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Huber T, Frühwirth M, Hartenbach F, Franzmair S, Ullmann D, Trieb K, Rath B. Revision Anterior Cruciate Ligament Reconstruction Using Rectus Femoris or Hamstring Tendon Shows Comparable Patient-Reported Outcome Measurements at Short-Term Follow-Up: A Retrospective Cohort Study. J Clin Med 2025; 14:3512. [PMID: 40429508 PMCID: PMC12112362 DOI: 10.3390/jcm14103512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2025] [Revised: 05/11/2025] [Accepted: 05/15/2025] [Indexed: 05/29/2025] Open
Abstract
Background: The isolated rectus femoris tendon (RT) is a less commonly used autograft for anterior cruciate ligament (ACL) reconstruction. Graft selection is a critical part of ACL reconstruction, especially in revision surgery. HYPOTHESIS This study compares patient-reported outcome measurements (PROMs) between revision ACL reconstruction with an RT autograft and a hamstring tendon (HT) autograft. We hypothesized that the RT autograft will yield comparable functional results and high patient satisfaction. STUDY DESIGN This was a cohort study; the level of evidence is III. Methods: Fifty-five patients (RT n = 28; HT n = 27) who underwent revision ACL reconstruction were included in this study, with a mean follow-up time of 40.3 months (range, 16.4-64.8) for RT and 61.2 months (range, 34.6-86.3) for HT. Apart from the harvesting technique, the surgical technique was the same for both groups. Clinical and intraoperative data were collected for our postoperative registry. In addition, funcinal outcome was measured using the International Knee Documentation Committee score (IKDC), the Lysholm score, Tegner activity scale, and numeric rating scale (NRS). The type and frequency of postoperative complications were documented. Results: At the final follow-up, no significant differences were observed between the RT and HT groups in the IKDC (mean ± SD: 74.7 ± 10.9 vs. 74.9 ± 12.9), Lysholm score (90.9 ± 15.0 vs. 89.0 ± 14.6), or Tegner activity scale (median [IQR]: 5 [4-6] vs. 5 [4-6]). The mean femoral tunnel diameter was 9.0 mm (range, 7.5-10 mm) for the RT and 8.2 mm (range 7.0-9.5 mm) for the HT. The use of the RT reduced the need for a two-stage procedure by 50% compared to HT (n = 5 vs. n = 10), although this difference was not statistically significant (p = 0.11). Stability measured by the Lachman test improved significantly in both groups from the pre- to postoperative period. Retear of the ACL graft was observed in two patients in both groups (7.1% RT and 7.4% HT). Conclusions: The RT and HT autografts achieved similar outcomes in PROMs for revision ACL reconstruction. Good tendon quality with parallel fibers and adjustable thickness characterize the RT. A tendency for a reduced rate of two-stage surgery with RT was noticed. CLINICAL RELEVANCE The incidence of revision ACL reconstruction is rising. Surgeons should be aware of all the available graft options. The isolated RT expands the range of autografts available for ACL reconstruction.
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Affiliation(s)
- Thorsten Huber
- Department of Orthopedics, Klinikum Wels-Grieskirchen, 4600 Wels, Austria; (T.H.); (S.F.); (D.U.); (B.R.)
| | - Marcel Frühwirth
- Department of Trauma Surgery, Klinikum Wels-Grieskirchen, 4600 Wels, Austria;
| | - Florian Hartenbach
- Department of Trauma Surgery, Klinikum Wels-Grieskirchen, 4600 Wels, Austria;
| | - Sarah Franzmair
- Department of Orthopedics, Klinikum Wels-Grieskirchen, 4600 Wels, Austria; (T.H.); (S.F.); (D.U.); (B.R.)
| | - David Ullmann
- Department of Orthopedics, Klinikum Wels-Grieskirchen, 4600 Wels, Austria; (T.H.); (S.F.); (D.U.); (B.R.)
| | - Klemens Trieb
- Department of Orthopedics, Paracelsus Medical University, 5020 Salzburg, Austria;
- Division for Orthopaedics and Traumatology, Center for Clinical Medicine, Danube Private University, 3500 Krems, Austria
| | - Björn Rath
- Department of Orthopedics, Klinikum Wels-Grieskirchen, 4600 Wels, Austria; (T.H.); (S.F.); (D.U.); (B.R.)
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Ripic Z, Letter M, Parrino R, Adams W, Kaplan LD, Baraga MG, Best TM, Signorile JF, Eltoukhy M. Knee joint mechanics during gait after anterior cruciate ligament reconstruction using a partial or full thickness quadriceps tendon autograft at 2 years after surgery. PM R 2025; 17:310-318. [PMID: 39548878 PMCID: PMC11889528 DOI: 10.1002/pmrj.13278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 08/16/2024] [Accepted: 08/21/2024] [Indexed: 11/18/2024]
Abstract
BACKGROUND Despite quadriceps weakness in individuals after quadriceps tendon anterior cruciate ligament reconstruction (QT-ACLR), and its association with knee joint mechanics, no studies have addressed gait mechanics in both partial-thickness (PT-Q) and full-thickness (FT-Q) options for QT-ACLR. OBJECTIVE To assess gait mechanics across a QT-ACLR cohort. We hypothesized that QT-ACLR would show changes in knee joint mechanics compared to control participants (CON) and nonoperated limbs. Additionally, we hypothesized that FT-Q operated limbs would show greater changes compared to PT-Q and CON. DESIGN Retrospective cohort study. SETTING University-affiliated sports medicine institute. PARTICIPANTS Sixteen patients who underwent QT-ACLR (7 FT-Q: Age (years) = 28.6 ± 7.3, post-op (months) = 23.5 ± 10.7, 9 PT-Q: Age = 25.2 ± 4.3, post-op = 24.4 ± 11.7) were recruited and compared to 11 CON (age = 23.4 ± 4.8). INTERVENTION Participants underwent gait testing with force plate integrated motion capture. MAIN OUTCOME MEASURES Mixed repeated-measures analyses of covariance, adjusted for gait speed, were used to determine significant main effects or interactions in peak knee flexion angle, sagittal knee range of motion, peak internal knee extension moment (KEM), and peak internal knee flexion moment. RESULTS When measured an average of 2 years after surgery, no main effect for limb or limb by depth interaction were detected. A significant effect by group was observed for peak KEM (p = .03, η2 = .27) and peak knee flexion angle (p = .04, η2 = .24) in the loading response phase. FT-Q (p = .02) and PT-Q (p = .03) showed lower KEM compared to the CON group in both limbs. The FT-Q group showed lower peak knee flexion angle compared to the CON group (p = .01). CONCLUSIONS Knee joint symmetry may be recovered 2 years following QT-ACLR, but lower KEM compared to CON for both graft options and lower peak knee flexion angle than CON for the FT-Q group may indicate a need for further investigation in QT-ACLR.
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Affiliation(s)
- Zachary Ripic
- Department of Kinesiology and Sport SciencesUniversity of MiamiMiamiFloridaUSA
- Sports Medicine InstituteUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Michael Letter
- Sports Medicine InstituteUniversity of Miami Miller School of MedicineMiamiFloridaUSA
- Department of OrthopaedicsUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Rosalia Parrino
- Department of Kinesiology and Sport SciencesUniversity of MiamiMiamiFloridaUSA
| | - William Adams
- Department of Kinesiology and Sport SciencesUniversity of MiamiMiamiFloridaUSA
| | - Lee D. Kaplan
- Sports Medicine InstituteUniversity of Miami Miller School of MedicineMiamiFloridaUSA
- Department of OrthopaedicsUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Michael G. Baraga
- Sports Medicine InstituteUniversity of Miami Miller School of MedicineMiamiFloridaUSA
- Department of OrthopaedicsUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Thomas M. Best
- Sports Medicine InstituteUniversity of Miami Miller School of MedicineMiamiFloridaUSA
- Department of OrthopaedicsUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Joseph F. Signorile
- Department of Kinesiology and Sport SciencesUniversity of MiamiMiamiFloridaUSA
- Center on AgingUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Moataz Eltoukhy
- Department of Kinesiology and Sport SciencesUniversity of MiamiMiamiFloridaUSA
- Department of Physical TherapyUniversity of Miami Miller School of MedicineMiamiFloridaUSA
- Department of Industrial and Systems EngineeringUniversity of MiamiMiamiFloridaUSA
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Sandon A, Kvist J, Hedevik H, Forssblad M. Return to competition after ACL reconstruction: Factors influencing rates and timing in Swedish football players. Knee Surg Sports Traumatol Arthrosc 2025. [PMID: 39865456 DOI: 10.1002/ksa.12579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2024] [Revised: 12/25/2024] [Accepted: 12/27/2024] [Indexed: 01/28/2025]
Abstract
PURPOSE To investigate the rate and timing for return to football league games after anterior cruciate ligament reconstruction (ACLR) in Swedish players, examining associations with sex, age, level, graft and additional ACL surgery. METHOD Data from the Swedish National Knee Registry (SNKLR) and the Swedish Football Association's IT System (FOGIS) were used. The study cohort comprised 971 football players, 64% males, who underwent primary ACLR. Demographics, graft type and surgical information were extracted from the SNKLR and game participation from FOGIS. Follow-up for return to competition (RTC) was conducted for 36 months, while additional ACLR follow-up was 3-7 years. Statistical analyses, including Kaplan-Meier survival curves and relative risk calculations, were employed to assess factors influencing RTC rates and timing. RESULTS Out of 971 players analyzed, 53% RTC within 3 years with no difference between males and females, at a mean of 15 months (median 14 months) from surgery to the first game. Eleven (2%) players RTC < 6 months from ACLR, 62 (12%) 6-9 months, 125 (24%) 9-12 months and 331 (63%) >12 months. Patellar tendon (PT) grafts demonstrated superior performance, showing quicker returns and higher RTC rates (p = 0.005) compared to hamstring (hazard ratio [HR]: 0.63 [0.48-0.84]) and quadriceps tendon grafts (HR: 0.53 [0.30-0.93]). Players competing in higher divisions pre-injury experienced significantly swifter and higher RTC rates (p < 0.001). Ninety-five (10%) had a registered additional ACLR. Players who RTC did not exhibit a significantly higher rate of revision (35 [7%] vs. 25 [5%]). However, those who returned faced a heightened risk of contralateral ACLRs compared to those who did not RTC (32 [6%] vs. 4 [1%] RR 1.72 [1.59-1.96], p < 0.001). CONCLUSION The study reveals that 53% of football players RTC after ACLR, predominantly after more than 12 months. The RTC was higher and faster in high-level players and those receiving a PT graft. The slow RTC may contribute to the relatively low rate of additional ACLRs. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Alexander Sandon
- Department of Molecular Medicine & Surgery, Stockholm Sports Trauma Research Center, Karolinska Institute, Stockholm, Sweden
| | - Joanna Kvist
- Department of Molecular Medicine & Surgery, Stockholm Sports Trauma Research Center, Karolinska Institute, Stockholm, Sweden
- Division of Physiotherapy, Department of Health, Medicine and Caring Science, Linköping University, Linköping, Sweden
| | - Henrik Hedevik
- Division of Physiotherapy, Department of Health, Medicine and Caring Science, Linköping University, Linköping, Sweden
| | - Magnus Forssblad
- Department of Molecular Medicine & Surgery, Stockholm Sports Trauma Research Center, Karolinska Institute, Stockholm, Sweden
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Zhou H, Qian J, Xing YM, Cui L, Bu YF. How effective is the addition of specific exercise therapy for patients after anterior cruciate ligament surgery? A systematic review and meta-analysis. Front Physiol 2025; 16:1501458. [PMID: 39927331 PMCID: PMC11802576 DOI: 10.3389/fphys.2025.1501458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2024] [Accepted: 01/06/2025] [Indexed: 02/11/2025] Open
Abstract
Context Anterior cruciate ligament (ACL) injuries are prevalent in sports and often require surgical intervention followed by rehabilitation. Several rehabilitation methods have been used for patients after ACL surgery. Objective This study aimed to assess the overall efficacy of exercise therapy in improving outcomes for patients following ACL surgery using a systematic review and meta-analysis of randomized controlled trials (RCTs). Data sources PubMed, Web of Science, Embase, and the Cochrane Library were searched for randomized controlled trials published from 1 January 2000 to 30 August 2024. Study quality was assessed using the Cochrane Risk-of-Bias tool. Study selection A total of 11 randomized controlled trials (whole-body vibration training = 4, core-stability training = 2, strength training = 3, blood flow restriction training = 1, and aquatic training = 1) involving 552 anterior cruciate ligament surgery patients were included. Data extraction Two researchers individually screened the key information for each eligible study and evaluated the quality of the studies. Any dispute was discussed by a third researcher. Results Compared with conventional therapy, exercise therapy significantly reduced pain scores (mean difference: -0.53, 95% CI: -0.82 to -0.24, and p < 0.001) and improved muscle strength (flexion: 13.76 and extension: 12.46) and knee function (effect size: 2.06 and p = 0.001). Secondary outcomes, although less pronounced, also demonstrated improvement. Limitation The sources of heterogeneity among the included studies were not fully identified, particularly concerning variations in exercise protocols or patient characteristics. Additionally, the therapeutic effects of specific exercise modalities (e.g., strength training versus aquatic training) were not directly compared. Conclusion Exercise therapy is effective in reducing pain, enhancing muscle strength, and improving knee function in ACL surgery patients. These findings underscore the importance of integrating tailored exercise therapies into rehabilitation programs. Systematic review registration number https://www.crd.york.ac.uk/PROSPERO/, identifier registration number. CRD42023476653.
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Affiliation(s)
- Hao Zhou
- Physical Education Institute, Jiangsu Normal University, Xuzhou, China
| | - Jia Qian
- Physical Education Institute, Jiangsu Normal University, Xuzhou, China
| | - Yu-Mei Xing
- Library, Jiangsu Normal University, Xuzhou, China
| | - Long Cui
- Physical Education Institute, Jiangsu Normal University, Xuzhou, China
| | - Yi-Feng Bu
- Physical Education Institute, Jiangsu Normal University, Xuzhou, China
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Dworsky-Fried J, Hadwen A, Bernardini L, Vivekanantha P, Grassi A, Ollivier M, de Sa D. Quadriceps tendon autograft diameters are routinely above 8 mm, and preoperative size estimation before anterior cruciate ligament reconstruction may not be necessary for this graft type: A systematic review. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 39686764 DOI: 10.1002/ksa.12558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2024] [Revised: 11/18/2024] [Accepted: 11/22/2024] [Indexed: 12/18/2024]
Abstract
PURPOSE To identify values of reported quadriceps tendon (QT) autograft diameter and length in anterior cruciate ligament reconstruction (ACLR), and to identify methods to predict these parameters. METHODS A search was conducted across three databases from inception to 30 March 2024. Data on study characteristics, demographics, anthropometric data, imaging techniques, and QT autograft or harvested QT tendon parameters were extracted. Values quantifying the statistical strength of associations between imaging or anthropometric characteristics and graft or tendon parameters as well as for associations between these parameters and postoperative outcomes were recorded. RESULTS A total of 3633 patients were included. The weighted mean QT autograft diameter and length were 8.9 (standard deviation [SD]: 0.7, range: 7.8-10.4) mm and 8.1 (SD: 1.3, range: 5.6-9.3) cm, respectively. A total of 93.8% of studies that reported mean QT autograft diameter found a value of 8 mm or greater. The QT groups had similar or significantly greater mean autograft diameter compared to the hamstring tendon (HT) groups in 91.7% of studies that reported significance. Regarding MRI measurements, 71.4% of the correlation coefficients reported showed a moderate positive correlation, 28.6% showed a low positive correlation and 14.3% showed a high positive correlation. Regarding anthropometric characteristics, 33.3% and 16.7%, 16.7% and 14.3% of studies that reported on the relationship between QT autograft diameter and height, weight, body mass index or age, respectively, found a low positive statistically significant correlation. Only statistically nonsignificant associations were reported between QT autograft parameters and post-operative outcomes and complications. CONCLUSIONS QT autografts used in ACLR have a mean diameter of 8 mm or greater and are consistently larger than HT autografts. Preoperative MRI measurements are better than anthropometric characteristics at predicting QT autograft parameters; however, preoperative prediction may not be necessary for this graft type. QT autograft parameters were not found to be significantly associated with any post-operative complication or outcome. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Joshua Dworsky-Fried
- Michael DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amanda Hadwen
- Michael DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Luca Bernardini
- School of Graduate Studies, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Prushoth Vivekanantha
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | | | - Matthieu Ollivier
- Institut du Mouvement et de l'appareil Locomoteur, Hôpital Sainte-Marguerite, Aix-Marseille Université, Marseille, France
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Shimomura K, Tsujii A, Tanaka A, Hamada M, Yonetani Y. Bone-Patellar Tendon-Bone Versus Quadriceps Tendon-Bone Autografts in Anatomic Rectangular Tunnel Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2024; 12:23259671241297104. [PMID: 39611121 PMCID: PMC11603535 DOI: 10.1177/23259671241297104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 05/07/2024] [Indexed: 11/30/2024] Open
Abstract
Background Anatomic rectangular tunnel anterior cruciate ligament reconstruction (ART-ACLR) can mimic the fiber arrangement of the native ACL and restore normal knee biomechanics, compared with the conventional round tunnel ACLR. ART-ACLR using a bone-patellar tendon-bone (BPTB) graft can provide satisfactory clinical outcomes; however, some issues such as secondary ACL injury and donor-site morbidity, including postoperative anterior knee pain (AKP), remain to be solved. Due to these issues, quadriceps tendon-bone (QTB) grafts have recently become more popular. Purpose To compare the 2-year clinical outcomes of ART-ACLR with BPTB and QTB autografts. Study Design Cohort study; Level of evidence, 3. Methods A total of 134 patients underwent primary ART-ACLR with BPTB (n = 70) or QTB (n = 64). All patients had a minimum follow-up period of 2 years postoperatively. Outcome evaluations included the International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), side-to-side differences (SSDs) with the KT-1000 knee arthrometer, rate of secondary ACL injury, and incidence of AKP. Results Regarding age, sex, height, weight,and concomitant procedures, there were no significant differences between the 2 groups. All clinical scores significantly improved from preoperatively to 6 months postoperatively and further increased throughout the 2-year postoperative period in both groups. The IKDC and all subscales of the KOOS, except Sport and Recreation, were equivalent between the BPTB and QTB groups at each postoperative time point. There were no significant differences in the SSD value of KT-1000 arthrometer between the 2 groups. The rates of secondary ACL injury were 10.0% on the ipsilateral side and 2.9% on the contralateral side in the BPTB group and 3.1% on the ipsilateral side and 4.7% on the contralateral side in the QTB group, with no significant difference between both groups. The incidence of AKP was 17.1% and 4.9% in the BPTB group and QTB group, respectively, with significance of P = .02). Conclusion The clinical scores, SSD value of the KT-1000 arthrometer, and secondary ACL injury rates were equivalent between the BPTB and QTB groups. However, the incidence of AKP was significantly lower in the QTB group, suggesting that QTB could be a favorable graft for ACLR.
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Affiliation(s)
- Kazunori Shimomura
- Department of Rehabilitation, Kansai University of Welfare Sciences, Osaka, Japan
- Department of Sports Orthopaedics, Hoshigaoka Medical Center, Osaka, Japan
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Akira Tsujii
- Department of Sports Medical Biomechanics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ayaka Tanaka
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masayuki Hamada
- Department of Orthopaedic Surgery, Seifu Hospital, Osaka, Japan
| | - Yasukazu Yonetani
- Department of Sports Orthopaedics, Hoshigaoka Medical Center, Osaka, Japan
- Osaka Nakanoshima Orthopedic Clinic, Osaka, Japan
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Tagliero AJ, Miller MD. Anterior Cruciate Ligament Tears in Soccer Players. Sports Med Arthrosc Rev 2024; 32:138-145. [PMID: 39087703 DOI: 10.1097/jsa.0000000000000391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
Anterior cruciate ligament (ACL) injuries to soccer players present unique challenges in sports medicine, given the sport's global prevalence and intricate injury dynamics. These injuries, especially in the youth and female demographic, have become a substantial concern in sports medicine. This review explores the epidemiology, mechanism of injury, diagnostic procedures, treatment modalities, and rehabilitation strategies related to ACL tears within the soccer community. Progress in diagnostics, treatments, and rehabilitation underscores the importance of evidence-based approaches. As soccer continues its ascent in popularity, addressing the specific risks and nuances of ACL injuries in this context remains of paramount significance.
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Affiliation(s)
- Adam J Tagliero
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Mark D Miller
- Department of Orthopedic Surgery, University of Virginia Health System, Charlottesville, VA
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D'Ambrosi R, Kambhampati SB, Meena A, Milinkovic DD, Abermann E, Fink C. The "Golden Age" of quadriceps tendon grafts for the anterior cruciate ligament: a bibliometric analysis. J ISAKOS 2024; 9:672-681. [PMID: 38492850 DOI: 10.1016/j.jisako.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/25/2023] [Accepted: 03/09/2024] [Indexed: 03/18/2024]
Abstract
IMPORTANCE Bibliometric research is a statistical analysis of publications to measure the scientific output in a specific field in order to highlight medical developments or knowledge gaps and to direct future scientific research. The quantity of orthopedic papers on the internet is astounding and is steadily growing as a result of recent advancements in technology and medicine. This is why choosing the right information is essential. AIM The purpose of this study was to analyze the current literature for trends in publications regarding quadriceps tendon (QT) grafting of the anterior cruciate ligament (ACL). EVIDENCE REVIEW PubMed was searched on August 28, 2023. References were collected from PubMed, and trends were analyzed using this information. This search retrieved 405 articles regarding human and animal studies. We analyzed the top 10 authors and journals in terms of publication numbers, citation numbers, and citations per year. The PubMed-by-year feature was used to compare the number of publications regarding ACL reconstruction by quadriceps grafting with all publications in PubMed. FINDINGS The number of yearly publications averaged 10 or less up to 2018, starting from 1982 when the first paper on the QT was published. However, the number of publications increased from 2018. While the total number of publications on this topic was 405, 260 were published from 2018 alone. The number of citations was 8262 in total overall years. It is expected that the last five years' publications, especially those for the last year, will be low in number, as it takes time for citations to accrue. The journal Arthroscopy published the most articles on this topic, with 57 papers and 1884 citations, followed by the American Journal of Sports Medicine, with 39 articles and 1576 citations. The top three journals on this topic were Arthroscopy, AmericanJournalofSportsMedicine, and KneeSurgery, SportsTraumatology, Arthroscopy. The most published author was Musahl V (with 24 articles), and the most cited author was Xerogeanes JW (with 570 citations). CONCLUSIONS AND RELEVANCE Global trend analysis suggests that research on anterior cruciate ligament reconstruction with the quadriceps has significantly increased in the last 5 years and that the number of papers on this topic is increasing steadily. We found that the publications and citations are exhibiting a rising trend, Arthroscopy is the most impactful journal, and Musahl V is the most impactful author on the topic. Xerogeanes JW is the author with the most citations on the topic. The promising clinical results of anterior cruciate ligament reconstruction with the QT have attracted the most research interest. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Riccardo D'Ambrosi
- IRCCS Ospedale Galeazzi - Sant'Ambrogio, Milan, 20161, Italy; Università degli Studi di Milano, Dipartimento di Scienze Biomediche per la Salute, Milan, 20133, Italy.
| | - Srinivas Bs Kambhampati
- Sri Dhaatri Orthopaedic, Maternity & Gynaecology Center, SKDGOC, Vijayawada, Andhra Pradesh, 520008, India.
| | - Amit Meena
- Division of Orthopedics, Shalby Multi-Specialty Hospital, Jaipur, 302021, India; Gelenkpunkt - Sports and Joint Surgery, FIFA Medical Centre of Excellence, Innsbruck, 6020, Austria.
| | - Danko Dan Milinkovic
- Department of Orthopedic and Trauma Surgery, Arcus Sportclinic, Pforzheim, 75179, Germany.
| | - Elisabeth Abermann
- Gelenkpunkt - Sports and Joint Surgery, FIFA Medical Centre of Excellence, Innsbruck, 6020, Austria.
| | - Christian Fink
- Gelenkpunkt - Sports and Joint Surgery, FIFA Medical Centre of Excellence, Innsbruck, 6020, Austria; Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Private University for Health Sciences, Medical Informatics and Technology, Innsbruck, 6060, Austria.
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Dadoo S, Herman ZJ, Hughes JD. Surgical Techniques in Primary ACL Reconstruction: Getting It Right the First Time. Clin Sports Med 2024; 43:399-412. [PMID: 38811118 DOI: 10.1016/j.csm.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
The ideal anterior cruciate ligament reconstruction (ACLR) is an individualized anatomic approach aimed at restoring the native structure and function of the knee. Surgeons are tasked with difficult decisions during operative planning, including the optimal graft choice for the patient and appropriate anatomic tunnel placement. Special considerations should additionally be given for skeletally immature patients and those at high-risk for failure, including younger, active patients participating in pivoting sports. The purpose of this review is to provide an overview of the individualized approach to ACLR, including the necessary preoperative and operative considerations to optimize patient outcomes.
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Affiliation(s)
- Sahil Dadoo
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water Street, Pittsburgh, PA 15203, USA.
| | - Zachary J Herman
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water Street, Pittsburgh, PA 15203, USA
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water Street, Pittsburgh, PA 15203, USA; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Greenberg EM, Bram J, DeFrancesco CJ, Landrum K, Stevens A, Ganley TJ. Pattern of strength recovery differences Exist in Adolescent athletes after anterior cruciate ligament reconstruction when using quadriceps versus Hamstring tendon autograft. Phys Ther Sport 2024; 68:1-6. [PMID: 38843685 DOI: 10.1016/j.ptsp.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/28/2024] [Accepted: 05/29/2024] [Indexed: 08/16/2024]
Abstract
OBJECTIVES To compare the timeline for post-operative quadriceps and hamstrings strength recovery following anterior cruciate ligament reconstruction (ACLR) using either a quadriceps tendon (QT) or hamstring tendon (HT) autograft. METHODS Patients (≤18 years) who underwent ACLR using autograft QT or HT were included. Isokinetic strength was extracted at 3, 6, and 12 months post-operatively. Effects of time and graft type on quadriceps or hamstring limb symmetry index (qLSI/hLSI) was assessed with two-way repeated measures ANOVA. Between group differences at each time point were assessed with unpaired t-tests. Chi-square and Kaplan-Meir analysis analyzed the proportions of subjects able to achieve ≥90% LSI. RESULTS A total of 75 subjects (QT n = 38 HT n = 37,15.8 years) were included. There were significant differences in qLSI, with greater symmetry within the HT group at all time points. A higher proportion of subjects with HT grafts were able to achieve ≥90% qLSI within 12 months of surgery (81% vs 45%, p = 0.001). CONCLUSION Compared to those with HT autografts, adolescents with QT autografts demonstrate a prolonged timeline for quadriceps recovery. While mean strength values above 90% are achieved, a significantly lower percentage of QT patients are able to achieve 90% qLSI by 12 months post-op.
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Affiliation(s)
- Elliot M Greenberg
- Children's Hospital of Philadelphia Sports Medicine and Performance Center, Philadelphia, PA, USA; Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Joshua Bram
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Christopher J DeFrancesco
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kevin Landrum
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alexandra Stevens
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Theodore J Ganley
- Children's Hospital of Philadelphia Sports Medicine and Performance Center, Philadelphia, PA, USA; Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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11
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Dadoo S, Herman ZJ, Nazzal EM, Drain NP, Finger L, Reddy RP, Miller L, Lesniak BP, Musahl V, Hughes JD. Outcomes After Anterior Cruciate Ligament Reconstruction With Quadriceps Tendon in Adolescent Athletes at Mean Follow-up of 4 Years. Orthop J Sports Med 2024; 12:23259671241254795. [PMID: 39100218 PMCID: PMC11295237 DOI: 10.1177/23259671241254795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 12/06/2023] [Indexed: 08/06/2024] Open
Abstract
Background Despite increasing use of quadriceps tendon (QT) autograft in anterior cruciate ligament (ACL) reconstruction (ACLR), limited data exist regarding its outcomes in high-risk adolescent athletes. Purpose To (1) report the outcomes after QT ACLR in adolescent athletes and (2) identify patient-related and surgery-related factors that may influence failure rates after QT ACLR. Study Design Case series; Level of evidence, 4. Methods All patients aged 14 to 17 years who underwent primary anatomic, transphyseal, single-bundle QT ACLR between 2010 and 2021 with a minimum 2-year follow-up were included for analysis. Demographic and surgical data as well as preoperative International Knee Documentation Committee (IKDC) and Marx activity scores were collected retrospectively. All patients were also contacted to assess postoperative patient-reported outcomes (PROs), including IKDC and Marx activity scores, and return-to-sports (RTS) data. Outcomes of interest included rates of revision ACLR and ipsilateral complications, contralateral ACL tears, difference in pre- and postoperative PROs, and rates of RTS. Patient and surgical characteristics were compared between groups who required revision ACLR versus those who did not. Results A total of 162 patients met inclusion criteria, of which 89 adolescent athletes (mean age 16.2 ± 1.1 years, 64% female) were included for analysis at mean follow-up of 4.0 years. Postoperative IKDC scores were significantly higher than preoperative scores (88.5 vs 37.5; P < .001), whereas Marx activity scores decreased postoperatively (14.3 vs 12.2; P = .011). Successful RTS occurred in 80% of patients at a mean time of 9.7 ± 6.9 months, and 85% of these patients returned to the same or higher level of sports. The most common reasons for failure to RTS included lack of time (n = 7, 70%) and fearing reinjury in the operative knee (n = 5, 50%). The overall revision ACLR rate was 10% (n = 9), and contralateral ACL tears occurred in 14% (n = 12) of patients. The overall ipsilateral knee reoperation rate was 22.5% (n = 20). No statistically significant differences in patient or surgical characteristics were observed between patients who underwent revision ACLR and those who did not. Conclusion At a minimum 2-year follow-up after QT ACLR, adolescent athletes experienced significantly improved postoperative IKDC scores, high rates of RTS, and low rates of graft failure, despite a relatively high ipsilateral reoperation rate. Surgeons may utilize this information when identifying the optimal graft choice for adolescent athletes who have sustained an ACL injury and wish to return to high level of sporting activities.
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Affiliation(s)
- Sahil Dadoo
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Zachary J. Herman
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ehab M. Nazzal
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nicholas P. Drain
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Logan Finger
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rajiv P. Reddy
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Liane Miller
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Bryson P. Lesniak
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jonathan D. Hughes
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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12
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Doorschodt TC, Smithuis FF, Helmerhorst GTT, Maas M. Postoperative Magnetic Resonance Imaging after Anterior Cruciate Ligament Reconstruction: An Overview and Practical Step-by-step Guide. Semin Musculoskelet Radiol 2024; 28:293-304. [PMID: 38768594 DOI: 10.1055/s-0044-1782207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Anterior cruciate ligament (ACL) rupture is a frequently encountered injury among athletes, often requiring surgical intervention to restore knee stability. Magnetic resonance imaging (MRI) after ACL reconstruction is common, especially in the evaluation of clinical complications leading to knee instability, decreased range of motion, or pain. This article provides a detailed overview of normal and abnormal postoperative findings including a practical step-by-step guide for MRI assessment. MRI findings must be correlated with surgical technique, time interval from surgery to imaging, and clinical examination.
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Affiliation(s)
- Tom C Doorschodt
- Radiology and Nuclear Medicine, OLVG, Amsterdam, The Netherlands
| | - Frank F Smithuis
- Radiology and Nuclear Medicine, Location University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Gijs T T Helmerhorst
- Department of Orthopaedic Surgery Flevoziekenhuis, Almere, The Netherlands
- Department of Orthopaedic Surgery and Sports, Amsterdam UMC, Amsterdam, The Netherlands
| | - Mario Maas
- Radiology and Nuclear Medicine, Location University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
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13
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Huber T, Frühwirth M, Hartenbach F, Franzmair S, Ullmann D, Rath B. A novel surgical technique for revision anterior cruciate ligament reconstruction using an isolated rectus femoris tendon autograft. Arch Orthop Trauma Surg 2024; 144:2723-2730. [PMID: 38753014 DOI: 10.1007/s00402-024-05268-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 03/03/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION Only a few anatomic studies have described an isolated rectus femoris tendon autograft for anterior cruciate ligament (ACL) reconstruction. This study aims to demonstrate a new surgical technique utilising the rectus femoris tendon for ACL reconstruction. This study hypothesises that the rectus tendon autograft will yield satisfying postoperative outcomes in terms of stability, with minimal complications at the harvest site. METHODS This retrospective study investigated the outcomes of 28 revision ACL reconstructions using a rectus tendon autograft with a mean follow-up of 41.7 (range, 24.0-64.8) months. A 3 cm longitudinal incision was used to harvest the rectus tendon with an open tendon stripper. Intraoperative collected data included the length of the tendon and thickness of a 4-fold graft. Further outcome parameters include anterior cruciate ligament stability and range of motion. Additionally, postoperative complications, especially donor site morbidity, were documented in type and frequency. RESULTS The mean tendon length measured 32.4 cm (range, 30-35 cm). After preparing a 4-fold graft, the mean diameter was 9.2 mm (range, 8.0-10 mm) at the tibial and 9.0 mm (range, 7.5-10 mm) at the femoral end. Stability evaluated by the Lachman test improved significantly from 2 (Interquartile range (IQR), 2-3) preoperatively to 0 (IQR, 0-1) postoperatively (p < .001). Rerupture of the anterior cruciate ligament graft was observed in 2 patients (7.1%). Four patients showed a persistent extension deficit of about 5 degrees postoperatively. Two of them underwent revision surgery due to a Cyclops lesion. Only one patient complained of prolonged pain at the harvest site (3.6%). CONCLUSION The 4-fold rectus tendon represents a novel autograft technique in revision ACL reconstruction. This study provides evidence of appropriate graft dimensions and satisfying postoperative outcomes regarding stability. The technique is associated with a low complication rate at the harvest site. STUDY DESIGN Case series; Level of evidence, IV.
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Affiliation(s)
- Thorsten Huber
- Department of Orthopedics, Klinikum Wels-Grieskirchen, Wels, 4600, Austria
| | - Marcel Frühwirth
- Department of Trauma Surgery, Klinikum Wels-Grieskirchen, Wels, 4600, Austria.
| | - Florian Hartenbach
- Department of Orthopedics, Klinikum Wels-Grieskirchen, Wels, 4600, Austria
| | - Sarah Franzmair
- Department of Orthopedics, Klinikum Wels-Grieskirchen, Wels, 4600, Austria
| | - David Ullmann
- Department of Orthopedics, Klinikum Wels-Grieskirchen, Wels, 4600, Austria
| | - Björn Rath
- Department of Orthopedics, Klinikum Wels-Grieskirchen, Wels, 4600, Austria
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14
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Koukoulias NE, Vasiliadis AV, Dimitriadis T. The Use of a Simple Vaginal Speculum to Harvest Quadriceps Tendon Autografts for Anterior Cruciate Ligament Reconstruction and Avoid Any Potential Pitfalls during Harvesting Procedure: Technical note. Sultan Qaboos Univ Med J 2024; 24:268-271. [PMID: 38828237 PMCID: PMC11139358 DOI: 10.18295/squmj.3.2024.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/03/2024] [Accepted: 02/01/2024] [Indexed: 06/05/2024] Open
Abstract
This technical note aimed to present a straigthforward method for harvesting quadriceps tendon autografts with the use of a simple vaginal speculum and direct visualisation of a scope. Anterior cruciate ligament reconstruction with quadriceps tendon autografts has gained popularity in recent years, with many harvesting techniques that use different harvesting systems available on the market. These techniques vary from transverse to longitudinal skin incisions and from open to minimally invasive approaches and have a learning curve, as with the majority of surgical procedures. The technique proposed in this technical note is minimally invasive, can be easily reproduced by any surgeon irrespective of their experience, has a short learning curve, requires no additional cost or technical support during the procedure and creates a stable working space that allows for freedom of manipulation of surgical instruments and the arthroscope.
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Affiliation(s)
- Nikolaos E. Koukoulias
- Department of Orthopaedic Surgery - Sports Trauma Unit, St. Luke’s Hospital, Thessaloniki, Greece
| | - Angelo V. Vasiliadis
- Department of Orthopaedic Surgery - Sports Trauma Unit, St. Luke’s Hospital, Thessaloniki, Greece
| | - Theofilos Dimitriadis
- Department of Orthopaedic Surgery - Sports Trauma Unit, St. Luke’s Hospital, Thessaloniki, Greece
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15
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Meena A, Farinelli L, Hoser C, Abermann E, Hepperger C, Patralekh MK, Herbort M, Fink C. Primary Versus Revision ACL Reconstruction Using Quadriceps Autograft: A Matched-Control Cohort Study. Orthop J Sports Med 2024; 12:23259671231224501. [PMID: 38313755 PMCID: PMC10836136 DOI: 10.1177/23259671231224501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 08/10/2023] [Indexed: 02/06/2024] Open
Abstract
Background The incidence of anterior cruciate ligament (ACL) reconstruction is increasing, and quadriceps tendon (QT) autograft is gaining popularity for both primary and revision ACL reconstruction. Purpose To evaluate the differences in the patient-reported functional outcomes, concomitant injuries, and graft failure in primary versus revision ACL surgery using QT autograft. Study Design Cohort study; Level of evidence, 3. Methods A total of 376 patients with primary ACL reconstruction and 138 patients with revision ACL reconstruction were retrospectively retrieved from a prospectively collected ACL registry. A minimally invasive technique was used for QT autograft harvesting. The surgical procedure and rehabilitation protocol were identical in both groups. To maintain a homogeneous cohort for the study, the groups were matched by age, sex, and preinjury outcome scores (Lysholm knee score, Tegner activity level, and visual analog scale [VAS] for pain). Initial baseline assessments of outcome scores were compared with scores collected at the 2-year postoperative mark. Results The mean age of the primary group and revision group was 32.9 ± 10.2 years (range, 18-55 years) and 32.3 ± 9.9 years (range, 19-55 years) respectively. Significant preinjury to postoperative improvements were noted in Lysholm (88.2 ± 16.4 vs 83.5 ± 15.0; P = .007) and VAS pain (0.9 ± 1.3 vs 1.5 ± 1.6; P = .001) scores after primary ACL reconstruction compared with revision reconstruction. However, no significant difference was found in Tegner activity level (6.7 ± 1.8 vs 5.9 ± 1.8; P > .430). Primary ACL injury was associated with significantly higher concomitant medial collateral ligament injuries (P = .019), while the revision group was associated with significantly higher concomitant cartilage (P = .001) and meniscal (P = .003) injuries. A significantly higher graft failure rate was noted in the revision group compared with the primary ACL reconstruction group (13.0% vs 5.6%; P = .005). Conclusion Both primary and revision ACL reconstruction with QT autograft had acceptable functional outcomes. The primary group had better outcomes than the revision group, possibly due to the lower prevalence of meniscal and cartilage injuries in the primary group compared with the revision group. The revision group was associated with higher graft failure than the primary group. QT autograft is a viable graft choice for both primary and revision ACL reconstruction.
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Affiliation(s)
- Amit Meena
- Gelenkpunkt–Sports and Joint Surgery, FIFA Medical Center of Excellence, Innsbruck, Austria
- Research Unit for Orthopedic Sports Medicine and Injury Prevention (OSMI), Private University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria
| | - Luca Farinelli
- Clinical Orthopedics, Department of Clinical and Molecular Sciences. Università Politecnica delle Marche, Ancona, Italy
| | - Christian Hoser
- Gelenkpunkt–Sports and Joint Surgery, FIFA Medical Center of Excellence, Innsbruck, Austria
- Research Unit for Orthopedic Sports Medicine and Injury Prevention (OSMI), Private University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria
| | - Elisabeth Abermann
- Gelenkpunkt–Sports and Joint Surgery, FIFA Medical Center of Excellence, Innsbruck, Austria
- Research Unit for Orthopedic Sports Medicine and Injury Prevention (OSMI), Private University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria
| | - Caroline Hepperger
- Gelenkpunkt–Sports and Joint Surgery, FIFA Medical Center of Excellence, Innsbruck, Austria
| | - Mohit Kumar Patralekh
- Central Institute of Orthopedics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Mirco Herbort
- Research Unit for Orthopedic Sports Medicine and Injury Prevention (OSMI), Private University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria
- OCM Clinic, Munich, Germany
| | - Christian Fink
- Gelenkpunkt–Sports and Joint Surgery, FIFA Medical Center of Excellence, Innsbruck, Austria
- Research Unit for Orthopedic Sports Medicine and Injury Prevention (OSMI), Private University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria
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16
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Swensen Buza S, Meyers KN, Adamec D, Ode GE, Maher SA, Sutton K. Patellar Fracture Forces Are Not Affected by Proximal Versus Distal Bone Block Anterior Cruciate Ligament Reconstruction Harvest Sites in a Cadaveric Model. Arthrosc Sports Med Rehabil 2024; 6:100824. [PMID: 38169780 PMCID: PMC10758729 DOI: 10.1016/j.asmr.2023.100824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 10/26/2023] [Indexed: 01/05/2024] Open
Abstract
Purpose To quantify the maximum load to fracture in patellae from which bone-patellar tendon-bone (BPTB) and bone-quadriceps tendon (BQT) autografts have been harvested for anterior cruciate ligament reconstruction in a cadaveric model. Methods Forty-six fresh-frozen patellae were isolated and divided into the BPTB harvest and BQT harvest groups with matching based on donor age and sex. Computed tomography scans were obtained to calculate bone mineral density (BMD) and patellar height, width, and thickness. BPTB and BQT grafts were harvested from the inferior patella and superior patella, respectively, and then ramped to failure in a 3-point bend test configuration to simulate a postoperative fracture produced by a direct impact after a fall. The presence of fracture, fracture pattern, and maximum load to fracture were recorded. Donor demographic characteristics; patellar height, width, and thickness; and maximum load were compared by the Student t test. Pearson correlations were used to determine whether maximum load was affected by BMD or patellar morphology. The level of significance was set at P < .05. Results Maximum load to fracture was not significantly different (P = .91) between the BPTB (5.0 ± 2.3 kN) and BQT (5.1 ± 2.6 kN) groups. Maximum load to fracture in the BPTB group did not correlate with BMD (P = .57) or patellar measurements (P = .57 for thickness, P = .43 for width, and P = .45 for height). Maximum load to fracture in the BQT group positively correlated with BMD and negatively correlated with patellar height. Maximum load to fracture in the BQT group did not correlate with patellar thickness or width. Fracture through the harvest site was observed in 87% of BPTB specimens and 78% of BQT specimens. Conclusions The location of the BPTB or BQT autograft harvest site did not significantly affect patellar load to fracture in a cadaveric model. Clinical Relevance It is important to understand patellar morphology and the effect of BPTB and BQT graft harvest-site locations on the biomechanical strength of the patella after anterior cruciate ligament reconstruction.
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Affiliation(s)
| | - Kathleen N. Meyers
- Department of Biomechanics, Hospital for Special Surgery, New York, New York, U.S.A
| | - Dakota Adamec
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, U.S.A
| | - Gabriella E. Ode
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, U.S.A
| | - Suzanne A. Maher
- Department of Biomechanics, Hospital for Special Surgery, New York, New York, U.S.A
| | - Karen Sutton
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, U.S.A
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17
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Jackson GR, Mameri ES, Tuthill T, Wessels M, Asif S, Sugrañes J, Batra AK, McCormick JR, Obioha OA, Kaplan DJ, Knapik DM, Verma NN, Chahla J. Adverse Events and Complications After Primary ACL Reconstruction With Quadriceps Tendon Autograft: A Systematic Review. Orthop J Sports Med 2023; 11:23259671231199728. [PMID: 38145223 PMCID: PMC10748908 DOI: 10.1177/23259671231199728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/19/2023] [Indexed: 12/26/2023] Open
Abstract
Background Anterior cruciate ligament reconstruction (ACLR) surgery with quadriceps tendon (QT) grafts, both with and without a patellar bone plug, have gained popularity in recent years in the primary and revision settings. Postoperative complications occur with the use of QT autografts. Purpose To systematically review the incidence of postoperative complications after primary ACLR QT autograft and compare complication rates in patients undergoing all-soft tissue QT grafts versus QT grafts with a patellar bone plug (QTPB). Study Design Systematic review; Level of evidence, 4. Methods A literature search using the 2020 PRISMA guidelines was performed by querying PubMed, Embase, and Scopus databases from database inception through August 2022. Included were evidence level 1 to 4 human clinical studies in English that reported complications after primary ACLR with QT autograft. The incidence of complications within the included studies was extracted. Differences in the incidence of postoperative complications between ACLR with QT with and without a patellar bone plug were calculated. Results A total of 20 studies from 2004 to 2022, comprised of 2381 patients (2389 knees; 68.3% male) with a mean age of 27 years (range, 12-58 years), were identified. The mean follow-up was 28.5 months (range, 6-47 months). The total incidence of complications was 10.3%, with persistent postoperative knee pain being the most common (10.8%). Patients who underwent ACLR with all-soft tissue QT grafts had a 2.7-times increased incidence of anterior knee pain (23.3% vs 8.6%) and reoperations (5.9% vs 3.2%) when compared with QTPB grafts (P < .01 for both). There was no appreciable difference in total complications, graft failures, ACLR revisions, cyclops lesions, or range of motion deficit (P > .05 for all). Patellar fractures occurred exclusively after QTPB (2.2%). Conclusion Complications after primary ACLR using QT autograft were recorded in 10.5% of knees, with anterior knee pain being the most common. No difference was reported in the overall incidence of complications with the use of the QT versus QTPB grafts; however, anterior knee pain was 2.7 times greater with use of a soft tissue quadriceps graft.
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Affiliation(s)
- Garrett R. Jackson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Enzo S. Mameri
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
- Instituto Brasil de Tecnologia da Saúde, Rio de Janeiro, Brazil
- Department of Orthopedics and Traumatology, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Trevor Tuthill
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Morgan Wessels
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Shaan Asif
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Joan Sugrañes
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
- Department of Orthopaedic Surgery, Hospital de La Santa Creu I Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Anjay K. Batra
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Johnathon R. McCormick
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Obianuju A. Obioha
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Daniel J. Kaplan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Derrick M. Knapik
- Department of Orthopaedic Surgery, Washington University and Barnes-Jewish Orthopedic Center, Chesterfield, Missouri, USA
| | - Nikhil N. Verma
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Jorge Chahla
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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18
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Olewnik Ł, Zielinska N, Aragones P, Ruzik K, Paulsen F, Borowski A, LaPrade RF. The accessory heads of the quadriceps femoris muscle may affect the layering of the quadriceps tendon and potential graft harvest lengths. Knee Surg Sports Traumatol Arthrosc 2023; 31:5755-5764. [PMID: 37932536 PMCID: PMC10719154 DOI: 10.1007/s00167-023-07647-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 10/24/2023] [Indexed: 11/08/2023]
Abstract
PURPOSE The aim of the study was to assess the quadriceps femoris system for the presence of additional layers. METHODS One hundred and twenty-eight lower limbs fixed in 10% formalin were examined. RESULTS Five types of quadriceps tendon layering were found based on the accessory heads of the quadriceps muscle. Type I (55%)-represented by four heads and four layers, and it was something new because standard orthopaedic textbooks described quadriceps tendon as a structure composed of only three layers. Type II (27.4%)-the first four layers were the same as in Type 1, but the accessory tendon of the fifth head of the quadriceps femoris muscle had the deepest attachments. Type III (10.9%)-this type included 6 heads of quadriceps femoris. It consisted of five layers. Type IV (3.1%)-this type included 7 quadriceps femoris heads. This type consisted of only four layers. Type V (3.1%)-this type included 8 heads of the quadriceps femoris heads. This type consist of 5 layers. CONCLUSION The findings of this study provide a detailed anatomy of the quadriceps tendon including the accessory tendons of the accessory heads of the quadriceps tendon. The accessory heads of the quadriceps femoris muscle contribute to the layering of the quadriceps tendon. The second conclusion of this study is the development of safe distances depending on the types. Not all types are perfect for harvesting-Type IV seems to be the safest type, in turn Type V the most dangerous.
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Affiliation(s)
- Łukasz Olewnik
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Lodz, Poland.
| | - Nicol Zielinska
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Lodz, Poland
| | - Paloma Aragones
- Department of Anatomy and Embryology, School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Kacper Ruzik
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Lodz, Poland
| | - Friedrich Paulsen
- Institute of Functional and Clinical Anatomy, Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Andrzej Borowski
- Orthopaedics and Pediatric Orthopaedics Department, Medical University of Lodz, 90-419, Lodz, Poland
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Inoue J, Takeuchi S, Dadoo S, Takaba K, Lesinak BP, Musahl V, Onishi K. Harvest location has a minimal impact on differences in cross-sectional area of quadriceps tendon in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2023; 31:4791-4797. [PMID: 37555861 DOI: 10.1007/s00167-023-07513-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/13/2023] [Indexed: 08/10/2023]
Abstract
PURPOSE Anterior cruciate ligament (ACL) reconstruction with quadriceps tendon (QT) has been gaining popularity. However, it is unknown how differences in harvest location of the QT affect its thickness and cross-sectional area (CSA). The present study aimed to clarify the differences in thickness and CSA of the QT based on location of tendon harvesting. METHODS Patients scheduled for, or who underwent, ACL reconstruction were prospectively included in the study. The short-axis images on ultrasound were used to assess the CSA of the QT at 30 and 60 mm proximal to the superior pole of the patella. QT autografts with CSAs greater than or equal to 10 mm of width were included and measured at three different locations, namely the center, medial one-third, and lateral one-third at the widest diameter of the QT. Patients with less than 10-mm width of the QT at 60 mm proximal to the superior pole of the patella were excluded. The thickness and CSA were compared based on the location of tendon harvest. RESULTS Thirty-seven patients were recruited for the study. The mean thickness and CSA were larger in the center of the QT compared to the lateral one-third at 30 mm proximal to the superior pole of the patella (thickness, 6.7 ± 1.3 mm vs. 5.9 ± 1.3 mm; P = 0.009; CSA, 65.6 ± 11.4 mm2 vs. 58.8 ± 11.9 mm2; P = 0.036). There were no significant differences in thickness and CSA of the QT among the three assessment locations at 60 mm proximal to the superior pole of the patella (n.s.). CONCLUSION The thickness and CSA of QT was greater in the center compared to the lateral one-third at 30 mm proximal to the QT insertion point. However, the difference in value was clinically non-significant, and therefore, harvest location of the QT autograft may not meaningfully impact intraoperative graft diameter. As a result, surgeons may choose the harvest location without concern for resultant graft diameter as long as the enough length of QT is secured. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jumpei Inoue
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Satoshi Takeuchi
- Department of Orthopaedic Surgery, Toyohashi Medical Center, Toyohashi, Japan
| | - Sahil Dadoo
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Keishi Takaba
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bryson P Lesinak
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kentaro Onishi
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA.
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Amirouche F, Solitro GF, Gligor BZ, Hutchinson M, Koh J. Investigating the effect of autograft diameter for quadriceps and patellar tendons use in anterior cruciate ligament reconstruction: a biomechanical analysis using a simulated Lachman test. Front Surg 2023; 10:1122379. [PMID: 37886636 PMCID: PMC10598649 DOI: 10.3389/fsurg.2023.1122379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 09/12/2023] [Indexed: 10/28/2023] Open
Abstract
INTRODUCTION Current clinical practice suggests using patellar and quadriceps tendon autografts with a 10 mm diameter for ACL reconstruction. This can be problematic for patients with smaller body frames. Our study objective was to determine the minimum diameter required for these grafts. We hypothesize that given the strength and stiffness of these respective tissues, they can withstand a significant decrease in diameter before demonstrating mechanical strength unviable for recreating the knee's stability. METHODS We created a finite element model of the human knee with boundary conditions characteristic of the Lachman test, a passive accessory movement test of the knee performed to identify the integrity of the anterior cruciate ligament (ACL). The Mechanical properties of the model's grafts were directly obtained from cadaveric testing and the literature. Our model estimated the forces required to displace the tibia from the femur with varying graft diameters. RESULTS The 7 mm diameter patellar and quadriceps tendon grafts could withstand 55-60 N of force before induced tibial displacement. However, grafts of 5.34- and 3.76-mm diameters could only withstand upwards of 47 N and 40 N, respectively. Additionally, at a graft diameter of 3.76 mm, the patellar tendon experienced 234% greater stiffness than the quadriceps tendon, with similar excesses of stiffness demonstrated for the 5.34- and 7-mm diameter grafts. CONCLUSIONS The patellar tendon provided a stronger graft for knee reconstruction at all diameter sizes. Additionally, it experienced higher maximum stress, meaning it dissociates force better across the graft than the quadriceps tendon. Significantly lower amounts of force were required to displace the tibia for the patellar and quadriceps tendon grafts at 3.76- and 5.34-mm graft diameters. Based on this point, we conclude that grafts below the 7 mm diameter have a higher chance of failure regardless of graft selection.
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Affiliation(s)
- Farid Amirouche
- Department of Orthopaedics, University of Illinois at Chicago College of Medicine, Chicago, IL, United States
- Department of Orthopaedics, Northshore University Health System, Evanston, IL, United States
| | - Giovanni Francesco Solitro
- Department of Orthopaedics, Louisiana State University College of Medicine, Shreveport, LA, United States
| | - Brandon Zachary Gligor
- Department of Orthopaedics, University of Illinois at Chicago College of Medicine, Chicago, IL, United States
| | - Mark Hutchinson
- Department of Orthopaedics, University of Illinois at Chicago College of Medicine, Chicago, IL, United States
| | - Jason Koh
- Department of Orthopaedics, Northshore University Health System, Evanston, IL, United States
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Dadoo S, Keeling LE, Runer A, Musahl V. Tips and Tricks for Anatomic ACL Reconstruction With Soft-Tissue Quadriceps Tendon and Remnant Repair. VIDEO JOURNAL OF SPORTS MEDICINE 2023; 3:26350254231156238. [PMID: 40308452 PMCID: PMC11962630 DOI: 10.1177/26350254231156238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 01/20/2023] [Indexed: 05/02/2025]
Abstract
Background Quadriceps tendon (QT) autograft represents an excellent option for anterior cruciate ligament (ACL) reconstruction (ACLR), with minimal donor site morbidity and failure rates comparable with bone-patellar tendon-bone (BPTB) autograft. This video aims to provide technical tips for ACLR using all-soft-tissue QT autograft. Indications ACLR with QT autograft is indicated in young, active ACL-injured patients who desire a return to sport. It represents a viable option in both primary and revision ACLR, as well as in skeletally immature patients. It is particularly indicated in those who kneel frequently, such as wrestlers or laborers, due to the lower incidence of postoperative anterior knee pain. Technique Description A vertical incision is used to harvest a 10 mm × 70 mm partial thickness, all-soft-tissue QT graft. Care is taken not to violate the capsule or musculature. If necessary, graft size is modified based on preoperative magnetic resonance imaging (MRI) measurement of the notch width. The graft is then prepared with continuous loop suspensory fixation on the femoral side and draw sutures on the tibial side. The lateral femoral notch is debrided to allow for visualization of the posterior wall to enable anatomic tunnel placement. When possible, the tibial stump is preserved. The femoral tunnel is drilled via an anteromedial portal and the tibial tunnel via a tibial guide. The graft is then passed through the tibial stump into the femur. It is fixed on the tibial side with a PEEK interference screw in full extension with application of a posterior drawer. Results Outcomes following ACLR with QT autograft are excellent, with laxity and patient-reported outcomes comparable with those following ACLR with BPTB and hamstring autograft. Furthermore, QT ACLR has been shown to result in less donor site morbidity than BPTB autograft, and lower rates of failure and infection compared with hamstring autograft. Conclusion ACLR with QT autograft is a good option in young, active patients in both the primary and revision settings. Advantages of QT ACLR include less donor site morbidity than BPTB, and lower rates of failure compared with hamstring autograft in young patients. Patient Consent Disclosure Statement The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
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Affiliation(s)
- Sahil Dadoo
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Laura E. Keeling
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Armin Runer
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Sports Orthopaedics, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Kanayama T, Nakase J, Kimura M, Yoshimizu R, Yanatori Y, Ishida Y, Tsuchiya H. Speed whip ripstop technique during anterior cruciate ligament reconstruction using quadriceps tendon results in higher fixation strength. Knee Surg Sports Traumatol Arthrosc 2023; 31:4068-4075. [PMID: 37318561 DOI: 10.1007/s00167-023-07482-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 06/06/2023] [Indexed: 06/16/2023]
Abstract
PURPOSE To compare the biomechanical strength of different fixation configurations using a suspensory button in a soft-tissue quadriceps tendon graft for Anterior Cruciate Ligament (ACL) reconstruction. METHODS Thirty fresh-frozen bovine Achilles tendons (10 mm wide, 50 mm long, and 4 mm thick) were used in this study. Tendons were assigned to three groups (n = 10 per group) with different suture configurations using adjustable loops with a suspensory button: group A, with the threads of an adjustable loop fixed by crossing at the tip of the loop and the entire loop; group B, continuous loops with hanging buttons were directly sutured to the tendon with eight simple sutures; group C, fixation was performed using the speed whip ripstop technique. Tensile tests with five cycles of preloading were performed at 50 N, held at 50 N for 1 min, and load-to-failure testing was conducted until rupture at 5 mm/min. The difference in the elongation and the maximum load-to-failure force were measured. RESULTS The average elongation was significantly larger in group B (16.6 ± 2.2 mm) than in groups A (10.3 ± 2.4 mm) and C (10.0 ± 1.0 mm), (p < 0.001). The average load-to-failure force varied significantly between the three groups, 157.5 ± 33.4 N in group A, 253.4 ± 45.5 N in group B, and 337.7 ± 21.0 N in group C, (p < 0.001). CONCLUSION Fixation using the speed whip ripstop technique to fix the suspensory button and soft-tissue transplant tendon resulted in minimal elongation and higher fixation strength. Simple devices that use this method have already been developed. Since it can be fixed using a relatively simple method, speed whip ripstop technique was shown to be advantageous for femoral fixation in ACL reconstruction using soft-tissue quadriceps tendon. The findings of this study could help surgeons reduce graft re-tear rates in ACL reconstruction using quadriceps tendons. LEVEL OF EVIDENCE N/A, laboratory control study.
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Affiliation(s)
- Tomoyuki Kanayama
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa-city, 920-8641, Japan
| | - Junsuke Nakase
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa-city, 920-8641, Japan.
| | - Mitsuhiro Kimura
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa-city, 920-8641, Japan
| | - Rikuto Yoshimizu
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa-city, 920-8641, Japan
| | - Yusuke Yanatori
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa-city, 920-8641, Japan
| | - Yoshihiro Ishida
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa-city, 920-8641, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa-city, 920-8641, Japan
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23
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Vermeijden HD, Holuba K, Yang XA, O’Brien R, van der List JP, DiFelice GS. Prospective Comparison of Postoperative Pain and Opioid Consumption Between Primary Repair and Reconstruction of the Anterior Cruciate Ligament. Orthop J Sports Med 2023; 11:23259671231187442. [PMID: 37786478 PMCID: PMC10541769 DOI: 10.1177/23259671231187442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 04/13/2023] [Indexed: 10/04/2023] Open
Abstract
Background Anterior cruciate ligament (ACL) reconstruction (ACLR) is associated with postoperative pain and necessitates using perioperative nerve blocks and multimodal analgesic plans. Purpose To assess postoperative pain and daily opioid use after ACL repair versus ACLR and to assess whether ACL repair could be performed successfully without using long-acting nerve blocks. Study Design Cohort study; Level of evidence, 2. Methods All eligible patients who underwent ACL surgery between 2019 and 2022 were prospectively enrolled. Patients were treated with primary repair if proximal tears with sufficient tissue quality were present; otherwise, they underwent single-bundle ACLR with either hamstring tendon or quadriceps tendon autograft. The patients were divided into 3 groups: ACLR with adductor canal nerve block (up to 20 mL of 0.25% bupivacaine with 2 mg dexamethasone), primary repair with nerve block, and primary repair without nerve block. Pain visual analog scale and number of opioids used were recorded during the first 14 postoperative days (PODs). Furthermore, patients completed the Quality of Recovery-15 (QoR-15) survey, and range of motion was assessed. Group differences were compared using Mann-Whitney U test and chi-square test. Results Seventy-eight patients were included: 30 (39%) underwent ACLR, 19 (24%) ACL repair with nerve block, and 29 (37%) ACL repair without nerve block. Overall, the ACL repair group used significantly fewer opioids than the ACLR group on POD 1 (1 vs 3, P = .027) and POD 2 (1 vs 3, P = .014) while also using fewer opioids in total (3 vs 8, P = .038). This difference was even more marked when only analyzing those patients who received postoperative nerve blocks (1 vs 8, P = .029). Repair patients had significantly higher QoR-15 scores throughout the first postoperative week, and they had greater range of motion (all P < .05). There were no significant differences in pain scores, opioid usage, or QoR-15 scores between patients who underwent repair with versus without nerve block. Conclusion The ACL repair group experienced less postoperative pain during the first 2 weeks after surgery and used significantly fewer opioids than the ACLR group. Furthermore, they had improved knee function and higher recovery quality than patients who underwent ACLR during the initial postoperative period. Postoperative nerve blocks may not be necessary after ACL repair.
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Affiliation(s)
- Harmen D. Vermeijden
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Department of Orthopaedic Surgery, Spaarne Gasthuis Hospital, Hoofddorp, the Netherlands
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Science, Amsterdam, the Netherlands
| | - Kurt Holuba
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Science, Amsterdam, the Netherlands
| | - Xiuyi A. Yang
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Science, Amsterdam, the Netherlands
| | - Robert O’Brien
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Science, Amsterdam, the Netherlands
| | - Jelle P. van der List
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Department of Orthopaedic Surgery, Spaarne Gasthuis Hospital, Hoofddorp, the Netherlands
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Science, Amsterdam, the Netherlands
| | - Gregory S. DiFelice
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
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Trasolini NA, Lan R, Bolia IK, Hill W, Thompson AA, Mayfield CK, Knapik DM, Cole BJ, Weber AE. Knee Extensor Mechanism Complications After Autograft Harvest in ACL Reconstruction: A Systematic Review and Meta-analysis. Orthop J Sports Med 2023; 11:23259671231177665. [PMID: 37465207 PMCID: PMC10350773 DOI: 10.1177/23259671231177665] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/09/2023] [Indexed: 07/20/2023] Open
Abstract
Background Existing systematic reviews have sought to characterize the relative donor-site morbidity of bone-patellar tendon-bone (BTB) and quadriceps tendon (QT) grafts after anterior cruciate ligament reconstruction (ACLR). However, no studies have reported the pooled proportions of patellar fractures and donor tendon ruptures across the body of literature. Purpose To estimate the proportion of patellar fractures, patellar tendon ruptures, and QT ruptures associated with BTB or QT autograft harvest during ACLR using published data. Study Design Systematic review; Level of evidence, 4. Methods A meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using 3 online databases (PubMed, Scopus, and Web of Science). A total of 800 manuscripts were included in the initial research of peer-reviewed articles in English that reported extensor mechanism complications associated with graft harvest in patients after ACLR. Pooled proportions of patellar fractures, patellar tendon ruptures, and QT ruptures were calculated for each graft type (BTB, QT) using a random-effects model for meta-analysis. Results A total of 28 studies were analyzed. The pooled proportion of patellar fractures was 0.57% (95% CI, 0.34%-0.91%) for the BTB harvest and 2.03% (95% CI, 0.78%-3.89%) for the QT harvest. The proportion of patellar tendon ruptures was 0.22% (95% CI, 0.14%-0.33%) after the BTB harvest, and the proportion of QT ruptures was 0.52% (95% CI, 0.06%-1.91%) after the QT harvest. The majority of included studies (16/28 [57.1%]) had an evidence level of 4. Conclusion Based on the current literature, the proportion of extensor mechanism complications after ACLR using either a BTB or a QT autograft is low, indicating that the extensor mechanism harvest remains a safe option. A higher proportion of patellar fractures was noted for QT grafts and a higher proportion of donor tendon ruptures was noted for QT grafts compared with BTB grafts.
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Affiliation(s)
- Nicholas A. Trasolini
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California USA
| | - Rae Lan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California USA
| | - Ioanna K. Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California USA
| | - William Hill
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California USA
| | - Ashley A. Thompson
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California USA
| | - Cory K. Mayfield
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California USA
| | - Derrick M. Knapik
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Brian J. Cole
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Alexander E. Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California USA
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Kimura M, Nakase J, Ishikawa T, Asai K, Yoshimizu R, Kanayama T, Yanatori Y, Ozaki N, Tsuchiya H. Growth-related changes in the ultrastructure of the quadriceps tendon. Knee 2023; 42:357-363. [PMID: 37150023 DOI: 10.1016/j.knee.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/16/2023] [Accepted: 04/12/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND The purpose of this study was to investigate the effect of growth on the ultrastructural characteristics of the quadriceps tendon (QT). METHODS Eighteen included patients were classified into three groups based on age and epiphyseal plate condition: the 'immature group' consisted of patients with open epiphyseal plates (11.5 ± 1.6 years old; mean ± standard deviation), the 'young group' consisted of patients aged <20 years with closed epiphyseal plates (15.8 ± 1.0 years), and the 'adult group' consisted of all patients aged >20 years (29.8 ± 11.3 years) irrespective of epiphyseal plate condition. Tendon tissue samples were used for ultrastructural analysis by transmission electron microscopy. Minimum collagen fibril diameters were measured from the cross sections of collagen fibril images using Image J software. The average number of collagen fibers per sample was 797 ± 109, and the average collagen fibril diameter of each sample was compared using one-way analysis of variance. RESULTS The mean collagen fibril diameter was 89.7 ± 14.4 nm in the immature group, 94.8 ± 16.4 nm in the young group, and 107.2 ± 12.1 nm in the adult group, with significant differences between the immature and adult groups, and between the young and adult groups (P = 0.001 and P = 0.021, respectively); however, no significant differences were observed between the immature and young adult groups (P = 0.49). CONCLUSIONS The collagen fibril diameter of the QT was found to have increased with growth. The study provided insights into graft selection.
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Affiliation(s)
- Mitsuhiro Kimura
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan; Department of Orthopedic Surgery, National Hospital Organization, Kanazawa Medical Center, Kanazawa, Japan
| | - Junsuke Nakase
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan.
| | - Tatsuya Ishikawa
- Department of Functional Anatomy, Graduate School of Medical Science Kanazawa University, Kanazawa, Japan
| | - Kazuki Asai
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan; Department of Orthopedic Surgery, National Hospital Organization Hokuriku Hospital, Kanazawa, Japan
| | - Rikuto Yoshimizu
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Tomoyuki Kanayama
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Yusuke Yanatori
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Noriyuki Ozaki
- Department of Functional Anatomy, Graduate School of Medical Science Kanazawa University, Kanazawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
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Migliorini F, Torsiello E, Trivellas A, Eschweiler J, Hildebrand F, Maffulli N. Bone-patellar tendon-bone versus two- and four-strand hamstring tendon autografts for ACL reconstruction in young adults: a Bayesian network meta-analysis. Sci Rep 2023; 13:6883. [PMID: 37106008 PMCID: PMC10140035 DOI: 10.1038/s41598-023-33899-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 04/20/2023] [Indexed: 04/29/2023] Open
Abstract
Bone-patellar tendon-bone (BPTB), two- and four-strand hamstring tendon (4SHT and 2SHT, respectively) are the most common autografts used for anterior cruciate ligament (ACL) reconstruction. The present study compared BPTB, 2SHT, and 4SHT for ACL reconstruction in terms of joint laxity, patient reported outcome measures (PROMs), rate of failure and anterior knee pain (AKP). The time to return to sport and the peak torque between the autografts were also compared. Finally, prognostic factors leading to worse outcomes were also investigated. It was hypothesized that all grafts yield similar proprieties in terms of joint laxity, patient reported outcome measures (PROMs) and rate of failure, but that the BPTB autograft causes a greater rate of anterior knee pain (AKP). The literature search was conducted. All clinical trials comparing BTPB and/or 2SHT, and/or 4SHT were accessed. Grafts other than BTPB and/or 4SHT and/or 2SHT were not considered. Articles reporting outcomes of allografts or synthetic grafts were not eligible, nor were those concerning revision settings. Articles reporting ACL reconstruction in patients with multi-ligament damage were also not eligible. Data from 95,575 procedures were retrieved. The median length of follow-up was 36 months. The median age of the patients was 27.5 years. With regard to joint laxity, similarity was found in terms of Lachman and Pivot shift tests between all three autografts. The BPTB demonstrated the greatest stability in terms of instrumental laxity. BPTB demonstrated the greatest PROMs. BPTB demonstrated the greatest rate of AKP, while AKP in 2SHT and 4SHT was similar. Concerning failure, statistically significant inconsistency was found (P = 0.008). The 4SHT demonstrated the quickest return to sport, followed by BPTB, and 2SHT. There was evidence of a negative association between the time span between injury to surgery, Lysholm score (P = 0.04), and Tegner scale (P = 0.04). Furthermore, there was evidence of a weak positive association between the time span between injury to surgery and return to sport (P = 0.01). BPTB may result in lower joint laxity, greater PROMs, and greater peak flexion torque compared to 2SHT and 4SHT autografts. On the other hand, BPTB reported the lowest peak extension torque and the greatest rate of AKP. Finally, a longer time span between injury and surgery negatively influences outcome.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Ernesto Torsiello
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
| | - Andromahi Trivellas
- Department of Orthopaedic and Trauma Surgery, Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, 90095, USA
| | - Jörg Eschweiler
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
- School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Thornburrow Drive, Stoke on Trent, England
- Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England
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Meena A, Di Paolo S, Grassi A, Raj A, Farinelli L, Hoser C, Tapasvi S, Zaffagnini S, Fink C. No difference in patient reported outcomes, laxity, and failure rate after revision ACL reconstruction with quadriceps tendon compared to hamstring tendon graft: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2023:10.1007/s00167-023-07380-5. [PMID: 36961538 DOI: 10.1007/s00167-023-07380-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/01/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE The purpose of this study was to synthesize and quantitatively assess the outcomes of ACL Revision using a quadriceps tendon (QT) graft and to compare them with those of ACL Revisions performed with hamstring tendons (HT) graft. METHODS A comprehensive search based on the PRISMA protocol was performed across PubMed, Scopus, Embase, and Cochrane Library from inception until February 2022. Clinical studies reporting the outcomes of ACL Revision with QT autograft were included. Subjective and Objective IKDC, Tegner activity level, Lysholm knee score, KOOS score, VAS for pain, knee laxity (KT-1000/2000 arthrometer, Lachman test, and pivot-shift test), and graft failure were assessed. A systematic review and meta-analysis were performed and a quality assessment of the included studies was carried out with the MINORS score. RESULTS Seven studies met the selection criteria and were included in the systematic review for the qualitative synthesis of data. A pooled mean of all the variables was provided for the 7 studies, while 3 studies included a control group of ACL Revision with HT and were included in a meta-analysis. A total of 420 participants with a mean age of 28.9 ± 10.5 years and a mean postoperative follow-up of 39.3 ± 16.4 months were assessed. Of these, 277 patients underwent ACL Revision with QT and 143 patients underwent ACL Revision with HT. In the QT group, average graft failure was 9.8% compared to 17.4% in the HT group. KOOS Sport and pivot-shift test showed better postoperative outcomes in QT than HT, although it was not statistically significant (p = 0.052). CONCLUSION The QT autograft was associated with an improved trend of rotatory laxity, PROMs and failure rate compared to HT autograft after revision ACL reconstruction. The QT autograft for revision ACL reconstruction is supported by the current literature. It is a viable graft that should be considered for both primary and revision ACL reconstruction. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Amit Meena
- Gelenkpunkt-Sports and Joint Surgery, FIFA Medical Centre of Excellence, Olympiastraße 39, 6020, Innsbruck, Austria
- Research Unit for Orthopedic Sports Medicine and Injury Prevention (OSMI), Medical Informatics and Technology, Private University for Health Sciences, Innsbruck, Austria
- Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, ON, Canada
| | - Stefano Di Paolo
- Department for Life Quality Studies, University of Bologna, Bologna, Italy
| | - Alberto Grassi
- IIa Clinica Ortopedica E Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Akshya Raj
- Central Institute of Orthopedics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029, India
| | - Luca Farinelli
- Clinical Orthopedics, Department of Clinical and Molecular Sciences, Università Politecnica Delle Marche, Ancona, Italy
| | - Christian Hoser
- Gelenkpunkt-Sports and Joint Surgery, FIFA Medical Centre of Excellence, Olympiastraße 39, 6020, Innsbruck, Austria
- Research Unit for Orthopedic Sports Medicine and Injury Prevention (OSMI), Medical Informatics and Technology, Private University for Health Sciences, Innsbruck, Austria
| | | | - Stefano Zaffagnini
- IIa Clinica Ortopedica E Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Christian Fink
- Gelenkpunkt-Sports and Joint Surgery, FIFA Medical Centre of Excellence, Olympiastraße 39, 6020, Innsbruck, Austria.
- Research Unit for Orthopedic Sports Medicine and Injury Prevention (OSMI), Medical Informatics and Technology, Private University for Health Sciences, Innsbruck, Austria.
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Zhou Y, Fuimaono-Asafo A, Frampton C, van Niekerk M, Hirner M. Quadriceps tendon autograft is comparable to hamstring tendon and bone-patella-tendon-bone up to 2 years after isolated primary anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2023:10.1007/s00167-023-07370-7. [PMID: 36894784 DOI: 10.1007/s00167-023-07370-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 02/24/2023] [Indexed: 03/11/2023]
Abstract
PURPOSE To evaluate the functional and graft survivorship outcomes of the three most common autograft options for primary anterior cruciate ligament reconstruction (ACLR)-hamstring tendon (HT), bone-patella-tendon-bone (BPTB), and quadriceps tendon (QT). METHODS Patients captured by the New Zealand ACL registry who underwent a primary ACLR from 2014 to 2020 were considered for the study. Patients with associated knee injury (including meniscus, chondral, osseous, and additional ligamentous injury) and previous knee surgery were excluded. Comparison was made between HT, BPTB, and QT autografts with respect to Marx and KOOS (Knee Osteoarthritis Outcome Score) scores at minimum 2 years follow-up. In addition, graft survivorship was evaluated by comparing all-cause revision per 100 graft years and revision-free proportion at 2 years post-surgery. RESULTS 2,582 patients (1,921 HT, 558 BPTB, 107 QT) were included in the study. Differences in adjusted functional outcomes between HT and BPTB were found at 12 months (mean Marx; HT 6.2; BPTB 7.1; P < 0.001) (mean KOOS Sport and Recreation; HT 75.1; BPTB 70.5; n.s.) and 24 months (mean KOOS Sports and Recreation; HT 79.2; BPTB 73.9; P < 0.001). QT was comparable to HT and BPTB in all functional scores at 12 months and 2 years. No statistically significant differences were found in revision rate between all three autograft groups up to 2 years post-surgery (revision rate per 100 graft years; HT 1.05; BPTB 0.80; QT 1.68; n.s. HT vs. BPTB; n.s. HT vs. QT; n.s. QT vs. BPTB). CONCLUSIONS QT was found to be comparable to both HT and BPTB in all functional scores and revision rates up to 2 years post-surgery. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Yushy Zhou
- Whangarei Hospital, Northland District Health Board, Maunu Road, Private Bag 9742, Whangarei, 0148, New Zealand.
| | - Atua Fuimaono-Asafo
- Whangarei Hospital, Northland District Health Board, Maunu Road, Private Bag 9742, Whangarei, 0148, New Zealand
| | - Chris Frampton
- Department of Psychological Medicine, University of Otago, Otago, New Zealand
| | - Michael van Niekerk
- Whangarei Hospital, Northland District Health Board, Maunu Road, Private Bag 9742, Whangarei, 0148, New Zealand
| | - Marc Hirner
- Whangarei Hospital, Northland District Health Board, Maunu Road, Private Bag 9742, Whangarei, 0148, New Zealand
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Thor J, Han Dave LY, Tapasvi S, Beyzadeoglu T. Short graft anterior cruciate ligament reconstruction: Current concepts. J ISAKOS 2023; 8:29-36. [PMID: 36202296 DOI: 10.1016/j.jisako.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/14/2022] [Accepted: 09/23/2022] [Indexed: 11/13/2022]
Abstract
Short graft anterior cruciate igament reconstruction is increasing in popularity for performing a primary ACLR. The short graft coupled with the all-inside technique using closed sockets and suspensory fixation at both femoral and tibial ends are its defining features. The outcomes of this technique have been comparable to well established transportal ACLR techniques. It has the benefits of preserved hamstring strength and less pain attributed to transtibial drilling. However, there is a learning curve involved and will require time before mastery of the technique. Furthermore, in combined osteotomy or multiligament surgery, the use of short graft anterior cruciate ligament reconstruction with sockets preserve bone stock and the single tendon harvest spares the other tendons for use in other ligament reconstruction.
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Affiliation(s)
- Jessica Thor
- Department of Orthopaedic Surgery,Changi General Hospital, Singapore.
| | - Lee Yee Han Dave
- Department of Orthopaedic Surgery, National University Hospital, Singapore.
| | | | - Tahsin Beyzadeoglu
- Professor of Orthopedics & Traumatology Halic University & Beyzadeoglu Clinic Istanbul, Turkey.
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30
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DeFroda SF, Hanish S, Muhammad M, Cook JL, Crist B. Graft Options for Hip Labral Reconstruction. JBJS Rev 2022; 10:01874474-202212000-00001. [PMID: 36480655 DOI: 10.2106/jbjs.rvw.22.00124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
➢ Arthroscopic hip labral reconstruction is a complex procedure which is growing in use as indications, techniques, and surgical expertise advance. ➢ Graft selection is an important component of labral reconstruction based on relative advantages and disadvantages of available types of autografts and allografts. ➢ The ideal graft should mimic the native acetabular labrum form and function while also being affordable, readily available, and associated with low morbidity. ➢ High rates of patient satisfaction and positive patient-reported outcomes have been reported after labral reconstruction using several graft types.
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Affiliation(s)
- Steven F DeFroda
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Stefan Hanish
- School of Medicine, University of Missouri, Columbia, Missouri
| | - Maaz Muhammad
- School of Medicine, University of Missouri, Columbia, Missouri
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - Brett Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
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31
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Clinger B, Xerogeanes J, Feller J, Fink C, Runer A, Richter D, Wascher D. Quadriceps tendon autograft for anterior cruciate ligament reconstruction: state of the art. J ISAKOS 2022; 7:162-172. [PMID: 36096362 DOI: 10.1016/j.jisako.2022.08.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 07/29/2022] [Accepted: 08/24/2022] [Indexed: 12/24/2022]
Abstract
The ideal graft for anterior cruciate ligament reconstruction (ACLR) continues to be debated. Although first described in 1984, use of the quadriceps tendon (QT) autograft has only recently gained popularity. The biomechanical properties of the QT autograft are favourable compared to bone-patellar tendon-bone (BPTB) and doubled hamstring (HS) grafts with a higher load to failure and a modulus of elasticity that more closely approximates the native anterior cruciate ligament (ACL). The QT graft can be harvested with or without a bone plug, as either a full thickness or a partial thickness graft, and even through minimally invasive techniques. The surgeon must be aware of potential harvest risks including patellar fracture or a graft that is of insufficient length. Numerous short-term studies have shown comparable results when compared to BPTB or hamstring HS autografts with similar graft failure rates, patient-reported outcomes. A major advantage of QT ACLR is reduced donor site morbidity compared to BPTB. However, some persistent quadriceps weakness after QT ACLR has also been reported. The current literature shows that use of the QT autograft for ACLR provides equivalent clinical results compared to other autografts with less donor site morbidity. However, future studies with longer follow-up and higher level of evidence are needed to identify specific populations where the QT may have additional advantage.
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Affiliation(s)
- Bryce Clinger
- Department of Orthopaedics and Rehabilitation, University of New Mexico, Albuquerque, NM, 87131, USA
| | - John Xerogeanes
- Department of Orthopaedics, Emory University, Atlanta, GA, 30322, USA
| | | | | | - Armin Runer
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, 6020, Austria
| | - Dustin Richter
- Department of Orthopaedics and Rehabilitation, University of New Mexico, Albuquerque, NM, 87131, USA
| | - Daniel Wascher
- Department of Orthopaedics and Rehabilitation, University of New Mexico, Albuquerque, NM, 87131, USA.
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Zakharia A, Lameire DL, Abdel Khalik H, Kay J, Uddandam A, Nagai K, Hoshino Y, de Sa D. Quadriceps tendon autograft for pediatric anterior cruciate ligament reconstruction results in promising postoperative function and rates of return to sports: A systematic review. Knee Surg Sports Traumatol Arthrosc 2022; 30:3659-3672. [PMID: 35445330 DOI: 10.1007/s00167-022-06930-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/03/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the performance of the quadriceps tendon (QT) autograft in pediatric anterior cruciate ligament reconstruction (ACLR). METHODS A systematic search of MEDLINE, PubMed, and EMBASE was conducted on March 1, 2021. Studies of all levels of evidence reporting outcomes and/or complications after QT autograft ACLR in pediatric patients (≤ 18 years old) were eligible for inclusion. Study demographics, patient demographics, reported outcomes, and complications were abstracted. Screening and data abstraction were designed in accordance with PRISMA and R-AMSTAR guidelines. Descriptive statistics were presented when applicable, with data for heterogeneous outcomes presented in narrative summary fashion. RESULTS A total of 14 studies examining 596 patients (46.3% female), mean age 15.4 years, were included in this systematic review. Mean postoperative Lysholm scores ranged from 94.0 to 99.5. Mean postoperative IKDC subjective scores ranged from 75.9 to 94.0. Limb symmetry index ranged from 96.8 ± 10.4 to 100.4 ± 7.6% across multiple hop tests. Return to sports (RTS) rates ranged from 88.9 to 91.7%. Eleven studies reported postoperative complications, whereby 16 patients (4.8%) experienced contralateral complications and injuries. Forty-six patients (9.4%) experienced ipsilateral complications, including ten graft failures (2.5%) and two growth disturbances (0.6%). CONCLUSIONS QT autograft ACLR in the pediatric population retains the potential of regaining a preinjury level of knee stability, and yields promising postoperative function and rates of RTS, yielding comparable outcomes relative to HT autograft and the reference-standard BPTB ACLR that have previously been described in the literature. Moreover, use of the QT autograft is associated with low rates of postoperative complications, including graft failure and growth disturbances in this active and high-risk patient population in observational studies to date. Therefore, clinical equipoise exists to further appraise the influence of QT autograft on postoperative outcomes compared to aforementioned autograft options in a randomized control trial fashion. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | - Darius L Lameire
- Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada
| | - Hassaan Abdel Khalik
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Jeffrey Kay
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Abhilash Uddandam
- MacSports Research Program, McMaster University, Hamilton, ON, Canada
| | - Kanto Nagai
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada.
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Panas K, Salomon K, Shen V, Munassi S, Remaley DT. Minimally Invasive Anterior Cruciate Ligament With Quadriceps Tendon Graft: A Proximal-to-Distal Harvest Technique. Arthrosc Tech 2022; 11:e2067-e2072. [PMID: 36457410 PMCID: PMC9705914 DOI: 10.1016/j.eats.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/03/2022] [Indexed: 11/07/2022] Open
Abstract
Recent systematic reviews have shown anterior cruciate ligament reconstruction using quadriceps tendon (QT) grafts to have superior clinical outcomes compared with traditional bone-patella tendon-bone and hamstring tendons grafts. Using minimally invasive techniques to harvest the QT graft can reduce postoperative pain and intraoperative surgical time. This technique is usually performed with a distal-to-proximal approach but often has issues of inadvertently harvesting a graft short of the desired length or causing a hematoma. As an alternative, we introduce a minimally invasive approach with a proximal-to-distal harvest technique that results in better visualization of tissue planes, more consistent graft sizes, lower risk of inadvertent arthrotomy, and reduced risk of hematoma. The minimally invasive QT graft harvest with a proximal-to-distal approach can offer unique advantages over the current standard distal-to-proximal approach.
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Affiliation(s)
- Kenton Panas
- University of South Florida, Tampa, Florida, U.S.A.,Address correspondence to Kenton Panas, M.D., Orthopaedic Surgery, University of South Florida, 12901 Bruce B. Downs Blvd., Tampa, FL 33612.
| | | | - Victor Shen
- University of South Florida, Tampa, Florida, U.S.A
| | - Steven Munassi
- Foundation for Orthopaedic Research and Education, Tampa, Florida, U.S.A
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Bourgeault-Gagnon Y, Leang AK, Bédard S, Lebel K, Balg F, Vézina F. A Partial-Thickness Quadriceps Autograft Reliably Augments the Size of the Hamstring Graft During Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2022; 4:e2005-e2009. [PMID: 36579052 PMCID: PMC9791862 DOI: 10.1016/j.asmr.2022.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/24/2022] [Indexed: 11/06/2022] Open
Abstract
Purpose To measure the increase in diameter resulting from the augmentation of a hamstring autograft with a partial width rectus femoris tendon band in anterior cruciate ligament reconstruction. Methods Thirty-three cadaveric knees were dissected to harvest semitendinosus and gracilis tendons (4S) along with a 6-mm wide tendon band from the rectus femoris. Harvesting was done according to the usual surgical techniques of both harvests. Measures of length and diameter in 4S and 4S augmented with the rectus femoris band (4S +Q) configurations were performed separately by 3 evaluators. Results The quadriceps augmentation led to an average increase of 1.49 mm (95% confidence interval 1.03-1.95 mm) in diameter of the 4-strand hamstring grafts. The previously demonstrated threshold diameter of 8.5 mm was attained in only 30% of 4S grafts within this population in comparison with 88% when augmented with a quadriceps band. Conclusions In conclusion, supplementing doubled hamstring graft (4S) with quadricipital tendon in anterior cruciate ligament reconstruction (ACLR) increases the graft diameter by an average of 1.49 mm. It has the physical potential to reliably augment hamstring grafts that measure 7.5 mm in diameter or more in order to obtain an 8.5 mm when necessitated. Clinical Relevance Increased graft diameter is associated with a decreased risk of graft failure after ACLR. Because of this, it is important to identify methods to increase the size of grafts. This study investigates the use of a partial-width rectus femoris tendon band as an option to reliably augment graft sizes during ACLR.
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Affiliation(s)
| | | | - Sonia Bédard
- Sherbrooke University, Sherbrooke, Québec, Canada,Center for Research at the CHUS (CIUSSS de l’Estrie CHUS), Sherbrooke, Québec, Canada
| | - Karina Lebel
- Sherbrooke University, Sherbrooke, Québec, Canada,Research center on aging (CIUSSS de l’Estrie CHUS), Sherbrooke, Québec, Canada
| | - Frédéric Balg
- Sherbrooke University, Sherbrooke, Québec, Canada,Center for Research at the CHUS (CIUSSS de l’Estrie CHUS), Sherbrooke, Québec, Canada
| | - François Vézina
- Sherbrooke University, Sherbrooke, Québec, Canada,Address correspondence to Dr, François Vézina. Sherbrooke University, 3001 12th Avenue North, Sherbrooke, J1H 5H4, (Quebec), Canada.
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35
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Sim K, Rahardja R, Zhu M, Young SW. Optimal Graft Choice in Athletic Patients with Anterior Cruciate Ligament Injuries: Review and Clinical Insights. Open Access J Sports Med 2022; 13:55-67. [PMID: 35800660 PMCID: PMC9255990 DOI: 10.2147/oajsm.s340702] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/23/2022] [Indexed: 12/03/2022] Open
Abstract
Anterior cruciate ligament (ACL) rupture is a common sporting-related knee injury with a potentially detrimental impact on the athlete’s career, yet there is no formal consensus on the optimal graft choice for reconstructing the ruptured ACL in this specific population. Options for reconstruction include autograft, allograft, and artificial grafts. However, each has associated failure risk and donor site morbidity. Our operational definition of the athlete is a skeletally mature individual participating in high level activity with the expectation to return to pre-injury level of activity. The athlete has unique injury characteristics, post-operative expectations, and graft demands that differ to the general population. Long-term outcomes are of particular importance given on-going mechanical demands on the reconstructed knee. Therefore, the purpose of this review is to consolidate current literature on the various ACL reconstruction graft options, with a focus on the optimal graft for returning the athlete to activity with the lowest rate of re-injury.
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Affiliation(s)
- Katarina Sim
- Department of Orthopaedics, North Shore Hospital, Auckland, New Zealand
- Correspondence: Katarina Sim, Department of Orthopaedics, North Shore Hospital, 124 Shakespeare Road, Takapuna, Auckland, 0620, New Zealand, Email
| | - Richard Rahardja
- Department of Orthopaedics, North Shore Hospital, Auckland, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Mark Zhu
- Department of Orthopaedics, North Shore Hospital, Auckland, New Zealand
| | - Simon W Young
- Department of Orthopaedics, North Shore Hospital, Auckland, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
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Direct suturing quadriceps tendon to a continuous loop with a suspensory button provides biomechanically superior fixation in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2022; 30:2307-2313. [PMID: 34807305 DOI: 10.1007/s00167-021-06805-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/11/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To compare the biomechanical strength of different fixation configurations using suspensory buttons in a soft-tissue quadriceps tendon (QT) grafts in anterior cruciate ligament (ACL) reconstruction. METHODS Forty bovine QTs, 6-cm long and 10-mm wide, were allocated into four groups with different suture configurations using suspensory buttons (n = 10 in each group): Group A, a baseball suture with a knot tied to the continuous loop with a suspensory button; Group B, same configuration as in Group A but with the knot tied at the opposite end of the baseball suture; Group C, a continuous loop with a suspensory button stitched directly to the QT with simple sutures, and Group D, a baseball suture tied directly to a suspensory button. Biomechanical testing was performed by preloading followed by cyclic loading for 500 cycles between 10 and 100 N. The length of elongation (mm) and maximum load to failure (N) were recorded, and compared among the four groups. RESULTS Group C showed significantly smaller elongation (4.1 mm [95% CI 3.1-5.2]) than Group A (8.2 mm [95% CI 7.0-9.4]), Group B (10.5 mm [95% CI 7.7-13.3]), and Group D (8.5 mm [95% CI 7.0-9.9]) (A-C; P = 0.004, B-C; P = 0.0001, C-D; P = 0.0018). The maximum load to failure in Group C (386 N [95%CI 306-466]) was significantly higher than that in Group A (196 N [95% CI 141-251]), Group B (226 N [95% CI 164-289]), and Group D (212 N [95%CI 171-253]) (A-C; P = 0.0001, B-C; P = 0.0009, C-D; P = 0.0002). No significant differences were observed between Group A, B, and D in terms of elongation and maximum load to failure. CONCLUSION The soft-tissue QT graft fixation configuration stitched directly to a continuous loop with suspensory button using simple sutures exhibits small elongation and high maximum load to failure among the four configurations. Regarding clinical relevance, direct suturing of the soft-tissue QT to a continuous loop with a suspensory button may be advantageous for femoral fixation in ACL reconstruction from a biomechanical perspective, and warrant future development of a novel fixation device using this principle.
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Tajima T, Yamaguchi N, Morita Y, Yokoe T, Nagasawa M, Ota T, Kawagoe S, Nakamura Y, Chosa E. Remnant-Preserved Single-Bundle Anterior Cruciate Ligament Augmentation in Multi-ligamentous Knee Reconstruction. J Knee Surg 2022. [PMID: 35688445 DOI: 10.1055/s-0042-1749603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This study was conducted to present remnant-preserving anterior cruciate ligament (ACL) augmentation as a useful option for partial ACL injury in multiligament knee injury (MLKI) cases, which may also contribute to conserving graft resources. The present study involved patients diagnosed with MLKI at our institute from Spring 2006 to February 2021. A total of 71 MLKI cases were provided surgery due to knee instability and disability. For every patient, an arthroscopic diagnostic was performed to ensure that ACL tear and a remnant were present. When the ACL remnant was classified into group 2, 3, or 4 of Nakamae's classification, remnant-preserved single bundle ACL augmentation was performed. Graft selection and the combination of injured ligaments were evaluated. The side-to-side difference under an anterior tibial load of 134 N with an arthrometer and the leg symmetry index at 60 degrees/s were measured. The present procedure was performed for five cases (male/female: 4/1, mean age: 33.6 years). The mean follow-up period was 26.4 months. The combination of torn ligaments was as follows: 3 cases of ACL + medial collateral ligament, one case of ACL + posterior cruciate ligament, and one case of ACL + posterolateral corner. An ACL augmentation graft was performed using an ipsilateral gracilis tendon in 2 cases, a contralateral full semitendinosus tendon in 2 cases, and the ipsilateral distal 1/2 of the semitendinosus tendon in 1 case. The mean side-to-side difference was 1.07 ± 0.4 mm. The mean leg symmetry index was 82.6 ± 12.2% in knee extension and 96.3 ± 9.9% in knee flexion. Although the present study was a small case series, the remnant-preserved single-bundle ACL augmentation for MLKI surgery provided good clinical outcome and conserved the graft resource. Even in the MLKI case, this technique is one of the useful surgical options. The level of evidence of this study is level IV (case series).
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Affiliation(s)
- Takuya Tajima
- Department of Medicine of Sensory and Motor Organs, Division of Orthopedic Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Nami Yamaguchi
- Department of Medicine of Sensory and Motor Organs, Division of Orthopedic Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yudai Morita
- Department of Medicine of Sensory and Motor Organs, Division of Orthopedic Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Takuji Yokoe
- Department of Medicine of Sensory and Motor Organs, Division of Orthopedic Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Makoto Nagasawa
- Department of Medicine of Sensory and Motor Organs, Division of Orthopedic Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Tomomi Ota
- Department of Medicine of Sensory and Motor Organs, Division of Orthopedic Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Shuichi Kawagoe
- Department of Medicine of Sensory and Motor Organs, Division of Orthopedic Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yoshihiro Nakamura
- Department of Medicine of Sensory and Motor Organs, Division of Orthopedic Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Etsuo Chosa
- Department of Medicine of Sensory and Motor Organs, Division of Orthopedic Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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Greif DN, Shallop BJ, Allegra PR, Cade WH, Minesinger KE, Luxenburg D, Kaplan LD, Baraga MG. A Comparison of Two-Year Anterior Cruciate Ligament Reconstruction Clinical Outcomes Using All-Soft Tissue Quadriceps Tendon Autograft With Femoral/Tibial Cortical Suspensory Fixation Versus Tibial Interference Screw Fixation. Arthroscopy 2022; 38:881-891. [PMID: 34252561 DOI: 10.1016/j.arthro.2021.06.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 06/04/2021] [Accepted: 06/28/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To contribute to future quadriceps tendon harvest and fixation guidelines in the setting of anterior cruciate ligament reconstruction by comparing 2-year patient-reported subjective knee outcome scores and incidence of graft-related complications between the shorter harvest all-inside tibial-femoral suspensory fixation (TFSF) approach versus the longer harvest standard tibial interference screw fixation technique. METHODS Patients who underwent primary anterior cruciate ligament reconstruction with all soft tissue quadriceps tendon autograft from January 2017 to May 2019 were identified for inclusion. Patients were matched into 2 cohorts of 62 based on reconstruction technique. All patients completed baseline and minimum 2-year International Knee Documentation Committee, Tegner Activity Level, and Lysholm questionnaires and were queried regarding subsequent procedures and complications to the operative knee. RESULTS Average graft length for the all-inside TFSF was 69.55 (95% confidence interval 68.99-70.19) mm versus 79.27 (95% confidence interval 77.21-81.34) mm in the tibial screw fixation cohort (P = .00001). Two-year Lysholm scores were greater in the TFSF cohort (P = .04) but were not clinically significant. There was no difference in 2-year International Knee Documentation Committee (P = .09) or Tegner (P = .69) scores between cohorts, but more patients in the TFSF cohort returned to or exceeded their baseline activity level compared with the tibial screw fixation cohort (73% vs 61%, P = .25). Seven patients in the TFSF cohort versus 13 in the tibial screw fixation cohort reported anterior knee pain or kneeling difficulty (P = .22). There were no differences in reported complications. CONCLUSIONS All-inside soft-tissue quadriceps tendon autograft with TFSF resulted in clinically comparable subjective outcome scores at 2 years to tibial screw fixation. There were also no differences in complications or reports of anterior knee pain or kneeling difficulty. All-inside TFSF can be a viable alternative to tibial screw fixation for all-soft tissue quadriceps autograft. LEVEL OF EVIDENCE III, comparative therapeutic trial.
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Affiliation(s)
- Dylan N Greif
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, Florida, U.S.A..
| | - Brandon J Shallop
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, Florida, U.S.A
| | - Paul R Allegra
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, Florida, U.S.A
| | - William H Cade
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, Florida, U.S.A
| | - Kayla E Minesinger
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, Florida, U.S.A
| | - Dylan Luxenburg
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, Florida, U.S.A
| | - Lee D Kaplan
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, Florida, U.S.A
| | - Michael G Baraga
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, Florida, U.S.A
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Preoperative ultrasound predicts the intraoperative diameter of the quadriceps tendon autograft more accurately than preoperative magnetic resonance imaging for anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2022; 30:52-60. [PMID: 33459834 DOI: 10.1007/s00167-020-06408-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Sizing of potential autografts is essential to match the native anterior cruciate ligament (ACL) dimensions when performing ACL reconstruction (ACLR). We aimed to investigate the accuracy and reliability of the thickness and cross-sectional area (CSA) assessments for the prediction of the intraoperative diameter of the QT autograft using preoperative ultrasound and MRI. METHODS Thirty patients (mean age ± standard deviation, 19.9 ± 5.0 years), who underwent ACLR using QT autograft, were included. The maximum thickness of the QT was assessed at 15 and 30 mm proximal using ultrasound with a long axis image, and at 15 mm proximal to the superior pole of the patella using MRI with a sagittal image. The CSA was assessed at the central 10 mm of the medial-lateral QT width at 30 mm proximal using ultrasound with a short axis image, and at 15 mm proximal to the superior pole of the patella using MRI with an axial image. Intraoperatively, QT autograft was harvested with a 10 mm width and the diameter was measured using a graft sizing device. RESULTS Intra- and inter-observer reliabilities of all measurements using ultrasound and MRI were good (Intra-class correlation coefficient, 0.720-0.941). Correlation coefficient with the intraoperative diameter of the QT autograft was higher in ultrasound (R = 0.738-0.791, P < 0.001) than MRI (R = 0.449-0.543, P = 0.002-0.013). CONCLUSIONS Preoperative ultrasound predicted the intraoperative diameter of the QT autograft more accurately than MRI. Ultrasound may be used clinically to assure a sufficiently large QT autograft diameter to match the diameter of the patient's native ACL. LEVEL OF EVIDENCE Level III.
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Takeuchi S, Byrne KJ, Kanto R, Onishi K, Fu FH. Morphological Evaluation of the Quadriceps Tendon Using Preoperative Ultrasound in Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2022; 50:111-117. [PMID: 34786977 DOI: 10.1177/03635465211054095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND An evaluation of quadriceps tendon (QT) morphology preoperatively is an important step when selecting an individually appropriate autograft for anterior cruciate ligament (ACL) reconstruction. However, to our knowledge, there are no studies that have assessed the morphology of the entire QT in an ACL-injured knee preoperatively using ultrasound. PURPOSE We aimed to investigate the morphological characteristics of the QT using preoperative ultrasound in ACL-injured knees. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS A total of 33 patients (mean age, 26.0 ± 11.5 years) with a diagnosed ACL tear undergoing primary ACL reconstruction were prospectively included. Using ultrasound, short-axis images of the QT were acquired in 10-mm increments from 30 to 100 mm proximal to the superior pole of the patella. The length of the QT was determined by 2 contiguous images that did and did not contain the rectus femoris muscle belly. The width of the superficial and narrowest parts of the QT, the thickness of the central and thickest parts of the QT, and the cross-sectional area at the central 10 mm of the superficial QT width were measured at each assessment location. The estimated intraoperative diameter of the QT autograft was calculated using a formula provided in a previous study. RESULTS There were no significant relationships between QT morphology and any of the demographic data collected. The length of the QT was less than 70 mm in 45.5% of patients (15/33). The width, thickness, cross-sectional area, and estimated intraoperative diameter of the QT autograft were significantly greater at 30 mm than at 70 mm proximal to the superior pole of the patella. CONCLUSION Preoperative ultrasound may identify a QT that is too small for an all-soft tissue autograft in ACL reconstruction. Furthermore, harvesting a QT with a fixed width may result in autografts that are smaller proximally than they are distally. Assessing the morphology of the QT preoperatively using ultrasound may help surgeons to adequately reconstruct the native length and diameter of the ACL with a QT autograft.
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Affiliation(s)
- Satoshi Takeuchi
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, Toyohashi Medical Center, Toyohashi, Japan
| | - Kevin J Byrne
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ryo Kanto
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kentaro Onishi
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Brinlee AW, Dickenson SB, Hunter-Giordano A, Snyder-Mackler L. ACL Reconstruction Rehabilitation: Clinical Data, Biologic Healing, and Criterion-Based Milestones to Inform a Return-to-Sport Guideline. Sports Health 2021; 14:770-779. [PMID: 34903114 PMCID: PMC9460090 DOI: 10.1177/19417381211056873] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
CONTEXT Anterior cruciate ligament (ACL) reconstruction (ACLR) and postoperative rehabilitation continues to be a multidisciplinary focus in both research and clinical environments. Recent research on ACLR warrants a reexamination of clinicians' current rehabilitation practices to optimize the strikingly variable clinical outcomes after ACLR and return to sport. The purpose of the article and updated guidelines is to use contemporary evidence to systematically revisit our practice guidelines and validate our clinical milestones with data from our university-based practice. EVIDENCE ACQUISITION Using the PubMed search engine, articles that reported on ACLR rehabilitation and protocols, guidelines, graft type, healing and strain, return to sport, psychological considerations, and secondary injury prevention published from 1979 to 2020 were identified using the search terms ACLR protocols, guidelines, ACLR rehabilitation, ACL graft, ACL open kinetic chain (OKC) exercise and closed kinetic chain (CKC) exercise, ACLR return to sport, ACLR psychological factors, and ACL injury prevention. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 5. RESULTS Clinical milestones after ACLR were validated using clinical data collected from 2013 to 2017 at a university-based practice. Variables including knee joint range of motion, effusion, Knee Outcome Survey-Activities of Daily Living Scale, and quadriceps strength index were tracked throughout rehabilitation and analyzed to help inform an updated ACLR rehabilitation guideline. CONCLUSION Incorporating the latest research, combined with direct clinical data, provides a current, realistic, and clinically benchmarked strategy for ACLR rehabilitation. Commonly held clinical beliefs regarding rehabilitation after ACL injury must be challenged by the latest research to improve patient outcomes and decrease the risk of reinjury. Key updates to the practice guidelines include the use of frequent and accurate quadriceps strength testing, delayed return-to-sport timeline, immediate use of open kinetic chain exercise, criterion-based progressions for running, sprinting, plyometrics, agility, cutting/pivoting, return to competition, and the inclusion of a secondary prevention program after return to sport. STRENGTH OF RECOMMENDATION TAXONOMY (SORT) B.
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Affiliation(s)
| | - Scott B. Dickenson
- Department of Physical Therapy,
University of Delaware, Newark, Delaware
| | - Airelle Hunter-Giordano
- Department of Physical Therapy,
University of Delaware, Newark, Delaware,Airelle Hunter-Giordano,
PT, DPT, OCS, SCS, Department of Physical Therapy, University of Delaware, 540
South College Avenue, Suite 160, Newark, DE 19713 (
) (Twitter: @AirelleGiordano)
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Abstract
In the last decade, there have been significant advances in our understanding of anterior cruciate ligament (ACL) reconstruction. Recent prospective cohort studies have identified risk factors for ACL reconstruction graft failure such as younger patient age, increased activity level, nonanatomic tunnel placement, and the use of allograft. Among these, the most easily modifiable risk factor is graft choice. Given that the surgeon's recommendation has been shown to be one of the most important factors behind patients' graft choice, it is critical that the operating surgeon have a thorough understanding of all the ACL graft options available to choose the graft that would be most suitable for the patient's personalized reconstruction (i.e., patient's anatomy, sport, level of competition, age, risk factors for failure, and graft used in previous ACL surgery). The purpose of this review is to provide an up-to-date understanding of the current ACL graft reconstruction options. The indications, advantages, and disadvantages of the different ACL reconstruction graft options available will be discussed.
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Karpinski K, Häner M, Bierke S, Diermeier T, Petersen W. Comparing Knee Laxity After Anatomic Anterior Cruciate Ligament Reconstruction Using Quadriceps Tendon Versus Semitendinosus Tendon Graft. Orthop J Sports Med 2021; 9:23259671211014849. [PMID: 34368380 PMCID: PMC8312171 DOI: 10.1177/23259671211014849] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 01/12/2021] [Indexed: 01/08/2023] Open
Abstract
Background: The choice of graft in anterior cruciate ligament (ACL) reconstruction is still under discussion. The hamstrings are currently the most used grafts for primary ACL reconstruction in Europe. However, increased interest has arisen in the quadriceps tendon (QT) as an alternative autologous graft option for primary ACL reconstruction. Purpose: To evaluate knee stability and the subjective outcome after ACL reconstruction using either autologous QT graft in implant-free femoral press-fit fixation technique or semitendinosus tendon (ST) graft. Study Design: Cohort study; Level of evidence, 2. Methods: We evaluated 50 patients who underwent ACL reconstruction, including 25 patients who received autologous ipsilateral QT graft (QT group) and 25 patients who received the ipsilateral ST graft (ST group). The follow-up for this prospective comparative study was at least 2 years after surgery, comprising KT-1000 arthrometer testing, pivot-shift test, Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm score, and rerupture rate. Results: The mean patient age was 31.72 years (9 women, 16 men) in the QT group and 32.08 years (13 women, 12 men) in the ST group. The mean ± standard deviation postoperative side-to-side difference assessed using KT-1000 arthrometer was 1.56 ± 1.56 mm for the QT group and 1.64 ± 1.41 mm for the ST group, with no significant difference. No significant difference was found on any of the KOOS subscale scores (P = .694) or the Lysholm score (P = .682). No rerupture or positive pivot-shift test occurred during follow-up. No difference was found in donor-site morbidity between the study groups. Conclusion: Clinical outcomes were not significantly different between QT and ST grafts in the current study. Thus, the QT may serve as a good alternative graft for primary ACL reconstruction.
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Bone Mesenchymal Stem Cells Contribute to Ligament Regeneration and Graft-Bone Healing after Anterior Cruciate Ligament Reconstruction with Silk-Collagen Scaffold. Stem Cells Int 2021; 2021:6697969. [PMID: 33981343 PMCID: PMC8088362 DOI: 10.1155/2021/6697969] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/25/2021] [Accepted: 04/15/2021] [Indexed: 11/29/2022] Open
Abstract
Anterior cruciate ligament (ACL) reconstruction was realized using a combination of bone mesenchymal stem cells (BMSCs) and silk–collagen scaffold, and an in vivo evaluation of this combination was performed. By combining type I collagen and degummed silk fibroin mesh, silk–collagen scaffolds were prepared to simulate ligament components. BMSCs isolated from bone marrow of rabbits were cultured for a homogenous population and seeded on the silk–collagen scaffold. In the scaffold and BMSC (S/C) group, scaffolds were seeded with BMSCs for 72 h and then rolled and used to replace the ACL in 20 rabbits. In the scaffold (S) group, scaffolds immersed only in culture medium for 72 h were used for ACL reconstruction. Specimens were collected at 4 and 16 weeks postoperatively to assess ligament regeneration and bone integration. HE and immunohistochemical staining (IHC) were performed to assess ligament regeneration in the knee cavity. To assess bone integration at the graft–bone interface, HE, Russell–Movat staining, micro-CT, and biomechanical tests were performed. After 4 weeks, vigorous cell proliferation was observed in the core part of the scaffold in the S/C group, and a quantity of fibroblast-like cells and extracellular matrix (ECM) was observed in the center part of the graft at 16 weeks after surgery. At 4 and 16 weeks postoperatively, the tenascin-C expression in the S/C group was considerably higher than that in the S group (4 w, p < 0.01; 16 w, p < 0.01). Furthermore, bone integration was better in the S/C group than in the S group, with histological observation of trabecular bone growth into the graft and more mineralized tissue formation detected by micro-CT (4 w, bone volume fraction (BV/TV), p = 0.0169, bone mineral density (BMD), p = 0.0001; 16 w, BV/TV, p = 0.1233, BMD, p = 0.0494). These results indicate that BMSCs promote ligament regeneration in the knee cavity and bone integration at the graft–bone interface. Silk–collagen scaffolds and BMSCs will likely be combined for clinical practice in the future.
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Buerba RA, Zaffagnini S, Kuroda R, Musahl V. ACL reconstruction in the professional or elite athlete: state of the art. J ISAKOS 2021; 6:226-236. [PMID: 34272299 DOI: 10.1136/jisakos-2020-000456] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 10/27/2020] [Accepted: 11/07/2020] [Indexed: 01/26/2023]
Abstract
Anterior cruciate ligament (ACL) injuries are on the rise at all levels of sport, including elite athletics. ACL injury can have implications on the athlete's sport longevity, as well as other long-term consequences, such as the development of future knee osteoarthritis. In the elite athlete, ACL injury can also have ramifications in terms of contract/scholastic obligations, sponsorships and revenue-generating potential. Although the goal of anterior cruciate ligament reconstruction (ACLR) is to return any athlete to the same preinjury level of sport, management of ACL injuries in the elite athlete come with the additional challenge of returning him or her to an extremely high level of physical performance. Despite outcome studies after ACLR in elite athletes showing a high return-to-sport rate, these studies also show that very few athletes are able to return to sport at the same level of performance. They also show that those athletes who undergo ACLR have careers that are more short-lived in comparison to those without injury. Thus, returning an elite athlete to 'near peak' performance may not be good enough for the athletic demands of elite-level sports. A possible explanation for the variability in outcomes is the great diversity seen in the management of ACL injuries in the elite athlete in terms of rehabilitation, graft choices, portal drilling and reconstruction techniques. Recently, the advent of anatomical, individualised ACLR has shown improved results in ACLR outcomes. However, larger-scale studies with long-term follow-ups are needed to better understand the outcomes of modern ACLR techniques-particularly with the rise of quadriceps tendon as an autograft choice and the addition of lateral extra-articular tenodesis procedures. The purpose of this article was thus to provide an up-to-date state-of-the-art review in the management of ACL injuries in the elite athlete.
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Affiliation(s)
| | - Stefano Zaffagnini
- 2nd Orthopaedic Surgery and Traumatology Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Ryosuke Kuroda
- Orthopaedic, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Volker Musahl
- Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Escudeiro de Oliveira D, Picchi Zaccharias V, Mayumi Horita M, Gabriel Betoni Guglielmetti L, Duarte Junior A, Baches Jorge P. Anterior Cruciate and Anterolateral Ligament Reconstruction Using Hamstring and Peroneus Longus Tendons: Surgical Technique Description. Arthrosc Tech 2021; 10:e397-e402. [PMID: 33680771 PMCID: PMC7917200 DOI: 10.1016/j.eats.2020.10.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/17/2020] [Indexed: 02/03/2023] Open
Abstract
The main objective of this study is to describe a surgical technique that combines intra- and extra-articular techniques using the semitendinosus, gracilis, and peroneus longus to perform reconstruction of the anterior cruciate ligament and anterolateral ligament. This technique offers a more stable, fast, low-cost, and widely accessible procedure and consists of drilling 3 tunnels-1 femoral and 2 tibial tunnels-in which the grafts are fixed with interference screws. The fact that the peroneus longus graft is long and thick allows for robust reconstruction of the aforementioned ligaments.
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Affiliation(s)
- Diego Escudeiro de Oliveira
- Address correspondence to Diego Escudeiro de Oliveira, M.D., R. Dr. Cesário Mota Júnior, 61, Vila Buarque, São Paulo (SP), Brazil 01221-020.
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Posterior cruciate ligament injuries: what do we really know? Knee Surg Sports Traumatol Arthrosc 2021; 29:669-671. [PMID: 33483766 PMCID: PMC7917039 DOI: 10.1007/s00167-020-06425-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 12/18/2020] [Indexed: 11/30/2022]
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Open Full-Thickness Quadriceps Tendon Autograft Harvest With Repair for Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2020; 9:e1459-e1465. [PMID: 33134047 PMCID: PMC7587024 DOI: 10.1016/j.eats.2020.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/05/2020] [Indexed: 02/03/2023] Open
Abstract
Historically, one of the most common graft choices for anterior cruciate ligament (ACL) reconstruction in the pediatric population has been the hamstring autograft. Although pediatric ACL reconstructions with a hamstring autograft have allowed a majority of children and adolescents to return to athletics, it has been reported that anywhere between 6% and 38% of these patients will go on to experience subsequent graft rupture. The quadriceps tendon autograft is an alternative to the hamstring tendon autograft that demonstrates superior preliminary outcomes, and we currently recommend it for skeletally immature patients undergoing primary and revision ACL reconstruction. This paper aims to describe our technique for an open full-thickness quadriceps tendon harvest with repair.
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