Comparison of Clinical Outcomes after Revision Anterior Cruciate Ligament Reconstruction using a Bone-patellar Tendon-bone Autograft and that Using a Double-Bundle Hamstring Tendon Autograft

Purpose The purpose of this study was to compare clinical outcomes between revision anterior cruciate ligament reconstruction (ACLR) using a bone-patellar tendon-bone (BPTB) autograft and that using a double-bundle hamstring tendon (HT) autograft. Methods Consecutive cases of revision ACLRs were reviewed. The Lysholm knee scale and Knee Osteoarthritis Outcome Score (KOOS) were recorded at the final follow-up. The pivot shift test, Lachman test, and anterior knee laxity measurement using an arthrometer were evaluated before revision ACLR and at final follow-up. Contralateral knee laxity was also evaluated, and side-to-side differences noted. The Lysholm knee scale, KOOS, the pivot shift test, Lachman test, and anterior knee laxity were compared between HT versus BPTB autograft recipient groups using the Mann–Whitney test or the t-test. Results Forty-one patients who underwent revision ACLR and followed up for at least 2 years were included. The graft source was a BPTB autograft in 23 patients (BPTB group) and a double-bundle HT autograft in 18 patients (HT group). The mean postoperative follow-up period was 44 ± 28 months in the BPTB group and 36 ± 18 in the HT group (p = 0.38). The HT group had significantly higher KOOS in the pain subscale (less pain) than the BPTB group at the final follow-up (BPTB group 84.2 vs. HT group 94.4; p = 0.02). The BPTB group showed significantly smaller side-to-side difference in anterior knee laxity (superior stability) than the HT group (0.3 vs. 2.6 mm; p < 0.01). The percentage of patients with residual anterior knee laxity in the BPTB group was significantly lower than that in the HT group (9.5% vs. 46.7%; odds ratio, 8.3; p = 0.02). Study Design This was a level 3 retrospective study. Conclusion Revision ACLR with a BPTB autograft was associated with superior results regarding restoration of knee joint stability as compared with that with a double-bundle HT autograft, whereas double-bundle HT autograft was superior to BPTB autograft in terms of patient-reported outcomes of pain. The rest of the patient-reported outcomes were equal between the two groups.

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

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

Comparison of anterior knee laxity, stiffness, genu recurvatum, and general joint laxity in the late follicular phase and the ovulatory phase of the menstrual cycle

Background One risk factor for anterior cruciate ligament (ACL) injury may be fluctuations in female hormones. This study examined variability in joint laxity, as a risk factor for ACL injury, during the menstrual cycle. Methods Subjects were 15 female university students with regular menstrual cycles. We measured estradiol (E2) concentration, anterior knee laxity (AKL), stiffness, genu recurvatum (GR), and general joint laxity (GJL) during the late follicular and ovulatory phases. AKL was measured as anterior tibial displacement of the femur after application of 44-, 89-, and 133-N loads on the tibia. Stiffness was calculated as Δforce/Δdisplacement at loads of 44–89 N and between 89 and 133 N. GR was measured prone, with the base of the patella distal to the edge of the bed. The University of Tokyo joint laxity test was used to evaluate GJL. Results E2 concentration was significantly higher in the ovulatory phase than in the late follicular phase (p = 0.018), AKL and stiffness did not differ significantly between phases, and GR and GJL were significantly higher in the ovulatory phase than in the late follicular phase (p = 0.011, 0.031). Conclusion These findings suggest that E2 concentrations may affect GR and GJL during the menstrual cycle.

Anterior Cruciate Ligament Reconstruction Using Autologous Hamstrings Augmented With the Ligament Augmentation and Reconstruction System Versus Hamstrings Alone: A Comparative Cohort Study

Background: Few studies have reported the return-to-sports (RTS) rate in patients after augmentation of autologous anterior cruciate ligament reconstruction (ACLR) with the Ligament Augmentation and Reconstruction System (LARS). Purpose/Hypothesis: The purpose of this study was to compare postoperative outcomes in patients who underwent ACLR with single-bundle 4-strand hamstring autograft either without augmentation (HA-ACLR group) or with LARS augmentation (AUG-ACLR group). It was hypothesized that clinical outcomes and RTS rates would be better in the AUG-ACLR group at the 1-year follow-up, with similar outcomes in both cohorts by 2 years. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent ACLR between April 2014 and December 2017 were included in the current comparative study if they were skeletally mature and had 1- and 2-year follow-up outcomes; patients with concomitant meniscal surgery were also included. Included were 66 patients with AUG-ACLR (mean age, 26.8 years; 67% male) and 130 patients with HA-ACLR (mean age, 27.5 years; 61% male). Subjective outcome measures included the International Knee Documentation Committee Subjective Knee Evaluation Form, Knee injury and Osteoarthritis Outcome Score, Lysholm scale, Tegner activity scale, and the Noyes sports activity rating scale. Objective measures included knee laxity, maximal isokinetic knee flexion and extension strength, and the results of 4 functional hop tests. Results: There were no significant differences between the study groups in age, sex distribution, body mass index, time to surgery, or number of concurrent meniscal surgeries. At the 1-year follow-up, the AUG-ACLR group had a significantly higher Tegner score ( P = .001) and rates of RTS ( P = .029) and return to preinjury level of sport ( P = .003) compared with the HA-ACLR group. At the 2-year follow-up, there were no differences in these measures between groups. There were no between-group differences in other subjective outcomes, knee laxity, or strength and hop test results at either postoperative time point. There were also no differences in rerupture rates or other complications between the groups. Conclusion: Patients with AUG-ACLR had higher 1-year postoperative Tegner scores and rates of RTS and preoperative sport level compared with the HA-ACLR group. The 2-year rerupture rate for the AUG-ACLR group was low, and no intra-articular inflammatory complications were noted.

Double bundle ACL reconstruction leads to better restoration of knee laxity and subjective outcomes than single bundle ACL reconstruction

Purpose The purpose of this meta-analysis is to compare arthroscopic single bundle (SB) and double bundle (DB) anterior cruciate ligament (ACL) reconstructions in the light of all available randomised controlled trials (RCTs). A meta-analysis of this well-researched topic was performed and subgroup analyses of the medial portal (MP) technique and the transtibial technique (TT) were added as a new idea. The hypothesis was that the DB technique is superior to the SB technique also in subgroup analyses of the MP and TT techniques. Methods Instructions of the PRISMA checklist were followed. Systematic literature search from electronic databases, including PubMed, Cochrane library and Scopus was performed to find RCTs that compared the SB and DB techniques. Nine outcomes were used to compare these two techniques. Each study was assessed according to the Cochrane Collaboration’s risk of bias tool and three subgroup analyses (minimum 2-years’ follow-up, TT technique and MP technique) were performed. Results A total of 40 studies were included in this meta-analysis. When analysing all the included studies, the DB technique was superior to the SB technique in KT-1000/2000 evaluation (p < 0.01), IKDC subjective evaluation (p < 0.05), Lysholm scores (p = 0.02), pivot shift (p < 0.01) and IKDC objective evaluation (p = 0.02). Similar results were also found in the subgroup analyses of minimum 2-years’ follow-up and the TT technique. However, there were no differences between the two techniques in a subgroup analysis of the MP technique. Conclusion Generally, DB ACL reconstruction leads to better restoration of knee laxity and subjective outcomes than SB ACL reconstruction. The subgroup analysis of the MP technique revealed that surgeons can achieve equally as good results with both techniques when femoral tunnels are drilled through the medial portal. Level of evidence II.

Arthroscopic Centralization for Lateral Meniscal Injuries Reduces Laxity in the Anterior Cruciate Ligament–Reconstructed Knee

Background: A lateral meniscal (LM) disorder is one factor that causes rotational laxity after anterior cruciate ligament (ACL) reconstruction (ACLR). There are different types of irreparable meniscal disorders, one of which is a massive meniscal defect. Hypothesis/Purpose: The purpose of this study was to evaluate the kinematic effects of arthroscopic centralization on an irreparable LM defect. The hypothesis was that arthroscopic centralization for an irreparable LM defect with concomitant ACLR would improve knee rotational stability. Study Design: Controlled laboratory study. Methods: A total of 14 fresh-frozen human cadaveric knees were tested in 4 states: (1) intact ACL and intact lateral meniscus, (2) reconstructed ACL and intact lateral meniscus, (3) reconstructed ACL and lateral meniscus defect, and (4) reconstructed ACL and centralized lateral meniscus. Anatomic ACLR was performed using an 8 mm–diameter hamstring tendon graft. An LM defect (20% of the anteroposterior length) was created arthroscopically, and arthroscopic centralization was performed. Kinematics were analyzed using a 6 degrees of freedom robotic system under 4 knee loads: (1) an 89.0-N anterior tibial load, (2) a 5.0-N·m external rotation tibial torque, (3) a 5.0-N·m internal rotation tibial torque, and (4) a simulated pivot-shift load with a combined 7.0-N·m valgus and 5.0-N·m internal rotation tibial torque. Results: LM centralization reduced anterior tibial translation similar to that of the ACLR intact LM state under anterior tibial loading (~2 mm at 30° of flexion) and showed 40% to 100% of tibial displacement in the 4 knee states under simulated pivot-shift loading. The procedure overconstrained the knee under internal rotation tibial torque and simulated pivot-shift loading. Conclusion: Arthroscopic centralization reduced knee laxity after ACLR for a massive LM defect in a cadaveric model. Clinical Relevance: In cases involving irreparable LM injuries during ACLR, consideration should be given to arthroscopic centralization for reducing knee laxity. However, the procedure may overconstrain the knee in certain motions.

Severe bicompartmental bone bruise is associated with rotatory instability in anterior cruciate ligament injury

Purpose The presence and severity of bone bruise is more and more investigated in the non-contact anterior cruciate ligament (ACL) injury context. Recent studies have advocated a correlation between bone bruise and preoperative knee laxity. The aim of the present study was to investigate the correlation between bone bruise and preoperative rotatory knee laxity. Methods Twenty-nine patients (29.1 ± 9.8 years) with MRI images at a maximum of 3 months after ACL injury (1.6 ± 0.8 months) were included. The bone bruise severity was evaluated according to the International Cartilage Repair Society (ICRS) scale for lateral femoral condyle, lateral tibial plateau, medial femoral condyle, and medial tibial plateau. The intraoperative rotational knee laxity was evaluated through a surgical navigation system in terms of internal–external rotation at 30° and 90° of knee flexion (IE30, IE90) and internal–external rotation and acceleration during pivot-shift test (PS IE, PS ACC). The KOOS score was also collected. The association between ICRS grade of bone bruise and rotational laxity or KOOS was investigated. Results Significant correlation (p < 0.05) was found between the bone bruise severity on the medial tibial plateau and rotational laxity (IE90, PS IE, and PS ACC) and between the severity of bone bruise on femoral lateral condyle and KOOS-Symptoms sub-score. The presence of bone bruise on the medial tibial plateau was significantly associated with a lateral femoral notch sign > 2 mm (very strong odds ratio). No kinematical differences were found between none-to-deep and extensive-generalized lateral bone bruise, while higher IE30 and IE90 were found in extensive-generalized bicompartmental bone bruise than isolated extensive-generalized lateral bone bruise. Conclusion A severe bicompartmental bone bruise was related to higher rotatory instability in the intraoperative evaluation of ACL deficient knees. The severity of edema on the medial tibial plateau was directly correlated with higher intraoperative pivot shift, and the size of edema on the lateral femoral condyle was associated with lower preoperative clinical scores. Level of evidence Level II.