• acl reconstruction
• anterior cruciate ligament
• functional recovery
• graft choices
• knee stability
• outcome analysis
• surgical techniques

• allograft
• anterior cruciate ligament reconstruction
• dehydrated human amnion chorion membrane
• signal-to-noise ratio
• tegnor lysholm score

• anterior cruciate ligament
• laxity
• reconstruction
• risk factor
• tunnel widening

• Allograft
• Anterior cruciate ligament (ACL)
• Autograft
• Coordination variability

• Allograft
• MPFL reconstruction
• Patellofemoral instability

• Adolescent
• Adult
• Allografts
• Autografts/surgery
• Female
• Humans
• Joint Dislocations/surgery
• Joint Instability/surgery
• Ligaments, Articular/surgery
• Male
• Patellar Dislocation/surgery
• Patellofemoral Joint/surgery
• Plastic Surgery Procedures/methods
• Young Adult

• Università degli Studi di Salerno

• Anterior cruciate ligament reconstruction
• Athletes
• Failure
• Prevention
• Return to sport
• Surgical technique

Graft cell repopulation and tendon-bone tunnel healing are important after allograft anterior cruciate ligament reconstruction (ACLR). Freshly isolated bone marrow mononuclear cells (BMMNCs) have the advantage of short isolation time during surgery and may enhance tissue regeneration. Thus, we hypothesized that the effect of intra-articular BMMNCs in post-allograft ACLR treatment is comparable to that of cultured bone marrow stromal cells (BMSCs). A rabbit model of hamstring allograft ACLR was used in this study. Animals were randomly assigned to the BMMNC, BMSC, and control groups. Fresh BMMNCs isolated from the iliac crest during surgery and cultured BMSCs at passage four were used in this study. A total of 1 × 10⁷ BMMNCs or BMSCs in 100 µL phosphate-buffered saline were injected into the knee joint immediately after ACLR. The control group was not injected with cells. At two and six weeks post operation, we assessed graft cell repopulation with histological and cell tracking staining (PKH26), and tendon-bone healing with histological micro-computed tomography and immunohistochemical analyses for collagen I and monocyte chemoattractant protein-1 (MCP1). At two weeks post operation, there was no significant difference in the total cell population within the allograft among the three groups. However, the control group showed significantly higher cell population within the allograft than that of BM cell groups at six weeks. Histological examination of proximal tibia revealed that the intra-articular delivered cells infiltrated into the tendon-bone interface. Compared to the control group, the BM cell groups showed broader gaps with interfacial fibrocartilage healing, similar collagen I level, and higher MCP1 expression in the early stage. Micro-CT did not reveal any significant difference among the three groups. BMMNCs and BMSCs had comparable effects on cell repopulation and interfacial allograft-bone healing. Intra-articular BM cells delivery had limited benefits on graft cell repopulation and caused higher inflammation than that in the control group in the early stage, with fibrocartilage formation in the tendon-bone interface after allograft ACLR.

• ACL reconstruction
• allograft
• bone marrow mononuclear cells
• bone marrow stromal cells
• ligamentization
• tendon to bone healing

• Animals
• Anterior Cruciate Ligament/surgery
• Anterior Cruciate Ligament Reconstruction/methods
• Cells, Cultured
• Chemokine CCL2/metabolism
• Collagen Type I/metabolism
• Knee Joint/surgery
• Male
• Mesenchymal Stem Cell Transplantation/methods
• Mesenchymal Stem Cells/cytology
• Rabbits
• Tendons/surgery
• Transplantation, Homologous
• Wound Healing
• X-Ray Microtomography/methods

• 50 years
• ACL reconstruction
• Anterior cruciate ligament
• Return to sport

• Activities of Daily Living
• Aged
• Anterior Cruciate Ligament Injuries/surgery
• Anterior Cruciate Ligament Reconstruction
• Conservative Treatment
• Female
• Humans
• Joint Instability/surgery
• Knee Joint/surgery
• Lysholm Knee Score
• Male
• Middle Aged
• Osteoarthritis/surgery
• Physical Examination
• Postoperative Period
• Reoperation
• Retrospective Studies
• Sports

• ACL reconstruction
• Bone–patellar tendon–bone graft
• Donor site morbidity
• Free quadriceps tendon autograft
• Hamstring autograft

Background and aim of the work: There is still debate on which graft is better indicated for anterior cruciate ligament (ACL) surgical reconstruction. The objective of this study was to evaluate the medium-term clinical outcomes of ACL reconstruction comparing patients managed with bone patellar tendon bone allograft (BPTB) versus patients treated with hamstring autograft (GST). Methods: Patients enrolled during the period 2013-2016 underwent a personal interview with the use of specific evaluation questionnaires (Tegner e Lyshom, Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee), a clinical evaluation with the use of objective functional tests (Lachman test, pivot-shift) and a physical examination of the knee. Results: In this study 43 patients were enrolled: 21 patients were treated by autograft and 22 patients by allograft. Patients who received allograft ACL reconstruction returned to normal sport activity earlier than patients operated on using autograft (11.7±10.3 vs 17.9±14.6 weeks, p<0.05). Data obtained with subjective tests, clinical and physical examination were positive overall, with no differences observed between the two groups. Finally, 15 allograft patients and 12 autograft patients accepted to perform the proprioceptive tests: no difference was found between the two groups. Conclusions: At follow-up evaluation after ACL reconstruction, both BPTB allograft and GST autograft patient groups showed similar results at subjective, objective clinical evaluation and proprioceptive properties of the limb. In particular, the use of allogenic BPTB allowed the patients to return earlier to normal activities of daily-living and sport activity. (www.actabiomedica.it)

Anterior cruciate ligament reconstruction (ACLR) is the gold standard treatment for ACL tears to allow baseball players to return to sport (RTS). The optimal graft type and femoral tunnel drilling technique are currently unknown.

There is a high rate of RTS in professional baseball players after ACLR, with no significant difference in RTS rates or performance between cases and controls or between graft types or femoral drilling techniques.

Cohort study; Level of evidence, 3.

All professional baseball players who underwent ACLR between 2010 and 2015 were included. Demographic and performance data (pre- and postoperative) for each player were recorded. Performance metrics were then compared between cases and matched controls.

A total of 124 players (mean age, 23.7 ± 4.1 years; 83% minor league players) underwent ACLR. Of these, 80% returned to sport (73% to the same or higher level) at a mean 310 ± 109 days overall and 333 ± 126 days at the same or higher level. The most common graft type was an ipsilateral bone–patellar tendon–bone (BTB) autograft (n = 87; 70%). A total of 91 players underwent concomitant meniscal debridement or repair. No significant difference in any of the primary performance metrics existed from before to after ACLR. Compared with matched controls, no significant difference existed in RTS rates or any performance metrics after ACLR. No significant difference existed in RTS rates or primary performance outcome measures between graft types or femoral drilling techniques.

The RTS rate for professional baseball players after ACLR was 80%. No significant difference in performance metrics existed between BTB and hamstring autografts or between femoral drilling techniques. Furthermore, no significant difference in performance or RTS rates existed between cases and matched controls. Femoral drilling technique and graft type did not affect performance and RTS rates in professional baseball players after ACLR.

• Major League Baseball (MLB)
• anterior cruciate ligament reconstruction (ACLR)
• graft type
• knee
• return to sport (RTS)
• surgery

• bone-patellar-tendon-bone graft
• anterior cruciate ligament
• arthroscopy
• hydroxyapatite–bioglass ceramic
• bone graft substitute

Allograft tissues are commonly used by orthopedic surgeons and are processed using a variety of technologies to increase safety and clinical use. For safety, although disease transmission is a tangible risk, this possibility has been dramatically minimized through modern tissue-processing methods. These include steps to prevent processing tissues with unacceptable bioburden through rigorous screening using donor medical and social histories along with microbial testing of recovered tissue and viral testing of donor serum. Potential bioburden is also controlled through aseptic recovery and processing methods and then reduced through disinfection steps that can include antibiotics, detergents, mechanical process, chemical solutions, and terminal sterilization. Processing steps may also include decellularization methods to lower immunogenic potential of some tissues. To enhance fusion potential of bone void fillers, demineralization steps may be used, and the resultant demineralized bone matrices may be combined with a carrier to improve handling. Bone void fillers and osteochondral allografts may also be specially processed to retain a living cellular component. To preserve relevant biological, biochemical, and physical properties of allografts for clinical use and ease of handling, a number of methods may be used which include: (1) refrigeration in media, (2) freeze-drying, (3) cryopreservation, (4) freezing, and (5) media storage at room temperature. As academic and industry research continue to drive advances, the future direction of allograft tissue likely includes injectables, coatings, cellular therapies, and combinations with other materials. The technology approaches outlined here will be further described along with future directions.

Retrospective study to evaluate the functional results of patients with total knee arthroplasty and rupture of the patellar tendon, submitted to transplantation of the extensor knee apparatus with fresh frozen allograft.

Nine patients, operated between 2003 and 2015, with a minimum of one year of follow-up. All patients were reviewed by performing a functional evaluation using the Knee Society score. Preoperative values were compared with those of the final evaluation.

Mean survival was 2.7 ± 1.9 years (14–1). The knee score improved from 38 ± 4.5 to 70 ± 8.5, and functional score from 30 ± 6.5 to 90 ± 3.5. Mean extension deficit was 5 (1–15). Mean range of motion was 80 (60–100).

The use of allograft is a solution for extreme cases of patellar rupture after total knee arthroplasty, providing reasonable functional results and representing an alternative to knee arthrodesis.

• Allografts
• Knee arthroplasty
• Patellar ligament
• Rupture
• Transplantation

• allograft
• anterior cruciate ligament reconstruction
• low-dose gamma irradiation
• variability

• Anterior cruciate ligament reconstruction
• Arthroscopy
• Hamstring
• Second-look surgery
• Tibialis anterior

• ACL
• ACL reconstruction
• BPTB
• allograft
• autograft
• revision
• soft tissue allograft

• allografts
• anterior cruciate ligament
• autografts
• knee ligaments

Polyvinylpyrrolidone-iodine (PVP-I) is a broad-spectrum antimicrobial agent, but its effects on tendon-bone healing are unclear. The purpose of this study was to investigate the effects of PVP-I on bone marrow mesenchymal stem cells (BMSCs) in vitro and on tendon-bone healing in vivo. In this study, following investigation of the concentration-dependent effects of PVP-I on the viability and osteogenic differentiation of BMSCs, the appropriate concentration of PVP-I was selected for animal experiments. New Zealand white rabbits received autologous tendon transplantation with and without PVP-I treatment of the graft tendon. Subsequently, histological examination, biomechanical testing and reverse transcription-quantitative polymerase chain reaction (RT-qPCR) analyses were conducted. At 6 weeks post-surgery, connective tissue and osteogenesis was observed at the tendon-bone interface in the PVP-I group. At 12 weeks post-surgery, the interface width in the PVP-I group was much narrower compared with that of the control group. Furthermore, the biomechanical properties of the PVP-I group were significantly stronger than those in the control group (P<0.05). RT-qPCR examination revealed that the mRNA levels of bone morphogenetic protein-2 and osteopontin in the PVP-I group were higher than those in the control group at 6 weeks (P<0.05). In conclusion, these results indicated that PVP-I promoted tendon-bone healing via osteogenesis.

• anterior cruciate ligament
• bone marrow mesenchymal stem cells
• osteogenesis
• polyvinylpyrrolidone-iodine
• tendon-bone healing

• Anterior cruciate ligament
• Arthroscopy
• Hamstring autograft
• Reconstruction
• Second-look
• Tibialis allograft

Anterior cruciate ligament (ACL) reconstruction is one of the most common procedures in sports medicine. Several areas of controversy exist in ACL tear management which have engaged surgeons and researchers in debates towards identifying an ideal approach for these patients.

Cite this article: Paschos NK, Howell SM. Anterior cruciate ligament reconstruction: principles of treatment. EFORT Open Rev 2016;398-408. DOI: 10.1302/2058-5241.1.160032.

• ACL tear
• allograft
• anterior cruciate ligament
• autograft
• reconstruction
• rehabilitation
• timing
• tunnel position

• Allograft
• Anterior cruciate ligament
• Bone-patellar tendon-bone
• Double-layer
• Single-layer

• Allograft
• Anterior cruciate ligament
• Biomechanics
• Stiffness
• Strength

• allograft
• anterior cruciate ligament reconstruction
• autograft
• meta-analysis
• trial sequential analysis

• Adult
• Allografts
• Anterior Cruciate Ligament/surgery
• Anterior Cruciate Ligament Injuries/surgery
• Anterior Cruciate Ligament Reconstruction/methods
• Autografts
• Female
• Humans
• Knee Joint/surgery
• Male
• Transplantation, Autologous
• Transplantation, Homologous

• Allograft
• Anterior cruciate ligament
• Autograft
• Functional outcome
• Hamstring tendon
• Tibialis posterior tendon

• anterior cruciate ligament
• meta-analysis
• surgery
• systematic review

• Anterior cruciate ligament
• Knee
• Patient expectations

• Adult
• Anterior Cruciate Ligament/surgery
• Anterior Cruciate Ligament Injuries
• Anterior Cruciate Ligament Reconstruction/methods
• Anterior Cruciate Ligament Reconstruction/psychology
• Athletic Injuries/psychology
• Athletic Injuries/surgery
• Female
• Humans
• Knee Injuries/psychology
• Knee Injuries/surgery
• Knee Joint/surgery
• Male
• Patient Acceptance of Health Care
• Patient Satisfaction
• Prospective Studies
• Recovery of Function
• Reoperation/psychology
• Surveys and Questionnaires
• Young Adult

To avoid the risk of infectious disease transmission from donor to recipient, allografts should be terminally sterilized. In the previous paper (Kaminski et al. in Cell Tissue Bank 10:215–219, 2009) we presented the effect of various methods of preservation (deep fresh freezing, glycerolization, lyophilization), followed by irradiation with different doses of electron beam (EB), on material (intrinsic) mechanical properties of human patellar tendons cut out as for anterior cruciate ligament reconstruction, obtained in failure tensile test. As structural mechanical properties are equally important to predict the behaviour of the graft as a whole functional unit, the purpose of the present paper was to show the results for failure load and elongation, obtained in the same experiment. Paired Bone-Tendon-Bone grafts (BTB) were prepared from cadaveric human patella tendons with both patellar and tibial attachments. They were preserved by deep freezing, glycerolization or lyophilization and subsequently EB-irradiated with the doses of 25, 35, 50 or 100 kGy (fresh-frozen grafts) or a single dose of 35 kGy (glycerolized and lyophilized grafts). Each experimental (irradiated) group was provided with control (non-irradiated), donor-matched group. The specimens from all groups were subjected to mechanical failure tensile test with the use of Instron system in order to measure their structural properties (failure load and elongation). All lyophilized grafts were rehydrated before mechanical testing. In our study we did not observe significant deterioration of structural mechanical properties of BTB grafts processed by fresh-freezing and then terminal sterilized with growing doses of EB up to 100 kGy. In contrast, BTB grafts processed by glycerolization or lyophilization and irradiated with 35 kGy showed significant decrease of failure load. Obtained results suggest that deep-frozen irradiated grafts retain their initial mechanical properties to an extent which does not exclude their clinical application. However, biomechanical investigations constitute only the first step to evaluate the potential clinical usefulness of such allografts and further extensive in vivo studies are needed.

• Anterior cruciate ligament reconstruction
• Bone-Tendon-Bone allografts
• Glycerolization
• Lyophilization
• Radiation-sterilization
• Structural mechanical properties

• ACL injury
• Platelet rich plasma
• cell culture study
• platelet poor plasma

• Allograft
• Anterior cruciate ligament
• Autograft
• Meta-analysis

• allograft
• anterior cruciate ligament
• collagen birefringence
• decellularization
• reconstruction
• semitendinosus tendon

• allograft
• anterior cruciate ligament reconstruction
• autograft
• revision
• young age

Criteria for return to unrestricted activity after anterior cruciate ligament (ACL) reconstruction varies, with some using time after surgery as the sole criterion—most often at 6 months. Patients may have residual neuromuscular deficits, which may increase the risk of ACL injury. A single-leg squat test (SLST) can dynamically assess for many of these deficits prior to return to unrestricted activity.

A significant number of patients will continue to exhibit neuromuscular deficits with SLST at 6 months after ACL reconstruction.

Cross-sectional study; Level of evidence, 3.

Patients using a standardized accelerated rehabilitation protocol at their 6-month follow-up after primary ACL reconstruction were enrolled. Evaluation included bilateral SLST, single-leg hop distance, hip abduction strength, and the subjective International Knee Documentation Committee (IKDC) score.

Thirty-three patients were enrolled. Poor performance of the operative leg SLST was found in 15 of 33 patients (45%). Of those 15 patients, 7 (45%) had concomitant poor performance of the nonoperative leg compared with 2 of 18 patients (11%) in those who demonstrated good performance in the operative leg. The poor performers were significantly older (33.6 years) than the good performers (24.2 years) (P = .007). Those with poor performance demonstrated decreased hip abduction strength (17.6 kg operative leg vs 20.5 kg nonoperative leg) (P = .024), decreased single-leg hop distance (83.3 cm operative leg vs 112.3 cm nonoperative leg) (P = .036), and lower IKDC scores (67.9 vs 82.3) (P = .001).

Nearly half of patients demonstrated persistent neuromuscular deficits on SLST at 6 months, which is when many patients return to unrestricted activity. Those with poor performance were of a significantly older age, decreased hip abduction strength, decreased single-leg hop distance, and lower IKDC subjective scores.

The SLST can be used to identify neuromuscular risk factors for ACL rupture. Many patients at 6 months have persistent neuromuscular deficits on SLST. Caution should be used when using time alone to determine when patients can return to unrestricted activity.

• anterior cruciate ligament
• neuromuscular evaluation
• return to unrestricted activity
• single-leg squat test

• ACL injury
• Bone marrow edema
• MRI
• Prognosis
• Return to sport

• ACL
• BPTB
• Hamstring
• Reconstruction

Postoperatively, signal changes of the reconstructed anterior cruciate ligament (ACL) graft on magnetic resonance imaging (MRI) images commonly occurs, which may be a cause for concern. The signal intensity changes are usually expressed by signal/noise quotient (SNQ) value, representing graft maturity. To date, little is known about the factors influencing the SNQ value of the reconstructed ACL graft.

To evaluate ACL graft SNQ value and associated factors after ACL reconstruction.

Case series; Level of evidence, 4.

Male patients who underwent ACL reconstruction using autograft or allograft tendon from September 2004 to September 2011 were randomly invited to take part in this investigation, including functional scores, physical examination, and MRI scan. The femoral side graft was fixed with Endobutton CL or Rigidfix pins, and the tibial side graft was fixed with a bio-intrafix. SNQ values of each graft were measured on MRI to represent graft maturity. Sagittal ACL angle, ACL–Blumensaat line angle, and medial and lateral posterior tibial slope (PTS) were measured using MRI 3-dimensional dual-echo steady-state images. Potential risk factors, including age, body mass index, postoperative time, Tegner activity scale (TAS), sagittal ACL angle, ACL–Blumensaat line angle, medial PTS, lateral PTS, and primary graft diameter, were tested for their association with the graft SNQ value by multivariate stepwise regression analysis.

A total of 104 male subjects (mean follow-up, 30.7 months) were examined, including 62 allograft and 42 autograft reconstructions. There was a significant association between graft SNQ and postoperative time (r = −0.431, P < .001), TAS (r = 0.295, P = .002), and ACL–Blumensaat line angle (r = −0.304, P = .002). Univariate regression analysis showed that TAS (β = 6.15, P < .001) positively correlated, postoperative time (β = −0.26, P < .001) negatively correlated, and ACL–Blumensaat line angle (β = −0.40, P = .038) negatively correlated with graft SNQ. Multivariate stepwise regression analysis showed that TAS, postoperative time, ACL–Blumensaat line angle, and age were significant independent factors associated with graft SNQ.

The graft SNQ value had a significant positive correlation with physical activity level and a significant negative correlation with postoperative time in this study. Males with a shorter postoperative time and a higher physical activity level had higher graft signal intensity postoperatively.

• ACL
• MRI
• allograft
• autograft
• graft maturity
• signal intensity

• allograft
• anterior cruciate ligament reconstruction
• disease transmission
• irradiation
• sterilization
• tissue biomechanics
• transplantation