Background: Comprehensive studies evaluating quadriceps tendon (QT) autograft for anterior cruciate ligament (ACL) reconstruction are lacking. The optimal choice of graft between bone–patellar tendon–bone (BPTB), hamstring tendon (HT), and QT is still debatable. Hypothesis: The current literature supports the use of QT as a strong autograft with good outcomes when used in ACL reconstruction. Study Design: Meta-analysis; Level of evidence, 2. Methods: A systematic search of the literature was performed in PubMed, MEDLINE, Cochrane, and Ovid databases to identify published articles on clinical studies relevant to ACL reconstruction with QT autograft and studies comparing QT autograft versus BPTB and HT autografts. The results of the eligible studies were analyzed in terms of instrumented laxity measurements, Lachman test, pivot-shift test, Lysholm score, objective and subjective International Knee Documentation committee (IKDC) scores, donor-site pain, and graft failure. Results: Twenty-seven clinical studies including 2856 patients with ACL reconstruction met the inclusion criteria. Comparison of 581 QT versus 514 BPTB autografts showed no significant differences in terms of instrumented mean side-to-side difference ( P = .45), Lachman test ( P = .76), pivot-shift test grade 0 ( P = .23), pivot-shift test grade 0 or 1 ( P = .85), mean Lysholm score ( P = .1), mean subjective IKDC score ( P = .36), or graft failure ( P = .50). However, outcomes in favor of QT were found in terms of less donor-site pain (risk ratio for QT vs BPTB groups, 0.25; 95% CI, 0.18-0.36; P < .00001). Comparison of 181 QT versus 176 HT autografts showed no significant differences in terms of instrumented mean side-to-side difference ( P = .75), Lachman test ( P = .41), pivot-shift test grade 0 ( P = .53), Lysholm score less than 84 ( P = .53), mean subjective IKDC score ( P = .13), donor-site pain ( P = .40), or graft failure ( P = .46). However, outcomes in favor of QT were found in terms of mean Lysholm score (mean difference between QT and HT groups, 3.81; 95% CI, 0.45-7.17; P = .03). Conclusion: QT autograft had comparable clinical and functional outcomes and graft survival rate compared with BPTB and HT autografts. However, QT autograft showed significantly less harvest site pain compared with BPTB autograft and better functional outcome scores compared with HT autograft.
Purpose Comparing scar cosmesis and regional hypoesthesia at the incision site between quadriceps tendon (QT), bone–patellar tendon–bone (BPTB), and hamstring tendon (HT) for anterior cruciate ligament (ACL) reconstruction. Methods Ninety patients undergoing ACL reconstruction with QT, HT or BPTB were evaluated at 1‐year post‐op. Scar cosmesis was assessed using the patient and observer scar assessment scale (POSAS) and length of the incision. Sensory outcome was analyzed by calculating the area of hypoesthesia around the scar. The classical ACL reconstruction functional follow‐up was measured using the Lysholm score and KOOS. Results Concerning QT versus BPTB group, QT patients have a significantly lower mean POSAS (24.8 ± 6.3 vs. 39.6 ± 5.8; p < 0.0001), shorter mean incision (2.8 ± 0.4 cm vs. 6.4 ± 1.3 cm; p < 0.0001), lower extent of hypoesthesia (8.7 ± 5.1 cm2 vs. 88.2 ± 57 cm2; p < 0.0001), and better Lysholm score (90.1 ± 10.1 vs. 82.6 ± 13.5; n.s.). No significant difference was seen in KOOS (90.7 ± 7.2 vs. 88.4 ± 7.0; n.s.). Concerning QT versus HT group, no significant difference was found regarding mean POSAS score (24.8 ± 6.3 vs. 31.8 ± 6.2; n.s.), mean length of the incision (2.8 ± 0.4 cm vs. 2.5 ± 0.6 cm; n.s.), KOOS (90.7 ± 7.2 vs. 89.8 ± 8.2; n.s.) and mean Lysholm score (90.1 ± 10.1 vs. 87.8 ± 0.6; n.s.). The mean measured area of hypoesthesia was significantly higher in the HT group (70.3 ± 77.1 cm2 vs. 8.7 ± 5.1 cm2; p < 0.0001). Conclusion Quadriceps tendon harvesting technique has the safest incision by causing less sensory loss compared to BPTB and HT. It also has the advantage of a short incision with more cosmetic scar compared to BPTB, with no difference compared to HT. However, no significant difference in terms of functional outcome was shown between the three autografts. These findings provide surgeons evidence about their clinical practice and help with graft choice decisions. Level of evidence III.
Background: Medial meniscal ramp lesion (MMRL), lateral meniscus root tear (LMRT), and anterolateral ligament (ALL) tear are individual injuries that have been described in patients who have an anterior cruciate ligament (ACL) tear. However, the prevalence of these lesions and their combination has not been defined. Purposes: To define the individual and combined prevalence of MMRL, LMRT, and ALL tears in a case series of patients undergoing ACL reconstruction and to identify the risk factors for combined injuries. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients aged >15 years undergoing primary ACL reconstruction between January 2019 and June 2021 were enrolled in the study. A preoperative ultrasound scan was performed to look for an ALL tear. The presence of MMRL and LMRT was determined during a standardized arthroscopy exploration. A multivariate logistic regression model was used to determine the individual effect of patient variables on the risk of associated single, dual, triad, or tetrad injuries (MMRL, LMRT, ALL, ACL), represented by an adjusted odds ratio. Results: The case series consisted of 602 patients who underwent primary ACL reconstruction. An isolated ACL injury was present in 147 patients (24%). A dual injury was detected in 34 patients (6%) who had ACL-MMRL, 16 (2.65%) who had ACL-LMRT, and 265 (44%) who had ACL-ALL. A triad injury was detected in 80 patients (13.28%) who had ACL-ALL-MMRL, 36 (6%) who had ACL-ALL-LMRT, and 3 (0.5%) who had ACL-MMRL-LMRT. A tetrad injury pattern was detected in 21 patients (3.5%). Multivariate analysis showed that the occurrence of tetrad injury was significantly lower in older patients (adjusted odds ratio by year, 0.93 [95% CI, 0.88-0.99]; P = .028). Identifying LMRT increased the likelihood of finding MMRL-ALL injuries by 2.11 times (95% CI, 1.09-3.12; P = .031). Conclusion: Isolated ACL tear is less common than combined injuries, which are quite frequent. Younger age is a risk factor for combined injuries. The search for damaged secondary stabilizers of the knee must be meticulous and systematic, especially when 1 injured structure has already been diagnosed.
The reproducibility is found to be poor under optimum conditions of comparability. The patellar pressure influences strongly thelaxity value.
Background: In anterior cruciate ligament (ACL) reconstruction with anterolateral ligament (ALL) reconstruction, precise positioning of the ALL graft on the femur and tibia is key to achieve rotational control. The lateral femoral epicondyle is often used as a reference point for positioning of the ALL graft and can be located by palpation or with ultrasound guidance. Purpose: To compare the ALL graft positioning on the femoral side between an ultrasound-guided technique and a palpation technique for the location of the lateral epicondyle. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 120 patients receiving a primary combined ACL and ALL reconstruction between June and December 2019 were included. The location of the lateral epicondyle was determined by palpation in the palpation group (n = 60) and with preoperative ultrasound guidance in the ultrasound group (n = 60). Groups were comparable in age, sex, body mass index (BMI), and operated side. The planned positioning of the femoral ALL graft was proximal and posterior to the lateral epicondyle. The effective positioning of the femoral ALL graft was evaluated on postoperative lateral radiographs. The primary outcome was location of the graft in a 10-mm quadrant posterior and proximal to the lateral epicondyle. Results were analyzed in 2 subgroups according to BMI. Results: All 60 anterolateral grafts (100%) in the ultrasound group were positioned in a 10-mm quadrant posterior and proximal to the lateral epicondyle, as opposed to 52 (87%) in the palpation group ( P = .006). Errors in graft positioning with palpation occurred in overweight patients (BMI >25) as well as nonoverweight patients ( P = .3). Conclusion: Femoral positioning of the ALL graft posterior and proximal to the lateral epicondyle is more reproducible with ultrasound guidance when compared with palpation alone, regardless of BMI.
Background Digital surveys are commonly used to collect PROMS but could lead to a biased sample due to low response rate. Augmented care experience (ACE) is a process of offering higher quality of care for patients undergoing an ACLR via a Web-based platform. Hypothesis ACE improve participation to follow-up questionnaires using a Web-based platform (Orthense ®) Study design Cohort Study. Methods 101 patients scheduled for ACLR were divided in two groups: Control group (n = 50) in which patients were offered an Orthense® account to respond to 11 questionnaires post-operatively and a paper prescription of a cold knee brace (CKB) for post-operative cryotherapy; ACE group (n = 51), in addition to offering Orthense® account, the patients received in automated and digital process through their account a connection with a supplier who take in charge to send the CKB directly to their home without any additional charge. Age and sex, responses on total questionnaires, level of education, and satisfaction from the surgery at D+45 were collected. Results 31.7% female and 68.3% male with an average age of 29 years old participated. Patients in ACE group responded significantly better with mean response rate of 80.75% vs 51.64% in control group (p < 0.001). Mean response rate to 11 questionnaires was 66.34% in all patients. Female and older patients were factors associated with higher response rate. There was no significant variation in response rate over the time in both groups. Conclusion ACE showed to be an effective strategy to increase patient’s participation to a Web-based follow-up platform. Highlights
Background: Nonsurgical treatment of concomitant medial collateral ligament (MCL) in the setting of anterior cruciate ligament reconstruction (ACLR) increases the risk of graft failure. Few published cases of medial complex reconstruction combined with ACLR with no clear consensus on the optimal technique to treat these complex injuries. Indications: A female patient aged 41 years, with failure of ACLR in 2009 and 2 revisions in 2013 and 2014, associated with concomitant nontreated MCL and posterior oblique ligament (POL) injury. Physical examination showed valgus test laxity grade III at 30° of knee flexion and at full extension, with Lachman and pivot-shift test grade III. Imaging showed normal long-leg standing axis with 10° posterior tibial slope on radiograph, and associated MCL and POL injury on magnetic resonance imaging. Technique Description: ACLR and anterolateral tenodesis using the fascia lata leaving its distal insertion on the Gerdy tubercle, with double-stranded contralateral gracilis, was completed. A new femoral tunnel was made from outside to inside, with preservation of the previous tibial tunnel. The transplant was fixed with 2 interference screws. Second, the contralateral semitendinous autograft was used for MCL and POL reconstruction. A single strand of the graft was used for femoral fixation created on femoral epicondyle to cover MCL and POL origins, and double strands were used for distal fixation of MCL at the level of hamstring insertion and POL at the posteromedial corner of medial tibial plateau. The graft was secured with 3 interference screws at 30 knee flexion for MCL and full extension for POL. Results: The results include favorable functional and clinical outcome with improvement in the anteroposterior and rotatory knee stability at mid-term follow-up. Lateral extra-articular tenodesis in supplementing ACLR controls internal tibial rotatory knee stability. Double-bundle reconstruction of MCL and POL improved both valgus and anteromedial rotatory instability by restraining external rotation. Discussion/Conclusion: Surgeons should consider the need for surgical treatment of concomitant MCL injury to prevent chronic valgus laxity and increased strain on the anterior cruciate ligament (ACL) graft, potentially increasing the risk of ACLR revision. Our described technique offers a safe method for ACLR and lateral tenodesis with an advantage to avoid tunnel convergence, and medial stabilization to restore native valgus and rotatory stability and prevent increased stress on ACL graft.
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