To compare the outcomes of hamstring tendon (HT) and quadriceps tendon (QT) autografts for anterior cruciate ligament (ACL) reconstruction in patients aged 50 years or older in terms of patient-reported functional outcomes, graft failure rates, complications, return to sports activity, and sports preference.

Between 2010 and 2022, prospectively collected data were obtained from an institutional database. Patients aged 50 years or older who underwent primary arthroscopic ACL reconstruction with either HT or QT autograft and had a minimum 2-year follow-up were included. Patients with concomitant meniscal, cartilage, and medial collateral ligament injuries were also included. Patients undergoing revision ACL reconstruction, those undergoing primary ACL reconstruction with a graft other than HT or QT autograft, and those with contralateral knee injuries or ipsilateral osteoarthritis (Ahlbäck stage ≥2) were excluded. Patients were evaluated in terms of the Lysholm knee score, Tegner activity level, and visual analog scale (VAS) score for pain before injury and at 2-year follow-up, as well as graft failure, QT rupture, and return to sport. The Mann-Whitney test was used to analyze unpaired samples, whereas the Friedman test was used to analyze variables over time. The χ2 statistic test was used to determine differences in categorical data between groups.

The number of patients in the QT and HT groups was 85 and 143, respectively. In the QT and HT groups, the mean age was 54.4 years (range, 50-65 years) and 56.4 years (range, 50-65 years), respectively, and 49% and 51% of patients were men, respectively. The 2 groups did not differ significantly in terms of age, sex, time from injury to surgery, and concomitant injuries. No significant differences in preinjury patient-reported outcome measures, consisting of the Lysholm score, Tegner activity level, and VAS pain score, were found between the 2 groups (P > .05). At the 2-year follow-up, the Lysholm knee score, Tegner activity level, and VAS pain score improved to preinjury levels and no significant differences in preinjury and 2-year follow-up functional scores were noted between the 2 groups (P > .05). Furthermore, at the 2-year follow-up, the Lysholm score and VAS pain score did not show significant differences (P = .390 and P = .131, respectively) between the QT and HT groups. Similarly, no differences in Tegner activity level were observed between the HT and QT groups at the 2-year follow-up. No significant differences in terms of the minimal clinically important difference were detected between the 2 groups for the Lysholm knee score (P = .410) and Tegner activity level (P = .420). The 2 groups did not differ in terms of patients' percentage of sports participation at baseline and at the 2-year follow-up (P > .05). A significant decrease (P = .01) in participation in skiing/snowboarding was reported in the HT group at the 2-year follow-up compared with baseline (116 patients [81%] vs 98 patients [69%]). No case of graft failure or QT rupture was reported in either group.

Arthroscopic ACL reconstruction using HT or QT autografts in athletically active patients aged 50 years or older provides satisfactory patient-reported functional outcomes and allows recovery of the preinjury level of activity.

Level III, retrospective cohort study.

A 17-year old male athlete presented with right knee and lower extremity pain that was resistant to traditional physical therapy and pain management for almost two years. He had played ice hockey as a goalie since childhood but was unable to return to play because of the pain. He had to a history of several different injuries to the same knee and had several MRI scans and physician visits without any help. Pain was aggravated by physical activity especially when the knee was extended but there was no major problem in the knee itself. Palpation of the adductor canal greatly aggravated the pain radiating below the knee. As local anaesthetic to the adductor canal eased the pain saphenous nerve impingement was suspected. Successful decompression of the nerve was performed and pain disappeared right after surgery. He was able to return to play ice hockey as a goalie three months after surgery. Even though iatrogenic injuries to saphenous nerve are common after orthopaedic operations, compression of the nerve in adductor canal is a rare condition that can cause problems in the differential diagnosis of knee pain. If needed, surgical treatment seems to yield a good outcome.

The aim of this study was to compare radiological changes in patellar height (PH) and patellar tendon length (PTL) after closure and non-closure of the patellar donor site defect during anterior cruciate ligament reconstruction (ACLR) using a bone-patellar tendon-bone (BPTB) autograft.

In this retrospective study a total of 63 patients was included. All patients underwent an arthroscopically assisted ACLR using the mid-third BPTB autograft. In 30 patients the tendon donor site defect was closed. In 33 patients the tendon donor site defect was left open. The paratenon was approximated in all patients. Lateral radiographs were taken preoperatively and at 3 months after ACLR. PH was determined using the Insall-Salvati, Caton-Deschamps and Blackburne-Peel methods. PTL was measured by determining the distance between the inferior pole of the patella and the superior aspect of the tibial tubercle.

Overall, no change in patellar height were observed 3 months after ACLR for the Insal-Salvati (p = 0.54), Caton-Deschamps (p = 0.75) and Blackburne-Peel methods (p = 0.83). Also, the change in pre- and postoperative patellar height did not differ between the closure- and non-closure-group for the Insall-Salvati (p = 0.77), the Caton-Deschamps (p = 0.89) and the Blackburne-Peel (p = 0.70) methods. Overall, no significant change in PTL was observed 3 months after ACLR (p = 0.78). Between both groups, no significant difference was observed for PTL over time (p = 0.98).

Patellar height and patellar tendon length did not significantly change after anterior cruciate reconstruction using bone-patellar tendon-bone autografts regardless of patellar donor site closure.

IIIb.

Medial patellofemoral ligament (MPFL) reconstruction has been the standard of care for recurrent patellar dislocations and chronic patellar instability. MPFL repair has been used as an alternative surgical option. The purpose of this study was to assess patellar stability and patellofemoral contact mechanics following MPFL fixation with suture tape augmentation. We hypothesized that lateral patellar motion would be reduced.

In twelve cadaver knees, a hole was drilled near the midpoint of the medial patella. Three locations were drilled on the femur Schöttle's point, 1 cm anterior to Schöttle's point and 1 cm proximal to Schöttle's point. Each knee was then held at 30° of knee flexion, and the patella was subjected to a physiologic lateral force. The resulting motion was measured, and patellofemoral contact forces were recorded. This process was performed with the MPFL torn and then bolstered with suture tape augmentation anchored centrally in the medial patella and each of the three femur hole locations.

All MPFL augmentations provided significantly less lateral patellar motion compared to the torn condition. Contact area was significantly greater in the augmented condition than in the torn condition, but no statistical differences were observed in patellofemoral contact pressure. No significant differences in lateral patellar motion, contact pressure or contact area were found between femoral anchor positions.

MPFL fixation with suture tape augmentation significantly decreased lateral patellar motion compared to the torn condition without causing significant changes in contact pressures within the patellofemoral joint.

N/A.

Anterior cruciate ligament reconstruction (ACLR) often involves harvesting a bone-patellar tendon-bone (BPTB) autograft. How graft harvest affects tendon strain across the 3 distinct regions (medial, lateral, and central) is not known.

To (1) quantify strain in the 3 regions of the patellar tendon during 60% of maximum voluntary isometric contraction (MVIC) in 90° of knee flexion and (2) assess how effort level in 2 different knee joint angles (60° and 90°) impacts strain in the medial and lateral regions of the patellar tendon, in 2 cohorts of patients after ACLR using a BPTB autograft (one group <24 months after surgery and another group ≥24 months after surgery).

Descriptive laboratory study.

Effort levels ranging from 20% to 100% of MVIC were performed at 90° and 60° of knee flexion on an isokinetic dynamometer, with simultaneous ultrasound imaging of tendon length to calculate regional strain. Linear mixed-effects models were used to evaluate regional strain at 60% of MVIC in 90° of knee flexion. The fixed effects of percentage of MVIC, joint angles, and time from surgery groups on patellar tendon strain were evaluated using separate models for the medial and lateral regions.

Fourteen participants in the short-term group (7.5 ± 1.9 months from surgery) and 15 participants in the long-term group (71.5 ± 16.5 months from surgery) were included. At 60% of MVIC in 90° of knee flexion, the short-term group demonstrated lower patellar tendon strain than the long-term group regardless of region (P < .01). The central region also had lower strain than the medial and lateral regions regardless of group (both P < .01). Finally, the rate at which strain increased with increasing effect levels differed between time from surgery groups in both medial and lateral regions.

The short-term group had lower strain in all regions of the patellar tendon after ACLR using BPTB autograft. The medial and lateral regions showed varying strain based on time from surgery and effort level. Varying knee joint angles and effort levels for graft site rehabilitation may have to be considered to target specific regions of the patellar tendon.

Clinicians should consider the time elapsed since surgery and the manipulation of knee angle as factors that can exert varying levels of strain on different regions of the patellar tendon after ACLR. Accelerating quadriceps strengthening to enhance strain distribution across the patellar tendon to promote tendon healing may be of benefit for optimizing postsurgery rehabilitation.

The impact of the bone tunnel size relative to body size on clinical results in anterior cruciate ligament (ACL) reconstruction remains unclear. This study aimed to assess the morphological alteration of the tibial tunnel aperture and relationship between the tibial tunnel size relative to the proximal tibia among the tibial tunnel widening (TW) and clinical results following ACL reconstruction. This study comprised 131 patients who had undergone anatomical ACL reconstruction utilizing bone-patellar tendon-bone autografts. The morphology and enlargement of the tibial tunnel were examined via three-dimensional computed tomography 1 week and 1 year postoperatively. The anteroposterior (AP) and mediolateral (ML) positions were determined as a percentage relative to the proximal AP and ML tibial dimensions, respectively. Clinical assessment was conducted 2 years postoperatively. The association between the primary tibial tunnel size among TW and clinical outcomes was examined. The tibial tunnel significantly migrated posterolaterally. The ML diameter significantly widened; however, the AP diameter did not exhibit widening. AP widening was associated with the AP diameter of the primary tibial tunnel (r = -0.482, p < 0.01), and ML widening correlated with the ML diameter of that tunnel (r = -0.478, p < 0.01). However, there was no significant correlation observed between the primary tibial tunnel size and clinical outcomes. The tibial tunnel migrated and enlarged laterally in the ML plane, but did not enlarge in the AP plane. The primary tibial tunnel diameter relative to the proximal tibia negatively correlated with the tibial TW in the AP and ML planes. Level of evidence: level IV.

Hamstring tendon grafts are commonly utilized tendon autografts; however, the harvesting procedure can result in saphenous nerve injury due to its proximity to the semitendinosus and gracilis tendons. Injury to the main branch of the saphenous nerve is a less commonly reported and understood injury during these procedures.

This case report aimed to identify and present cases of iatrogenic injury to the main branch of the saphenous nerve during hamstring tendon graft harvesting.

A retrospective chart review of a tertiary-care hospital over the past 10 years was conducted. The search included clinical notes mentioning "saphenous neuropathy, neuralgia or neuritis" and magnetic resonance imaging (MRI) reports indicating saphenous nerve involvement. Patients with a history of a hamstring graft harvesting procedure and radiographically confirmed injury to the main branch of the saphenous nerve were included. Injury characteristics, symptoms, and sequential treatment were evaluated.

Three cases of iatrogenic injury to the main branch of the saphenous nerve during hamstring graft harvesting were identified. Reported symptoms included pain, paresthesia, numbness, hypersensitivity, swelling, and discoloration. All 3 patients had persistent symptoms despite non-operative treatment and therefore underwent surgical intervention, which involved resection and reconstruction using allograft or burial into adjacent musculature. Postoperatively, 2 of 3 patients demonstrated resolution of symptoms.

Iatrogenic injury to the main branch of the saphenous nerve is a complication that can occur during hamstring tendon harvesting procedures, leading to severe, persistent symptoms. A better understanding of the mechanism of injury is needed to minimize the risk of iatrogenic injury.

Anterior cruciate ligament (ACL) tears are frequent injuries in athletes that often require surgical reconstruction so that patients may return to their previous levels of performance. While existing data on patient-reported outcomes are similar between bone-patellar tendon-bone (BTB) and hamstring tendon (HT) autografts, the literature regarding return to sport (RTS), return to previous levels of sport activity, and graft failure rate remains limited.

To compare rates of RTS, return to previous activity levels, and graft retears among athletes undergoing primary ACL reconstruction using a BTB versus HT autograft.

Systematic review and meta-analysis; Level of evidence, 4.

The MEDLINE, Embase, and Cochrane Library databases were queried, and studies reporting on RTS after primary ACL reconstruction using a BTB or HT autograft were included. Exclusion criteria included revision reconstruction, ACL repair, quadriceps tendon autografts, allografts, graft augmentation, or double-bundle autografts. Rates of RTS, return to previous levels of activity, and retears were extracted and analyzed across included studies.

A total of 33 articles met inclusion criteria, with a patient cohort of 4810 athletes. The overall RTS rate for all athletes was 80.4% (95% CI, 75.3%-84.6%) at a mean follow-up of 35.7 months, with 54.6% (95% CI, 48.5%-60.6%) returning to preinjury levels of activity. No significant difference was found between BTB and HT autografts with respect to rates of RTS, return to preinjury activity levels, or reruptures. The overall RTS rate in patients after primary ACL reconstruction with a BTB autograft was 83.3% (95% CI, 77.0%-88.2%), with 56.1% (95% CI, 49.3%-62.7%) returning to preinjury levels of activity. Conversely, the overall RTS rate in patients after primary ACL reconstruction with an HT autograft was 77.9% (95% CI, 70.3%-84.0%), with 53.5% (95% CI, 42.8%-63.9%) returning to preinjury levels of activity. The overall graft rerupture rate for the entire patient cohort was 3.6% (95% CI, 2.5%-5.1%), for patients with BTB grafts was 3.2% (95% CI, 1.9%-5.3%), and for patients with HT grafts was 4.4% (95% CI, 2.8%-6.8%).

Primary ACL reconstruction using BTB autografts demonstrated similar rates of RTS, return to previous activity levels, and reruptures compared with reconstruction using HT autografts.

Anterior cruciate ligament injuries (ACLi) impact football players substantially leading to performance declines and premature career endings. Emerging evidence suggests that ACLi should be viewed not merely as peripheral injuries but as complex conditions with neurophysiological aspects. The objective of the present study was to compare kicking performance and associated cortical activity between injured and healthy players. Ten reconstructed and 15 healthy players performed a kicking task. Kicking biomechanics were recorded using wearable inertial measurement unit sensors. Cortical activity was captured with a 64-electrode mobile electroencephalography. Multiscale entropy (MSE) analysis of biomechanics revealed increased variability in foot external rotation among injured players. Source-derived event-related spectral perturbations indicated significant differences in posterior alpha and frontal theta oscillations between the two groups. Furthermore, kick-related complexity of these regions as indexed by MSE was reduced in injured players at medium and coarse scales. Our findings suggest sensorimotor changes during kicking in injured players, which may necessitate compensatory strategies involving augmented attention at the cost of processing visuospatial information. This conflict may hinder the integration of task-relevant information across distributed networks. Our study provides preliminary insights into the neurophysiological implications of ACLi within football context and underscores the potential for prospective research.

Historically, anterior cruciate ligament (ACL) ruptures in the paediatric age group were managed conservatively with bracing, casting, activity modification, and physical therapy. However, most of these patients had to reduce their sports activities, and secondary damages to the affected knee were prevalent.

Published scientific literature in Embase, Web of Science, PubMed, and Google Scholar databases.

ACL reconstruction in children with open physes patients is debated. Any damage to the physes around the knee could lead to growth abnormalities and axial deviation of the knee.

Different grafts are available and suitable for ACL reconstruction in skeletally immature patients; however, which graft performs better remains unclear.

This systematic review compared bone-patellar tendon-bone (BPTB), hamstring tendon (HT), and quadriceps tendon (QT) autografts for ACL reconstruction in skeletally immature patients. The joint laxity, Patient-reported outcome measures (PROMs), return to sport, and complications were compared.

In skeletally immature patients, HT, BPTB, and QT autografts for ACL reconstruction yielded good outcomes. Comparative studies are strongly required to establish the most suitable autograft.

Arthroscopic-assisted medial patellofemoral ligament reconstruction (MPFLR) is a common surgical procedure for patellar dislocation. We present the protocol of a randomised controlled clinical trial to compare postoperative pain, knee function and quality of life outcomes of MPFL reconstruction using the non-absorbable surgical sutures (FiberWire) and semitendinosus tendon.

This single-blind, randomised controlled trial enrolled patients with patellar dislocation who were undergoing inpatient surgery at the Department of Orthopedics, Xiangya Hospital, Central South University. Participants were randomly allocated to either the experimental or the control group using a random number table method, with an equal number of 15 subjects in each group. The experimental group was treated with a FiberWire for the MPFLR, whereas the control group received reconstruction using the semitendinosus tendon. A standardised postoperative rehabilitation protocol was implemented for both groups. All subjects will be evaluated for imaging, pain, knee function and quality of life at five time points: preoperatively and at 1 month, 3 months, 6 months and 12 months postoperatively. MRI scans will be performed preoperatively and at 12 months postoperatively to assess changes in patellar tilt angles and congruence angles. Pain assessment is performed using the Visual Analogue Scale (VAS). Knee function will be assessed using the Kujala score, Lysholm score and International Knee Documentation Committee (IKDC) knee function score. Quality of life was assessed using the 12-Item Short Form Survey scale.

The trial was approved by the Medical Ethics Committee of Xiangya Hospital of Central South University on 26 October 2021 (ethics number: 202110478) and registered in the China Clinical Trials Registry on 15 March 2022. Data will be published in peer-reviewed journals and presented at national and international conferences.

ChiCTR2200057574.

In this article, we explain a simple method to effectively enhance the graft size and maintain the tissue integrity of a hamstring autograft. The triple-fold technique is useful for creating a soft-tissue size and length suitable for anterior cruciate ligament reconstruction.

Acromioclavicular joint dislocation is a common pathology, affecting mostly young male patients. High-grade injuries require surgical treatment, but evidence is lacking regarding a gold standard technique. Chronic cases frequently are treated with graft reconstruction, but complications and availability remain as a limitation for autograft and allograft use, respectively. The objective of this Technical Note is to describe the treatment of chronic acromioclavicular dislocations by a reconstruction made with a local tendon graft, the pectoralis minor, in addition to transferring the coracoacromial ligament as a horizontal stabilizer.

Adductor canal block (ACB) is commonly included in multimodal analgesia regimens for knee surgery. Nonetheless, the incidence, etiology, and procedure-specific risk of saphenous nerve injury after knee surgery with ACB have not been established.

We sought to identify the risk of saphenous nerve injury during knee surgery with ACB.

We conducted a retrospective cohort study of patients at a single institution who underwent elective knee surgery with ultrasound-guided ACB between January 1, 2014, and December 31, 2018, and had subsequent saphenous nerve injury. The primary outcome was the incidence of saphenous nerve injury within 3 months of surgery, by surgical type and approach. Secondary outcomes included attribution of the most likely etiology and clinical outcome of the injury.

In 28,196 cases of knee surgery with ACB, we identified 18 cases (0.06%) of saphenous nerve injury. The most common surgery associated with saphenous nerve injury was anterior cruciate ligament (ACL) reconstruction with autograft (8/18 cases); 3 cases of injury were seen after TKA, 2 after medial patellofemoral ligament reconstruction, 2 after arthroscopy/meniscal surgery, and 1 after patellar fixation. The most likely etiology of nerve injury was attributed to ACB in 5 of 18 cases (28%) and to non-ACB cause in 13 of 18 (72%). Prognosis was rated as unknown in 11 of 18, poor in 2 of 18, favorable in 3 of 18, and full recovery in 2 of 18.

This 5-year retrospective, single-institution cohort study found a low overall incidence of saphenous nerve injury after knee surgery with ACB, but the injury likelihood varied based on surgery and approach. Although not statistically significant, ACL reconstruction with hamstring autograft and ACB performed for postoperative rescue analgesia were most frequently associated with nerve injury.

Background: Anterior cruciate ligament (ACL) rupture is a frequent injury among athletes, particularly women. Various techniques have shown effectiveness, but their impact on laxity and clinical outcomes varies. This study aims to compare the rupture rates of patellar tendon (PT) reconstruction versus hamstring reconstruction (HR) combined with anterolateral ligament reconstruction (ALLR) in young women. The secondary objectives include comparing functional ACL-RSI and subjective IKDC scores, as well as the Tegner scale, between these two groups. The hypothesis is that adding ALLR to HR will result in rupture rates and functional scores similar to those of PT reconstruction. Methods: Between 2015 and 2019, 96 patients were treated at two facilities, with 70 having an average follow-up of 44 ± 14.5 months: 35 underwent PT reconstruction, and 35 had HR combined with ALLR. Patients were re-evaluated remotely after at least 2 years using a standardised questionnaire and assessing subjective IKDC, ACL-RSI, and Tegner scores. Results: Rupture rates were 5.7% in both groups. The mean subjective IKDC score was 81% for the HR + ALLR group versus 80.8% for the PT group (p = 0.09). The mean ACL-RSI score was 66% for HR + ALLR versus 68% for PT (p = 0.78). The HR + ALLR group lost an average of 0.4 points on the Tegner scale postoperatively, while the PT group lost an average of 0.77 points (p = 0.09). Conclusions: Hamstring surgery combined with anterolateral surgery provides subjective results, as assessed by patients using subjective scales and questionnaires, that are as good as those obtained with PT surgery in young women. Notwithstanding, the results are not corroborated by clinical or radiological examination.

The aim of this study was to evaluate the feasibility of a novel technique that focuses on vertical and horizontal stabilization of the acromioclavicular joint using two local autologous grafts, the pectoralis minor (Pm) and the coracoacromial ligament (CAL).

Ten fresh-frozen shoulder cadaveric pieces were dissected. Length and width of the Pm and CAL were measured in their anatomical position and anatomical variants were noted. The Pm tendon was harvested at the myothendinous junction keeping the insertion at the coracoid process. The CAL was detached from the coracoid process keeping the acromial insertion. The free limbs of both grafts were prepared with the Krackow technique and the Arthrex SpeedWhip technique, respectively. The primary coracoclavicular reduction and fixation were with the button system or with two subcoracoid ultrahigh-strength suture cerclage through and around the clavicle. The Pm graft was fixed inside a clavicular tunnel by a cortical button and the CAL was transferred and fixed to the lateral clavicle using a knotless anchor or intramedullary when lateral clavicle resection was performed.

The median length of the Pm was 50 mm (interquartile range [IQR]: 50-54), and the median length of the CAL was 36.5 mm (IQR 34-40) which decreased by 15% and 23% once were prepared with the Krackow and Arthrex SpeedWhip techniques to 44.5 mm (IQR: 30-65) and 30 mm (IQR: 22-32), respectively. The diameter of the prepared Pm graft was 5 mm (IQR: 4.5-6) and the CAL graft 5.5 mm (5-6). All grafts were able to reach the fixation points. The procedure was feasible in 100% of the cases.

A biplanar reconstruction using autologous Pm and CAL appears feasible in restoring the acromioclavicular joint stability.

Level IV. Basic science, anatomy, cadaveric dissection.

To compare patient-reported outcomes measurements and subsequent surgical interventions in patients treated with anterior cruciate ligament reconstruction (ACLR) using either quadriceps tendon autograft with a patellar bone block (bQT) or soft tissue only (sQT).

All ACLRs performed between January 2010 and March 2022 were prospectively followed for 24 months and retrospectively evaluated. All primary ACLRs with full 24 months of follow-up data, without any previous surgery or any additional ligamentous interventions, were matched for major ACL risk factors, including sex, age, Tegner activity level [TAL], pivoting sports, and concomitant injuries. Patient-reported outcomes measurements (Lysholm score, visual analog scale for pain, and TAL) and subsequent surgical interventions were registered after 6, 12, and 24 months postoperatively. Binary logistic regression was used to assess the influence of graft type, age, preinjury TAL, sex, pivoting sports, and concomitant interventions on the need to undergo subsequent surgery.

After matching, 246 patients were included in the final analysis. Both groups did not differ regarding any preoperative patient demographics or intraoperative details. At final follow-up, no significant differences in mean Lysholm score (sQT: 90.8 ± 10.6, bQT: 91.8 ± 10.6, P = .46), median TAL (sQT: 6 [1-10], bQT: 6 [1-10], P = .53), and visual analog scale for pain (sQT: 0.7 ± 1.1, bQT: 0.7 ± 1.2, P = .70) were reported between both groups. A total of 70.3% (sQT-A: 70.7%, bQT: 69.9%, P = .89) of patients returned to or exceeded their preinjury activity level. In terms of revision ACLR, there was no statistically significant difference between bQT (3.3%) and sQT (4.1%). Similarly, no difference was observed in contralateral ACLR (bQT: 7.3% sQT: 11.4%). Regression analysis indicated that none of the studied factors, including the use of a patellar bone block, influenced subsequent surgery, revision ACLR, or contralateral ACLR.

Harvesting an additional patellar bone block in quadriceps tendon ACLR does not seem to affect postoperative patient-reported outcomes, ACL revision, or contralateral ACL reconstruction rates.

Level III, cohort study.

Patellar tendinopathy is more prevalent in males versus female athletes and commonly presents in the medial region of the tendon. Separate measures of patellar tendon strain in the medial, central, and lateral regions of the tendon, however, have not been quantified. The purpose was to investigate the differences in tendon strain between the medial, lateral, and central regions of the patellar tendon in healthy men and women. Strain in the medial and lateral regions of the patellar tendon in healthy participants (10 males, 10 females) was evaluated using ultrasound during isometric quadriceps contractions at 20%, 40%, 60%, 80%, and 100% of maximum voluntary contraction (MVIC) in 60° and 90° of knee flexion. Central strain was also measured at 60% MVIC in 90° of knee flexion. Mixed models were used to determine strain between tendon regions and sex at 60% MVIC in 90° of knee flexion. Sequential modeling was used to fit region, sex, %MVIC, and angle to predict strain. The central region had less strain compared with both medial and lateral regions. The lateral region had higher strain compared with the medial region regardless of sex. Females had higher strain compared with males, regardless of region. Knee position did not influence tendon strain. Patellar tendon strain differs by region and sex. The varying prevalence between sex and in location of patellar tendinopathy may in part be explained by the unbalanced strains. Differential assessment of regional patellar tendon strain may be of importance for understanding injury risk and recovery with exercise.

The ideal graft for anterior cruciate ligament (ACL) reconstruction (ACLR) in young athletes has a high return-to-sport (RTS) rate and a low reinjury rate. Quadriceps tendon autografts are being used with increasing frequency for ACLR in this population, despite a paucity of evidence to support their use.

To report the RTS rate, ipsilateral reinjury rate, and contralateral ACL injury rate in a young athletic population undergoing primary ACLR using an all-soft tissue quadriceps tendon (ASTQT) autograft.

Cases series; Level of evidence, 4.

Patients aged 14 to 22 years who underwent primary ACLR using an ASTQT autograft by a single surgeon between January 1, 2005, and April 30, 2020, were identified via electronic medical records and contacted ≥24 months after ACLR to complete a survey regarding subsequent ipsilateral or contralateral ACL injuries and RTS. Patients who had undergone previous ACLR (ipsilateral or contralateral) were excluded.

A total of 656 patients (330 male, 326 female; mean age, 17.9 years) were identified, and 395 patients completed the survey (60.2%; 174 male, 221 female; mean age, 17.8 years) with a mean follow-up of 73 ± 29 months (range, 24-139 months). The RTS rate was high (male: 87.7%; female: 82.8%; P = .19). Male and female patients had similar rates of revision ACLR (male: 12.6%; female: 10.0%; P = .40) and contralateral ACL injuries (male: 13.8%; female: 11.3%; P = .46).

A high RTS rate and similar rates of ipsilateral and contralateral ACL injuries were found for male and female patients in a young athletic population undergoing primary ACLR using an ASTQT autograft. These results help one to better understand the utility of ASTQT grafts to support successful ACLR in young athletic populations, for which ASTQT grafts appear to yield favorable outcomes.

Anterior cruciate ligament reconstruction (ACLR) is most commonly performed with hamstring tendon (HT) or bone-patellar tendon-bone (BTB) autografts, although the quadriceps tendon (QT) autograft has recently increased in popularity. This systematic review and meta-analysis review compares QT and HT autografts for primary ACLR with a sole focus on randomised controlled trials (RCTs).

A prospective protocol was registered on PROSPERO (CRD42023427339). The search included MEDLINE, Embase and Web of Science until February 2024. Only comparative RCTs were included. The primary outcome was the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form score. Secondary outcomes included: other validated patient-reported outcome measures (PROMs), objective strength scores, complications, and return to sport and work.

From 2,609 articles identified, seven were included (n = 474 patients). This meta-analysis did not identify a significant difference in post-operative IKDC scores (5 articles; p = 0.73), Lysholm scores (3 studies; p = 0.80) or Tegner activity scales (2 studies; p = 0.98). There were no differences in graft failure rates (4 studies; p = 0.92) or in overall adverse events (4 studies; p = 0.83) at 24 months post-ACLR as per meta-analysis. Donor site morbidity scores were significantly lower in the QT group (MD -4.67, 95% CI -9.29 to -0.05; 2 studies, 211 patients; p = 0.05, I2 = 34%).

There were no differences between QT and HT in PROMs, graft failure rates or overall complications based on low- to moderate-quality evidence. There may possibly be lower donor site morbidity with the QT autograft, however, the evidence is not sufficient to draw definitive conclusions.

This study aims to evaluate the long-term outcomes of saphenous nerve (SN) injuries from hamstring tendon harvesting during ACL reconstruction, focusing on clinical results and patient satisfaction after at least two years. Additionally, it investigates the incidence, recovery patterns, and impact of these injuries on functional outcomes, daily activities, and ACL re-rupture rates immediately post-surgery and at final follow-up.

A retrospective review was conducted on patients who had undergone ACL reconstruction with hamstring tendon grafts at a single institution between January 2015 and January 2020. The incidence of SN injuries was assessed immediately after surgery and at final follow-up. Additionally, the recovery rate and time were evaluated, and the impact of these injuries on functional outcomes was measured using the Lysholm Knee Score (LKS) and patient-reported effects on daily activities.

Of the 159 patients analyzed, iatrogenic SN injuries were initially observed in 87 (54.7%) patients post-ACLR. By the final follow-up, paresthesia had resolved in 36 (22.6%) patients within an average of 11.1 months. Persistent SN injuries were recorded in 51 (32.1%) patients, affecting various extents of the infrapatellar branch (IPBSN) and the sartorial branch (SBSN) of the saphenous nerve. Patients with persistent SN injuries experienced a significant impact on daily activities and had lower LKS scores compared to those without injuries or with recovered injuries. Furthermore, a higher re-rupture rate was associated with persistent SN injuries.

The study finds that SN injuries during hamstring graft harvesting for ACL reconstruction are common, with a significant portion of patients experiencing persistent sensory deficits for at least two years postoperatively. These injuries are observed to adversely affect patient satisfaction and functional outcomes and to increase the re-rupture rate.

Among the graft options for anterior cruciate ligament reconstruction (ACLR), hamstring autografts are widely regarded as the preferred choice for primary ACLR among orthopedic surgeons worldwide. However, concerns persist regarding postoperative knee flexor weakness. We aimed to compare knee extensor and flexor strengths between hamstring autograft and tibialis anterior allograft groups in ACLR patients, who were propensity score-matched based on baseline characteristics. A retrospective analysis included 58 matched pairs who underwent isokinetic strength tests at 6 and 12 months post operation. Isokinetic muscle strength tests found no significant difference in knee extensor and flexor strength at 6 months post operation between the hamstring autograft and tibial anterior allograft groups. At 12 months, the hamstring autograft group exhibited significantly greater knee flexor deficit (total work and average power) compared to the allograft group, despite no differences in extensor strength or patient-reported outcomes. This study highlights the impact of hamstring autograft harvesting on muscle strength and recovery following ACLR in short-term period.

Precision anterior cruciate ligament reconstruction (ACLR) refers to the individualized approach to prerehabilitation, surgery (including anatomy, bony morphology, and repair/reconstruction of concomitant injuries), postrehabilitation, and functional recovery. This individualized approach is poised to revolutionize orthopedic sports medicine, aiming to improve patient outcomes. The purpose of this article is to provide a summary of precision ACLR, from the time of diagnosis to the time of return to play, with additional insight into the future of ACLR.

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.

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.

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%).

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.

Case series; Level of evidence, IV.

During anterior cruciate ligament (ACL) reconstruction, there are various autograft options. Donor-site morbidity is an important consideration while deciding the type of the autograft. Gracilis and semitendinosus autografts are commonly used in ACL reconstruction, resulting in weakness of the hamstring muscle.

We hypothesized that if we preserved the tibial insertion site of the sartorial fascia (SF) during hamstring tendon harvest, there would be better recovery of knee flexor strength.

Case-control study; Level of evidence, 3.

In this retrospective study, 34 patients (aged 20-59 years) underwent ACL reconstruction using hamstring tendon autograft with 2 different incision techniques on the SF. The tibial attachment site of the SF was preserved in 17 patients. The insertion site of the muscle was incised transversely in 17 patients. The follow-up duration was ≥2 years. Patients were recalled to the institute for examination and muscle strength assessment. The results were compared between the groups in terms of flexor and extensor knee isokinetic muscle strength at 60 and 180 deg/s.

There was no statistical difference between the groups in terms of age, sex, or body mass index. When compared with patients whose SF attachment site was incised, patients with a preserved SF tibial insertion were found to have a higher flexion peak torque at the angular speed of 180 deg/s (P < 002). No statistically significant difference was noted at 60 deg/s.

During collection of gracilis and semitendinosus autografts, preserving the SF tibial attachment site was associated with better knee flexion peak torque.

This study aimed to evaluate patellar tendon loading profiles (loading index, based on loading peak, loading impulse, and loading rate) of rehabilitation exercises to develop clinical guidelines to incrementally increase the rate and magnitude of patellar tendon loading during rehabilitation.

Twenty healthy adults (10 females/10 males, 25.9 ± 5.7 yr) performed 35 rehabilitation exercises, including different variations of squats, lunge, jumps, hops, landings, running, and sports specific tasks. Kinematic and kinetic data were collected, and a patellar tendon loading index was determined for each exercise using a weighted sum of loading peak, loading rate, and cumulative loading impulse. Then the exercises were ranked, according to the loading index, into tier 1 (loading index ≤0.33), tier 2 (0.33 < loading index <0.66), and tier 3 (loading index ≥0.66).

The single-leg decline squat showed the highest loading index (0.747). Other tier 3 exercises included single-leg forward hop (0.666), single-leg countermovement jump (0.711), and running cut (0.725). The Spanish squat was categorized as a tier 2 exercise (0.563), as was running (0.612), double-leg countermovement jump (0.610), single-leg drop vertical jump (0.599), single-leg full squat (0.580), double-leg drop vertical jump (0.563), lunge (0.471), double-leg full squat (0.428), single-leg 60° squat (0.411), and Bulgarian squat (0.406). Tier 1 exercises included 20 cm step up (0.187), 20 cm step down (0.288), 30 cm step up (0.321), and double-leg 60° squat (0.224).

Three patellar tendon loading tiers were established based on a combination of loading peak, loading impulse, and loading rate. Clinicians may use these loading tiers as a guide to progressively increase patellar tendon loading during the rehabilitation of patients with patellar tendon disorders and after anterior cruciate ligament reconstruction using the bone-patellar tendon-bone graft.

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.

To evaluate the differences in the patient-reported functional outcomes, concomitant injuries, and graft failure in primary versus revision ACL surgery using QT autograft.

Cohort study; Level of evidence, 3.

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.

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).

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.

Multiple different materials are used for filling bone defects following bone-patellar tendon-bone (BPTB) graft ACL reconstruction surgery. The theoretical objective being to minimize kneeling pain, improve clinical outcomes and reduce anterior knee pain following surgery. The impact of these materials is assessed in this study.

A prospective monocentric cohort study was conducted from January 2018 to March 2020. There were 128 skeletally mature athletic patients who underwent ACL reconstruction using the same arthroscopic-assisted BPTB technique, with a minimum follow-up of two years identified in our database. After obtaining approval from the local ethics committee, 102 patients were included in the study. Patients were divided into three groups based on type of bone substitute. The Bioactive glass 45S5 ceramic Glassbone™ (GB), collagen and hydroxyapatite bone void filler in sponge form Collapat® II (CP), and treated human bone graft Osteopure®(OP) bone substitutes were used according to availability. Clinical evaluation of patients at follow-up was performed using the WebSurvey software. A questionnaire completed in the 2nd post-operative year included three items: The ability to kneel, the presence of donor site pain, and the palpation of a defect. Another assessment tool included the IKDC subjective score and Lysholm score. These two tools were completed by patients preoperatively, and postoperatively on three occasions (6 months, 1 year, and 2 years).

A total of 102 patients were included in this study. In terms of Kneeling pain, the percentage of GB and CP patients' who kneel with ease were much higher than that of OP patients (77.78%, 76.5% vs 65.6%, respectively). All three groups experienced an important increase in IKDC and Lysholm scores. There was no difference in anterior knee pain between the groups.

The use of Glassbone® and Collapat II® bone substitutes reduced the incidence of kneeling pain compared to Osteopure®. There was no influence of the bone substitute type on the functional outcome of the knee or on the anterior knee pain at two years of follow.

Soft-tissue grafts are an option for anterior cruciate ligament reconstruction. One of the major drawbacks of soft-tissue grafts is the delay in the osteointegration and ligamentization of the implanted graft. Enveloping the ends of the graft with periosteum sleeves can hasten the osteointegration process and help in quicker rehabilitation of the patient. This article describes a simple and unique way to augment the soft-tissue graft with periosteum for anterior cruciate ligament reconstruction.

Bone-patellar tendon-bone (BTB) anterior cruciate ligament reconstruction (ACLR) is one of the conventional techniques in the revision setting especially after a primary hamstring tendon graft. The use of the iliotibial band (ITB) augmented with allograft (AG) is an encouraging graft alternative for ACLR in terms of clinical and biomechanical data in the literature.

To compare the clinical outcomes of BTB graft with lateral extra-articular tenodesis, modified Lemaire (BTB-LET), and an ITB graft augmented with hamstring AG (ITB-AG) in the setting of revision ACLR.

Cohort study; Level of evidence, 3.

Descriptive data and clinical outcomes were prospectively collected from patients who underwent revision ACLR with either the BTB-LET or ITB-AG technique between 2012 and 2020 and who had a minimum follow-up of 2 years. The clinical outcomes were assessed by the Lysholm, Tegner, Anterior Cruciate Ligament-Return to Sport after Injury, International Knee Documentation Committee subjective knee evaluation form, and Knee injury and Osteoarthritis Outcome Score. Return to sports, complications, and revisions were also analyzed.

A total of 167 patients were included, with 106 patients in the BTB-LET group and 61 patients in the ITB-AG group. There were no significant group differences in sociodemographic characteristics; however, the mean follow-up was significantly longer in the BTB-LET compared with the ITB-AG group (52.0 vs 38.8 months, respectively; P = .0001). There were no significant differences in postoperative outcome scores; however, patients in the ITB-AG group had a higher rate of return to competitive pivoting sports (32.8% vs 17.9%; P = .0288) and a higher overall rate of return to preinjury sport (63.9% vs 47.2%; P = .0365). Complications, including revisions for meniscal or chondral lesions and retears (8 [8.3%] in the BTB-LET group and 2 [4.0%] in the ITB-AG group), were not significantly different. All retears were due to sports-related accidents.

In this study, ITB-AG was not different from BTB-LET in terms of functional outcomes scores but allowed better return to sport rate. Performing ITB-AG reconstruction in the setting of revision ACLR appears to be safe, effective, and associated with a satisfying return-to-sports rate.

To critically evaluate the efficacy and safety of early versus delayed anterior cruciate ligament reconstruction (ACLR) for anterior cruciate ligament (ACL) injuries based on the different cut-off values of the timing of operation.

PubMed, Medline, Embase, Cochrane library, China National Knowledge Infrastructure, Chinese Biomedical Literature, and Wanfang Digital Periodical database were searched from inception to November 2022 without language restrictions. Randomized controlled trials (RCTs) and cohort studies (CSs) comparing early ACLR with delayed ACLR for ACL injuries were included.

Twenty-four studies (10 RCTs and 14 CSs) were included. According to the information from included studies, 3 weeks, 4 weeks, 6 weeks, 6 months, and 12 months after ACL injuries were considered as the cut-off values of early and delayed ACLR. When 4 weeks were considered as the cut-off value, early ACLR could significantly improve Lysholm score, IKDC score and VAS score at 6 and 12 months postoperatively and decrease the incidence of adverse events compared with delayed ACLR (P < 0.05). However, no statistically significant difference in positive rate of Lachman test and incidence of meniscus injuries and chondral lesions between the two groups when 3 weeks, 6 weeks, 6 months or 12 months after ACL injuries were considered as the cut-off values of early and delayed ACLR (P > 0.05).

The present study suggests that early ACLR, especially conducted within 3-4 weeks after ACL injuries, may be more effective for improving knee function and relieving pain compared with delayed ACLR. More high-quality RCTs are warranted.

The hamstring tendons (gracilis and semitendinosus) are often used as an autograft for anterior cruciate ligament (ACL) reconstruction. Healing of this graft involves a slow biological process called ligamentization. To encourage this process, some authors have proposed preserving the insertion of the hamstring tendons.

Leaving the tibial insertion of the hamstring tendons intact will provide better early biological incorporation and superior tibial mechanical fixation resulting in various clinical advantages.

In January 2022, a systematic literature review was carried out independently by two authors of the Medline, PubMed and Embase databases. The keywords used were "pedicular" or "pedicled" or "preservation of tibial attachment" or "hamstring tibial insertion" AND "ACL reconstruction". Each author's data was analyzed separately.

Sixteen articles were analyzed. Preserving the hamstring tibial insertion during ACL reconstruction improves the graft's biological incorporation during the initial postoperative phase according to clinical studies with MRI analysis and provides a mechanical advantage at the graft's tibial attachment according to biomechanical studies (construct up to 65% stiffer). There was no difference in the clinical and functional scores when compared to the conventional technique in which the hamstring tendons are detached from their tibial insertion.

The main conclusion of this systematic literature review was that preserving the hamstring tibial insertion during ACL reconstruction appears to improve the graft's ligamentization with biological and mechanical advantages relative to detaching the hamstring tendons. The clinical and functional results were comparable to other techniques. Prospective studies with large cohorts are still needed to confirm these findings.

IV; Systematic review of literature.

Patellar tendons are assumed to be uniform in morphology and mechanical properties despite a higher prevalence of tendinopathies observed in the medial region. The purpose of this study was to compare the thickness, length, viscosity, and shear modulus of the medial, central, and lateral regions of healthy patellar tendons of young males and females in vivo. B-mode ultrasound and continuous shear wave elastography were performed on 35 patellar tendons (17 females, 18 males) over three regions of interest. A linear mixed-effects model (α = 0.05) was used to determine differences between the three regions and sexes followed by pairwise comparisons for significant findings. The lateral region (mean [95% confidence interval] = 0.34 [0.31-0.37] cm) was thinner compared with the medial (0.41 [0.39-0.44] cm, p < 0.001), and central (0.41 [0.39-0.44] cm, p < 0.001) regions regardless of sex. Viscosity was lower in the lateral (19.8 [16.9-22.7] Pa-s) versus medial region (27.4 [24.7-30.2] Pa-s, p = 0.001). Length had a region-by-sex interaction (p = 0.003) characterized by a longer lateral (4.83 [4.54-5.13] cm) versus medial (4.42 [4.12-4.72] cm) region in males (p < 0.001), but not females (p = 0.992). Shear modulus was uniform between regions and sexes. The thinner, and less viscous lateral patellar tendon may reflect the lower load the tendon experiences explaining the differences in regional prevalence of developing tendon pathology. Statement of Clinical Significance: Healthy patellar tendons are not uniform in morphology or mechanical properties. Considering regional tendon properties may help guide targeted interventions for patellar tendon pathologies.

The quest for a good and durable substitute to anterior cruciate ligament (ACL) is driving scientists to explore new promising areas of research. Autologous and allogenic ligament reconstruction bring satisfactory results in managing ACL surgery although their use is associated with significant drawbacks. To overcome the limitations of biologic grafts, many artificial devices have been developed and implanted as a substitute to the native ACL over the past decades. Although many synthetic grafts used in the past have been withdrawn from the market due to early mechanical failures ultimately leading to synovitis and osteoarthritis, there is recently a resurgence of interest in the use of synthetic ligaments for ACL reconstruction. However, this new generation of artificial ligaments, despite promising initial results, have shown to produce serious side effects such as high rupture rates, insufficient tendon-bone healing and loosening. For these reasons, recent advancements in biomedical engineering are focusing on improving technical features of artificial ligaments combining mechanical properties to biocompatibility. Bioactive coatings and surface modification methods have been proposed to enhance synthetic ligament biocompatibility and promote osseointegration. The path to the development of a safe and effective artificial ligament is still full of challenges, however recent advancements are leading the way towards a tissue-engineered substitute to the native ACL.

Combined anterior cruciate ligament and anterolateral ligament reconstruction (ACL+ALL r) is a common procedure to treat rotational instability and to prevent ACL graft failure. Recent studies have described numerous combined reconstruction techniques to obtain the most anatomical procedure with the least graft donor site morbidity and the best clinical results. Hamstring (HG) grafts are the most popular graft in literature. Leaving pedicle HG can preserve enough blood supply to improve tendon-bone healing with additional mechanical fixation of the graft on the tibial side. A single femoral tunnel reduces bone loss and prevents convergence of 2 femoral tunnels. We describe an original ACL and ALL reconstruction technique that preserves hamstring tibial insertion with a single blind femoral tunnel.

The purpose of this study was to evaluate the differences in the patient-reported functional outcomes, and graft failure in revision ACL reconstruction using quadriceps tendon (QT), Hamstring tendon (HT) and bone-patellar tendon-bone (BPTB) autografts.

Between 2010 and 2020, 97 patients who underwent revision ACL reconstruction (40 patients received a QT, 26 an HT and 31 a BPTB graft) met the inclusion criteria. Pre-injury and at 2-year postoperatively patients were evaluated for patient-reported functional outcomes; Lysholm knee score, Tegner activity level and VAS (visual analogue scale) for pain; and graft failure. Patient-reported outcomes and graft failure were compared between the QT, HT and BPTB groups. The patients with graft failure were not included for outcome analysis at 2-years of follow-up.

All three revision groups with QT, HT and BPTB autograft did not differ significantly in terms of age, sex, time from injury to surgery, concomitant injuries and single-stage or double-stage procedures (n.s.). No significant difference was found in the pre-injury patient-reported outcome; Lysholm knee score, Tegner activity and VAS for pain (n.s.) between the three groups. At the 2-year follow-up functional outcomes improved in all three groups and all the patients returned to pre-injury activity level; however, no significant difference was found in functional outcomes at the 2-year follow-up between the three groups (n.s.). Graft failure occurred in 4 (10%), 5 (19%) and 3 (10%) patients of QT, HT and BPTB groups, respectively. However, the rate of failure did not differ significantly between groups.

All three autografts (QT, HT and BPTB) demonstrated satisfactory patient-reported outcomes in revision ACL reconstruction. Compared with QT and BPTB grafts, HT graft showed a higher tendency for failure rates. With the increasing incidence of revision ACL reconstruction, surgeons should be aware of all the available graft options. The findings of this study will assist the surgeons in the graft selection for revision ACL reconstruction.

Level III.

Patellar tendon injuries occur via various mechanisms such as overuse, or due to surgical graft harvest for anterior cruciate ligament reconstruction (ACLR). Quantified patellar tendon stiffness after injury may help guide clinical care. Continuous shear wave elastography (cSWE) allows for the assessment of viscosity and shear modulus in tendons. The reliability of the measure, however, has not been established in the patellar tendon. The purpose of this study was to investigate the interrater reliability, intrarater reliability, and between-day stability of cSWE in both healthy and pathological patellar tendons.

Participants with patellar tendinopathy (n = 13), history of ACLR using bone-patellar tendon-bone autograft (n = 9), and with no history of patellar tendon injury (n = 13) were recruited. cSWE was performed 4 times by multiple raters over 2 days. Intraclass correlations (ICC) and minimum detectable change (MDC_95% ) were calculated.

Good to excellent between-day stability were found for viscosity (ICC = 0.905, MDC_95%  = 8.3 Pa seconds) and shear modulus (ICC = 0.805, MDC_95%  = 27.4 kPa). The interrater reliability measures, however, were not as reliable (ICC = 0.591 and 0.532).

cSWE is a reliable assessment tool for quantifying patellar tendon viscoelastic properties over time. It is recommended, however, that a single rater performs the measure as the interrater reliability was less than ideal.

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.

To compare the 5-year clinical and functional outcomes of the soft-tissue quadriceps tendon (QT) with those of the hamstring tendon (HT) autograft.

A retrospective review of patients undergoing anterior cruciate ligament reconstruction using either soft-tissue QT or double-tendon HT autograft with at least 5 years of follow-up was conducted. Surgical technique included anteromedial portal creation for the femoral tunnel and transtibial technique for the tibia. Graft fixation was achieved with interference composite screws for the QT and combination of interference composite screw and suture button for the HT cohort. The 2 groups were compared for differences in outcomes, including International Knee Documentation Committee (IKDC) score, Lysholm score, return to sport, and complications.

A total of 37 patients with QT autograft and 46 HT autografts were included in the study, with a mean follow up of 69.9 months and 70.9 months, respectively. The QT group demonstrated a larger graft size on average (9.64 mm vs 7.90 mm, P < .001). The IKDC and Lysholm scores were similar between the 2 groups at 2-years' postoperatively. At 5 years' postoperatively, the QT group demonstrated significantly greater IKDC (P = .018) and Lysholm (P = .007) scores. The cohorts demonstrated similar rates of achieving minimal clinically important difference thresholds at both 2 and 5 years' postoperatively. The 2 groups also demonstrated comparable rates of return to sport, time to return, and postoperative complications.

Although the QT autograft demonstrated increased patient-reported outcome scores when compared with the HT at 5 years' postoperatively, there was no clinically significant difference between the cohorts at 2 or 5 years' postoperatively. The QT autograft is an effective alternative to HT autograft with noninferior results to the HT autograft at mid-term follow-up.

III, retrospective comparison study.

The purpose of this study was to evaluate the patient-reported outcomes, graft failure, quadriceps rupture and sports preference after arthroscopic ACL reconstruction in patients older than 50 years who underwent arthroscopic ACL reconstruction with a quadriceps tendon (QT) autograft.

Between 2010 and 2020, prospectively collected data were obtained from an institutional database. Patients older than 50 years with primary arthroscopic ACL reconstruction and a minimum of 2 years of follow-up were included. Patients undergoing a revision ACL reconstruction or undergoing a primary ACL reconstruction using a graft other than a QT autograft, and patients with a contralateral knee injury or osteoarthritis (Ahlbäck stage 2 or higher) were excluded. A minimally invasive technique was used for QT autograft harvesting. Patients were evaluated for pre-injury and 2-year follow-up Lysholm knee score, Tegner activity level, Visual Analog Scale (VAS) for pain, graft failure, quadriceps tendon rupture, and return to sport.

A total of 57 patients were included in the study. The mean age of the cohort was 54.9 ± 5.2 (range 50-75). Of the 57 reconstructions, 16 (28%) were isolated ACL reconstructions, while 41 (72%) were complex reconstructions (concomitant meniscus, cartilage and/or collateral ligament injuries). At the 2-year follow-up Lysholm knee score, Tegner activity level and VAS for pain improved to pre-injury level and no significant difference was noted between pre-injury and 2-year follow-up functional scores (n.s.). No case of graft failure or quadriceps tendon rupture was reported. No significant difference was noted in the pre-injury and postoperative sports preference (n.s.) and all patients return to their desired sports activity.

Arthroscopic ACL reconstruction by using QT autograft in highly active older patients provides satisfactory patient-reported functional outcomes and allows recovery of the pre-injury level of activity. QT autograft is a good graft option in patients older than 50 years.

Level IV.

Although the outcomes of ACL reconstruction are generally satisfying, there are several patients who do not regain their pre-injury sporting level and suffer persistent symptoms. Orthopaedic practice has evolved significantly over the last five years to address these drawbacks. The aim of the present survey was to analyze the changes in the approach to ACL reconstruction among a population of young ESSKA surgeons dedicated to ACL surgery.

The survey was uploaded on the ESSKA website and was accessible to members under the age of 45. The ESSKA society has 1035 U45 members involved in multiple aspects of Orthopaedic practice. One hundred and forty questionnaires were returned. Several aspects of ACL surgery were investigated at baseline and 5 years prior. They included general details such as the volume of ACL reconstructions per surgeon per year, the graft choice in cases of low and high demanding patients, the technique for femoral tunnel drilling and the preferred device for femoral fixation. The approach to the management of damage to peripheral structures, as well as meniscal ramp and root tears were also investigated.

Hamstrings and quadrupled semitendinosus were the preferred graft choice in low-demanding patients (92.9%) while quadriceps tendon is gaining popularity in contact sport practitioners (from 4.3 to 10.7%). The percentage of surgeons using femoral screws had decreased from 37.9 to 29.3 while the percentage of those who used buttons increased from 52.9 to 69.3%. Extra-articular procedures (antero-lateral ligament (ALL) or lateral tenodesis have become popular. The percentage of surgeons who perform an additional peripheral reconstruction rose from 28.5 to 71.5%. Of those who perform the meniscal repair more than 50% of patients rose from 14.3 to 27.9%. Similarly, the percentage of surgeons who performed a medial meniscus ramp lesion repair rose from 29.4 to 54.7%. While the percentage of those who choose to perform a transtibial pull-out repair of lateral meniscus root tears significantly rose from 17.9 to 59.3%.

The present survey among under 45 years old ESSKA surgeons yields some notable findings. The new evidence on the impact of injuries on peripheral structures and menisci is stimulating surgeons towards a more anatomic approach if identified at the time of ACL reconstruction. This evidence will probably influence future research and decision-making.

IV.

To determine, by biomechanical analysis, safe patellar cut limits in anterior cruciate ligament (ACL) reconstruction that minimize fracture risks.

From three-dimensional reconstruction, triangular cuts were made in the patella, with a depth of 6.5 mm and variable width and length (10 to 20 mm and 8 to 12 mm, respectively, both with an interval of 1 mm). The combinations of cuts constituted 55 models for tests, with five variations in width and 11 variations in length, tested with the finite element method (FEM).

The mean of the localized principal maximum (traction force) values was 4.36 Pa (SD 0.87 ± 0.76) and the localized principal minimum (compression force) was -4.33 Pa (SD 1.05 ± 1.11). Comparing width and length to the tension force of the values of the main maximum, we found statistical significance from 11 mm for width and 13 mm for length.

In ACL reconstruction, the removal of the patellar bone fragment is safe for fragments smaller than 11 mm in width and 13 mm in length, which corresponds to 24% of the width and 28% of the length of the patella used. Level of Evidence II, Comparative Prospective Study.

Efficient hamstring tendon harvesting is a crucial part of anterior cruciate ligament reconstruction surgery using autografts. Harvesting of the gracilis and semitendinosus tendons is usually performed using an open approach, exposing the distal tibial attachment of the tendons at the pes anserinus and proceeding using a tendon stripper without direct tendon visualization. The success of the anterior cruciate ligament reconstruction surgery strongly depends, among other factors, on the preservation of the hamstring tendon length and integrity. Inadequate tendon release from their attachments and improper use of the tendon stripper, in addition to poor intraoperative visibility, may lead to premature tendon amputation, endangering the success of the operation. We describe an endoscopic-assisted technique of hamstring tendon harvesting that provides complete visualization of the tendons from the tibia attachment to the musculotendinous junction. The procurement of the tendons is completed under direct vision using any tendon stripper. This surgical technique offers a way to minimize complications that may arise during the standard open tendon harvesting techniques without additional visualization.

Peroneus longus tendon (PLT) autograft has been successfully used for isolated anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) reconstruction cases. Being a powerful evertor and flexor of great toe, there might be associated ankle morbidity with this autograft option. However, there are only a few studies exploring whether the ankle morbidity is significant or not. This study aims to assess the functional outcomes, donor site morbidity, and ankle strength after harvesting ipsilateral peroneus longus autograft for ACL reconstruction in revision ACL and multi-ligament injury cases.

This was a prospective case series. All of the patients were evaluated by clinical examination for knee for laxity, ankle joint stability, and using visual analog scale (VAS) for pain, International Knee Documentation Committee (IKDC) score, and Lysholm score, preoperatively and postoperatively at two-year follow-up. Morbidity of donor ankle was assessed using American Orthopedic Foot and Ankle Society (AOFAS) score, bilateral evertors, and first ray plantarflexion strength measurement using an isometer (Innovative Design Orthopedics) at two-year follow-up.

Ipsilateral PLT graft was used in ten patients of revision ACL reconstruction and 27 patients of the multi-ligament knee injury. The mean length of PLT harvested (cm) was 26.2 (standard deviation 2.6, range 22-31), and mean diameter of the doubled graft (mm) was 7.9 (standard deviation 0.68, range 7.5-8.5). There was a significant improvement in VAS score for pain, Lysholm, and IKDC scores (p =  < 0.001) at two -year follow-up. There were no cases of graft failure, superficial, or deep infection. Ankle dorsiflexion(p = 0.32), ankle plantarflexion (p = 0.19), eversion strength(p = 0.6), first ray plantarflexion strength(p = 0.52), and AOFAS score(p = 0.29) were found to be comparable to the normal side in all patients.

Peroneus longus autograft can be considered as a potential autograft option for ACL reconstruction in multi-ligament knee injuries and revision ACL reconstruction. No significant donor site morbidity was noted at follow-up.

Level IV.