Double-bundle non-anatomic ACL revision reconstruction with allograft resulted in a low revision rate at 10 years

Comparison of clinical, radiological, and second-look arthroscopic outcomes between hamstring autograft and tibialis allograft following remnant-tensioning anterior cruciate ligament reconstruction

BACKGROUND

The remnant-tensioning (RT) anterior cruciate ligament reconstruction (ACLR) has been reported to have excellent postoperative outcomes. However, the influence of graft selection on postoperative outcomes of autografts and allografts after RT-ACLR has been poorly investigated. The purpose of our study was to compare the clinical, radiological, and second-look arthroscopic outcomes of autografts and allografts following RT-ACLR.

METHODS

Between January 2013 and May 2020, 94 and 64 patients were enrolled in auto (hamstring tendon) and allo (tibialis tendon) groups, respectively. For subgroup analysis, patients were divided into two age categories: ≤34 and > 34 years of age. Stability tests, including the Lachman and Pivot shift tests, side-to-side differences on Telos stress radiographs and KT-2000 arthrometer, patient-reported outcome measurements (PROMs), and graft status on postoperative magnetic resonance imaging (MRI) and second-look arthroscopy, were evaluated and compared between the two groups.

RESULTS

The two groups showed no statistically significant differences in stability outcomes or PROMs for patients aged ≤ 34 and > 34 years. Furthermore, both groups demonstrated comparable postoperative graft status on postoperative MRI and second-look arthroscopy analyses in patients aged ≤ 34 and > 34 years.

CONCLUSION

RT-ACLR using allografts yielded similar postoperative clinical outcomes, MRI findings, and second-look results compared to autografts, irrespective of patients' age. Therefore, allografts may serve as a viable option for patients scheduled for RT-ACLR.

Patients Have Similar Clinical Outcomes and Failure Rates After Anterior Cruciate Ligament Reconstruction With Tibialis Anterior Tendon, Bone-Patellar Tendon-Bone, Hamstring Tendon, or Achilles Tendon Allografts: A Systematic Review

Purpose

To compare postoperative outcomes and functionality in patients who undergo primary allograft anterior cruciate ligament reconstruction (ACLR) with tibialis anterior (TA) tendon, bone-patellar tendon-bone (BPTB), hamstring tendon (HT), and Achilles tendon allografts.

Methods

In April 2024, a comprehensive search of the PubMed, Embase, and Cochrane Library databases was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Studies were included if they evaluated primary ACLR using allograft, were prospective randomized controlled trials or retrospective studies, compared outcomes in patients undergoing primary ACLR with different allograft types, and were published between 2000 and 2024. Data collection included patient demographic characteristics, graft type, activity level, drilling technique, concomitant and augmentation procedures, patient-reported outcome measures, complications, and graft rerupture rates. Pooling of data was avoided, and qualitative data comparison was conducted.

Results

The initial search identified 957 studies, 7 of which were included in this systematic review. Of these, 5 were randomized controlled trials and 2 were retrospective studies. A total of 735 patients were included, with 167 HT patients, 252 BPTB patients, 162 TA patients, and 153 Achilles patients. The mean ages within the cohorts ranged from 23.9 to 37.2 years. The mean follow-up times across studies ranged from 25.6 to 90.0 months. Demographic characteristics were similar among the graft cohorts, and each study had a low risk of bias. Failure rates ranged from 2% to 65% across studies. Similar International Knee Documentation Committee, Lysholm, and Tegner scores were reported among the graft types. Additionally, similar functional outcomes as measured by side-by-side differences in arthrometer readings and similar complication rates after primary ACLR with HT, BPTB, TA, and Achilles allografts were found.

Conclusions

Primary ACLR with allografts in patients older than 23 years is safe and effective with few differences in patient-reported outcomes, postoperative function, and graft failure rates among graft options.

Level of Evidence

Level IV, systematic review of Level I to IV studies.

Bone Patella Bone allografts show superior outcomes in revision ACL reconstruction: A systematic review and meta-analysis

BACKGROUNDS AND AIMS

This study explores the impact of allograft selection in revision ACL reconstruction (RACLR). Allografts reduce donor-site morbidity and surgery duration but are costly and may prolong graft integration times. We aimed to assess various allograft subtypes for their efficacy and failure rates in RACLR.

MATERIALS AND METHODS

Following Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines and a pre-defined protocol (ID: CRD42023432517), a systematic review of Cochrane Library, Embase, MEDLINE, Web of Science, and Scopus was performed for allograft studies. The primary outcome was failure rate (graft re-rupture/revision). Secondary outcomes included functional scores, infection rates, and return to sport levels. The meta-analysis weighted studies by standard error.

RESULTS

Studies assessing Bone Patella Bone (BPTB), Tibialis Anterior, and Achilles allografts were included. The results indicate non-statistically significant odds ratios when comparing re-rupture rates for BPTB versus both Achilles (OR 3.69) and Tibialis Anterior (OR 1.26) with low or no heterogeneity. Tibialis Anterior displayed a lower failure rate than Achilles (OR 1.26 vs. 3.69). Secondary outcomes favoured BPTB, showing positive KOOS and IKDC scores, while Achilles reported Lysholm scores (83.8 ± 11.3) and 62% return to sport. Tibialis Anterior outcomes included a Lysholm score (92 ± 4.0).

CONCLUSION

This study provides insights into graft selection for RACLR. BPTB demonstrated favourable graft failure rates compared to Tibialis Anterior and Achilles allografts. No statistically significant differences were observed in other outcomes between subtypes, emphasising the need for standardised reporting in RACLR studies and supporting avenues for future research.

Peracetic acid sterilized tendon and ligament allografts for knee reconstruction : For anterior cruciate ligament (ACL), posterior cruciate ligament (PCL) and complex knee surgery

BACKGROUND

The use of allografts and autografts has been met with mixed views on whether allografts are a suitable alternative to autografts.

QUESTION

We aimed to investigate if chemically sterilized allografts show similar rerupture rates to those reported in the literature for allografts and autografts in anterior (ACL) and posterior cruciate ligaments (PCL) and complex knee surgery.

MATERIALS AND METHODS

Retrospective data on knee reconstructions performed between 2011 and 2015 with tendon/ligamnet allografts sterilized with peracetic acid were collected in the form of a questionnaire. The inclusion criteria of 2 years for each patient were met by 38 patients, representing 22 ACL reconstructions, 5 PCL reconstructions, 3 OTHER surgeries, including the Larson technique and medial patellofemoral ligament (MPFL) reconstruction and 8 COMPLEX surgeries. The main endpoints were rerupture and complication rate. Secondary endpoints included stability of the knee (Lachman test, Pivot shift test) and the range of motion.

RESULTS

The rerupture rate was 7.9% (3 grafts). Reruptures only occurred in the ACL group. No reruptures were observed in the PCL, OTHER and COMPLEX surgery groups. Stability improved significantly after surgery and the range of motion returned to values similar to that of healthy knees.

CONCLUSIONS

Tendon allografts sterilized with peracetic acid show promising low rerupture rates and good clinical scores and the results are comparable to the literature on autografts and other allografts.

Serial change of femoral and tibial tunnel width after anterior cruciate ligament reconstruction with allograft

PURPOSE

To investigate progressive tunnel widening and its correlation with postoperative outcomes after anterior cruciate ligament (ACL) reconstruction using allografts.

METHODS

Sixty-five patients who underwent ACL reconstruction using a tibialis anterior allograft between 2015 and 2017 were enrolled. Femoral and tibial tunnel widths were measured on anteroposterior (AP) and lateral radiographs immediately and at 3, 6, 12, and 24 months postoperatively. Average femoral and tibial tunnel widths in AP and lateral views were calculated at three different measurement points. Tunnel widening was calculated as the difference in tunnel width immediately and 2 years postoperatively. The correlation between tunnel widening and the postoperative results was analysed.

RESULTS

Tunnel width changes between immediate and 2 years postoperatively were as follows, in AP and lateral views, respectively: femur, 3.0 mm ± 1.5 mm and 2.4 mm ± 1.4 mm; and tibia, 2.8 mm ± 1.4 mm and 2.9 mm ± 1.5 mm. Femoral tunnel widths significantly increased until 1 year, but not from 1 to 2 years postoperatively. Tibial tunnel width significantly increased until 2 years postoperatively. In all tunnels, the increments in tunnel widening decreased over time. Increased knee laxity significantly correlated with greater femoral tunnel widening in AP (r = 0.346, P = 0.006) and lateral views (r = 0.261, P = 0.049).

CONCLUSION

Femoral tunnel widths gradually increased until 1 year postoperatively, and tibial tunnel widths increased until 2 years after ACL reconstruction with allografts. The tunnel widening rate gradually decreased over time. Femoral tunnel widening of 3.7 mm and 3.2 mm on AP and lateral views, respectively, were the cut-off values for postoperative knee laxity.

LEVEL OF EVIDENCE

Level III.

The posterior cruciate ligament index as a reliable indirect sign of anterior cruciate ligament rupture is associated with the course of knee joint injury

PURPOSE

The objective of this study was to clarify the clinical value of the posterior cruciate ligament index (PCLI) in anterior cruciate ligament (ACL) rupture, to explore the relationship between the PCLI and course of disease, and to identify the influencing factors of the PCLI.

METHODS

The PCLI was defined a quotient of the X (the tibial and femoral PCL attachments) and the Y (the maximum perpendicular distance from X to the PCL). A total of 858 patients were enrolled in this case-control study, including 433 patients with ACL ruptures who were assigned to the experimental group and 425 patients with meniscal tears (MTs) who were allocated to the control group. Some patients in the experimental group have collateral ligament rupture (CLR). Information, such as the patient's age, sex, and course of disease, was recorded. All patients underwent magnetic resonance imaging (MRI) preoperatively, and the diagnosis was confirmed with the aid of arthroscopy. The PCLI and the depth of the lateral femoral notch sign (LFNS) were calculated based on the MRI findings, and the characteristics of the PCLI were explored.

RESULTS

The PCLI in the experimental group (5.1 ± 1.6) was significantly smaller than that in the control group (5.8 ± 1.6) (P < 0.05). The PCLI gradually decreased with time and was only 4.8 ± 1.4 in patients in the chronic phase (P < 0.05). This change was not due to the decrease in X but rather the increase in Y. The results also showed that the PCLI was not related to the depth of the LFNS or injuries of other structures in the knee joint. Furthermore, when the optimal cut-off point of the PCLI was 5.2 (area under the curve = 71%), the specificity and the sensitivity were 84% and 67%, respectively, but the Youden index was just 0.3 (P < 0.05).

CONCLUSION

The PCLI decreases due to the increase in Y instead of the decrease in X with time, especially in the chronic phase. The change in X in this process may be offset during imaging. In addition, there are fewer influencing factors that lead to changes in the PCLI. Therefore, it can be used as a reliable indirect sign of ACL rupture. However, it is difficult to quantify the diagnostic criteria of the PCLI in clinical practice. Thus, the PCLI as a reliable indirect sign of ACL rupture is associated with the course of knee joint injury, and it can be used to describe the instability of the knee joint.

LEVELS OF EVIDENCE

III.

Good stability and mid-term subjective outcomes after repeated anterior cruciate ligament (ACL) revision surgery using allografts

PURPOSE

To evaluate the mid-term clinical outcomes of a cohort of patients who underwent multiple ACL revision reconstructions. The hypothesis was that patients with pre-existing meniscal deficiency conditions, malalignment and cartilage degeneration would have obtained lower results.

METHODS

All cases of multiple ACL revisions performed with allograft tissue at one single sport-medicine institution were extracted and patients with a minimum 2 years of follow-up were included. WOMAC, Lhysolm, IKDC, and Tegner activity level before the injury and at last follow-up was collected and laxity evaluated with KT-1000 arthrometer and KiRA triaxial accelerometer.

RESULTS

From a cohort of 241 ACL revisions, 28 patients (12%) with Repeated ACL Revision reconstructions were included. Fourteen cases (50%) were considered "Complex" due to the addition of meniscal allograft transplantation (8) or meniscal scaffold (3) or high tibial osteotomy (3). The remaining 14 cases (50%) were considered as "Isolate". The mean WOMAC score was 84.6 ± 11.4, Lysholm 81.7 ± 12.3, subjective IKDC 77.2 ± 12.1, and median Tegner score 6 (IQR 5-6) at pre-injury and at final follow-up. Statistically significant inferior values of WOMAC (p = 0.008), Lysholm (p = 0.02) and Subjective IKDC (p = 0.0193) were detected between "Complex" and "Isolate" revision groups. Higher average values of anterior translation at KT-1000 at both 125 N (p = 0.03) and manual maximum displacement test (p = 0.03) were reported in "Complex" with respect to "Isolate" revisions. Four patients were considered as failures and occurred in patients with "Complex" revisions, none occurred in the "Isolate" (30% vs 0%; p = 0.04).

CONCLUSION

Good mid-term clinical results can be obtained after repeated ACL revision with allograft in patients who experienced multiple failures; however, those who need additional procedure due to malalignment or post-meniscectomy syndrome reported lower objective and subjective results.

LEVEL OF EVIDENCE

III.