoris long head tendon and the common fibular nerve were significantly longer in the lateral approach than in the medial approach at the P1 and P2 levels. The median values of the angles between the vertical line to the biceps femoris long head tendon and the common fibular nerve were significantly larger in the lateral approach than in the medial approach at both levels. CONCLUSIONS: The common fibular nerve is located just below the medial border of the biceps femoris long head tendon at a near-vertical degree from the skin. It is strongly recommended that the needle should be inserted on the lateral side of the biceps femoris long head tendon during needle electromyographic examination of the biceps femoris short head muscle.

Pickleball: Review and Clinical Recommendations for this Fast-growing Sport.

Pickleball is a single or doubles volley sport played with paddles and ball on a hardcourt. Growing in popularity in recent years, injuries can occur similar to racquet sports; however, there is a scarcity of references in the literature for sports medicine providers encountering these athletes and injuries. This review provides clinicians treating pickleball athletes with an overview of the sport, a case study demonstrating the significant injuries that can occur in pickleball, and a review of the available literature. We provide a discussion on common pickleball injuries, injury prevention strategies, and event coverage recommendations to better equip sports medicine providers with a base of knowledge and a clinical approach to treat these athletes, or "picklers," who enjoy this fast-growing sport.

Pseudoaneurysm following hamstring tendon harvest in arthroscopic anterior cruciate ligament reconstruction: a case report.

BACKGROUND: Vascular injury is a very rare complication following arthroscopic knee surgery. This is the first report of pseudoaneurysm at the saphenous branch of the descending genicular artery complicating semitendinosus tendon harvest in arthroscopic anterior cruciate ligament reconstruction. CASE PRESENTATION: A 19-year-old male had developed large ecchymosis, focal swelling and tenderness around his posteromedial knee after an arthroscopic anterior cruciate ligament reconstruction. Compartment syndrome of the lower leg and deep vein thrombosis were ruled out. A pseudoaneurysm formation was confirmed through an angiography and coil embolization was performed. At one year follow up, the patient reported improved functional outcome with good stability of the knee. However, mild paresthesia over the posteromedial calf was noted due to the compression injury of the saphenous nerve by the hematoma. CONCLUSIONS: The pseudoaneurysm was presumed to result from accidental vascular injury while dissecting the accessory bands of the semitendinosus and was successfully treated by coil embolization. Care must be taken to section the expansions of the hamstring tendon, especially when the patient presents with underlying coagulopathy or vascular disease.