Injury to the infrapatellar branch of the saphenous nerve during tendon graft harvesting for knee ligament reconstruction: An ultrasound simulation study

The clinical anatomy of the infrapatellar branch of the saphenous nerve (IPBSN) is of particular importance during operations in the area of the knee, especially when material for anterior cruciate ligament reconstruction is harvested. The nerve can easily be injured during the harvesting procedure, leading to postoperative complications that reduce quality of life. Three different skin incisions are commonly used during hamstring tendon harvesting: horizontal, vertical, and oblique. The aim of this ultrasound simulation study was to assess the risk of IPBSN injury associated with the type of skin incision and the point‐of‐emergence of the IPBSN relative to the sartorius muscle. Thirty healthy volunteers (60 lower limbs) were recruited for identification of the IPBSN. When it was found, using a high‐frequency ultrasound probe, three different 3 cm skin incisions over the pes anserinus were simulated. Vertical, horizontal, or oblique lines simulating incisions were marked over the pes anserinus and ultrasound was used to visualize the structures that could be injured during the marked incisions. The IPBSN was visualized in 58 lower limbs (96.7%). The results of the simulation study indicated that the vertical incision should be avoided during hamstring tendon harvesting, as it is associated with a significantly higher risk of injury (25.9%) to the IPBSN than the horizontal (3.5%) or oblique (8.6%) incisions. We recommend that a preoperative ultrasound assessment of IPBSN anatomy be performed to minimize the risk of iatrogenic injury to the nerve and associated complications. Clin. Anat. 30:868–872, 2017. © 2017 Wiley Periodicals, Inc.     

Saphenous nerve injury after anterior cruciate ligament reconstruction: Reduced numbness area after ligamentoplasty using quadriceps tendon compared with hamstring tendon

PurposeInjury to the infra-patellar branches of the saphenous nerve (IPBSN) is the main neurological complication of anterior cruciate ligament (ACL) reconstruction procedures. Surgical technique using quadriceps tendon (QT) autograft allows a less invasive tibial approach potentially protecting the IPBSN. The aim of this study was to compare the numbness surface of the cutaneous area supplied by the IPBSN after ACL reconstruction using either hamstring tendon (HT) or QT autografts.MethodsThis was a retrospective comparative cohort study including 51 patients who underwent ACL reconstruction (27 QT and 24 HT) between January 2017 and April 2018. A sensory clinical evaluation was performed on each patient: length of the tibial scar, eventual numbness surface area and the type of sensory disorder were reported. To be considered as an IPBSN lesion, the numbness area had to spread at least one-centimeter away from the scar.ResultsThe average follow-up was 15 months. In the HT group, the numbness area surface measured 21.2 ± 19 cm² (0–77) and the scar length was on average 31.3 ± 5.6 mm. In the QT group, the numbness area was reduced to 5 ± 10 cm² (P = .0007) as well as the scar length (13.3 ± 2.8 mm, P < .0001). We counted five (17.8%) and 19 (76%) real IPBSN lesions in the QT and HT groups, respectively (P = .0002). Hypoesthesia was the main sensory disorder observed (87.5%).ConclusionNumbness area of the cutaneous surface supplied by the IPBSN after ACL reconstruction is reduced using QT autograft compared with HT autograft.     

Over-the-top Anterior Cruciate Ligament (ACL) reconstruction plus lateral plasty with hamstrings in high-school athletes: Results at 10 years

BackgroundAnterior Cruciate Ligament (ACL) injuries have grown in adolescent population in the last decades, and if surgical reconstruction resulted safe in the short term, its impact in the long term is still unclear. The purpose of this study was to assess the long-term risk of failure, the rate of contralateral injury and the clinical reported outcomes in a cohort of high-school athletes after ACL reconstruction.Methods54 consecutive patients (mean age 16.3 ± 1.4 years) underwent ACL reconstruction with a single-bundle plus lateral plasty hamstring technique between May 2006 and July 2009. The number of subsequent ipsilateral reoperations and contralateral ACL reconstruction, Lhysolm, KOOS, VAS for pain and Tegner Activity Level was determined at a minimum follow-up of 10 years.ResultsIpsilateral ACL revision was performed in 8 (3.4%) patients, contralateral ACL reconstruction in 11 (21.1%). The average Lysholm score was 95.1 ± 9.2. The average KOOS was 96.5 ± 6.3 for the Pain subscale, 92.2 ± 9.0 for the Symptom subscale, 99.2 ± 1.8 for the ADL subscale, 94.1 ± 10.1 for the Sport subscale and 91.8 ± 14.5 for the Quality-of-life subscale. The average VAS for pain during activity was 1.7 ± 2.3. 90% returned to sport, 15% decreased the activity level, 61% of patients were still involved in sport, 35% at the same pre-injury level.ConclusionAt long-term, single-bundle hamstring ACL-R plus lateral-plasty in a cohort of high school athletes resulted to have a comparable graft failure rate and contralateral ACL injury with other surgical techniques.     

Septic arthritis in ACL reconstruction surgery with hamstring autografts. Eleven years of experience

BackgroundKnee joint infection after ACL reconstruction is a rare complication with a low reported incidence, but the consequences can be devastating. The purpose of the study was to determine the incidence of septic arthritis after primary ACL reconstruction with hamstring auto-graft and the risk factors that may be associated.MethodA retrospective study of all primary ACL reconstruction from January 2000 to May 2011. Electronic medical records were reviewed to determine the number of infections, operating time, associated procedure, time of presentation after surgery, infection treatment, microbiological cultures and graft retention. At the end of the follow-up (18–108 months) a functional assessment of all the infected patients was performed using the Lysholm score with the Lysholm score.ResultsWe analyzed 1564 cases of primary ACL reconstruction with hamstring autograft, of which seven cases were diagnosed with postoperative joint infection (incidence rate of 0.45%). The infectious agent most frequently isolated was a coagulase-negative Staphylococcus. Neither intraoperative factors nor age correlated with the development of the infection. The average Lysholm score was 95 points (range 89–100 points). All but two patients retained their reconstructed ACL. The results of the five patients in which the graft was preserved were significantly better than the two patients that had their grafts removed (p = 0.03).ConclusionWe conclude that septic arthritis post ACL reconstruction has a low incidence rate, which if handled at an early stage allows the patients a satisfactory return to their previous activities. Graft retention is important to obtain better functional results.Level of evidenceIV.     

Double-bundle anterior cruciate ligament reconstruction using autologous hamstring tendon hybrid grafts in a patient with hypermobile Ehlers-Danlos Syndrome: A case report

BackgroundEhlers-Danlos syndrome (EDS) is a connective tissue disorder characterized by skin hyperextensibility, joint hypermobility, and tissue friability. Hypermobile type Ehlers-Danlos syndrome (hEDS) is considered one of the EDS subtypes characterized by generalized joint hypermobility. Although there have been a few case reports which described surgical considerations for anterior cruciate ligament (ACL) reconstructions in patients with other types of EDS, no reports have described those in patients with hEDS.Case presentationWe report a case of ACL injury in an 18-year-old male patient with hEDS. The patient was successfully treated with an anatomic double-bundle ACL reconstruction using autologous hamstring tendon hybrid grafts which consist of hamstring tendons connected in a series with commercially available polyester tape. The autogenous tendon portion of the anteromedial and posterolateral bundles were composed of 4 and 2 strands of hamstring tendons, respectively. After 2 weeks of knee joint immobilization, continuous passive motion exercise of the knee joint and partial weight-bearing was allowed. A hinged knee brace was used for a period of 5 months postoperatively. Second-look arthroscopy at 30 months showed that the ACL graft had no laceration and an excellent coverage of the synovium. At 36 months after surgery, the side-to-side differences in the anterior laxity was remarkably improved. The operated knee showed negative Lachman test and had a full range of motion.ConclusionsTo the best of our knowledge, this represents the first report of anatomic double-bundle ACL reconstruction in patients with hEDS and demonstrates excellent clinical and functional outcomes.     

Anatomy of the anterior cruciate ligament related to hamstring tendon grafts. A cadaveric study

BackgroundThe aim of modern techniques for anatomic reconstruction of the ACL is to reproduce ACL footprints, in order to restore anatomy and therefore normal biomechanics. Is there an oversizing of the hamstring grafts related to ACL dimensions?MethodsTwenty-two paired cadaver knees were dissected. ACL dimensions at mid-portion and ACL footprints were measured after removing the synovial membrane.Hamstrings were harvested and prepared in a quadruple strand graft in order to measure the mean circumference.ResultsThe average ACL tibial and femoral insertion site areas of the ACL were 117.9 mm² (range, 90 to 130 mm) and 96.8 mm² (range, 80 to 121 mm), respectively.The average diameter and cross sectional area of the ACL tendon at mid-portion were 6.1 mm (range, 5 to 7 mm) and 29.2 mm² (range, 20 to 38.9), respectively. The average diameter and cross-sectional area of the 4-stranded hamstring tendons were 6.7 (range, 5 to 8) and 35.3 mm² (range, 20 to 50), respectively.There was a correlation between the 4-stranded hamstring grafts and ACL dimensions (footprints, ligament at mid substance, p < 0.01). The cross sectional area of hamstring tendon was significantly larger than the ACL area at mid-portion (mean 20.9%, p < 0.05).ConclusionWith current ACL reconstruction techniques, the graft is oversized at a mean of 21%, despite a good correlation between the ACL and the hamstring tendon, especially among small subjects and women. The question arises whether the anatomic reconstruction of the ACL should fill ACL footprints or mimic the ligament itself.Clinical relevanceHamstrings grafts are significantly larger than native ACL.     

Comparison of muscle strength and neuromuscular control up to 1 year after anterior cruciate ligament reconstruction between patients with dominant leg and non-dominant leg injuries

BackgroundThere has not been an investigation to determine whether leg dominance affects the recovery of quadriceps and hamstring strength, muscle reaction time (acceleration time, AT), and postural stability after anterior cruciate ligament (ACL) reconstruction in recreational-level athletic patients.MethodsA total of 100 patients with isolated ACL injuries (58 patients had dominant leg injuries; 42 patients had non-dominant leg injuries) participated. All patients received an anatomical single-bundle ACL reconstruction using an auto-hamstring tendon graft without preoperative rehabilitation. Leg dominance was defined as the kicking leg. The quadriceps and hamstring strength, AT, and postural stability (overall stability index (OSI)) of both legs were assessed at three different time points (preoperative, 6 months, 12 months), using an isokinetic dynamometer and postural stabilometry system.ResultsAll patients in both groups showed gradual improvement in quadriceps and hamstring muscle strength in the operated legs up to 1 year postoperatively. However, the mean value of quadriceps strength was lower in the operated non-dominant leg than the operated dominant leg 6 months postoperatively (P = 0.048). The AT and OSI of the operated legs in both groups recovered significantly 6 months postoperatively compared with their preoperative values; however, the AT and OSI values after 6 and 12 months were similar.ConclusionQuadriceps strength of the operated non-dominant leg was lower than that of the operated dominant leg 6 months postoperatively; however, the strength of the quadriceps and hamstring muscles was not different after 12 months between the operated dominant and non-dominant legs. Clinicians and physical therapists should consider these results during early rehabilitation and identify effective protocols to enhance quadriceps strength, especially in patients with non-dominant leg injuries.     

Return to play in paediatric & adolescent patients following anterior cruciate ligament reconstruction

BackgroundThere is an increased risk of anterior cruciate ligament (ACL) rupture and subsequent ACL reconstruction in patients <18 years old due to their high levels of sporting participation.PurposeThe purpose of this study was to assess the rate and timing of return to play (RTP) in paediatric and adolescent patients following ACL reconstruction, and to compare the outcomes between those undergoing ACL reconstruction with bone patella tendon bone autograft (BTB) and hamstring tendon (HT) autograft.Study DesignLevel of Evidence: Level III; Retrospective Comparative Cohort Study.MethodsThe institutional ACL registry was screened for patients <18 that had undergone a primary ACL reconstruction. Outcomes were analysed for patients undergoing either a BTB or HT autograft for rate and timing of return to play, functional outcomes and subsequent knee injuries. Statistical analysis was performed using SPSS.Results358 (BTB; 253, HT; 105) patients were followed up for 24-months (95% follow up). 86 athletes (27 BTB; 59 HT) were aged 13–15 years old with no significant difference in RTP rate or timing between graft types, however, there was a difference in ipsilateral re-ruptures (10.2% HT vs 0% BTB p = 0.03). 272 athletes (226 BTB; 46 HT) were aged 16–18 years old with no significant difference in RTP rate or timing between graft types, or ipsilateral re-ruptures (8.7% HT vs 2.7% BTB p = 0.07). Concurrent ligament, meniscal or chondral injuries found at the time was treated as necessary.ConclusionPaediatric and adolescent patients undergoing ACL reconstruction with either BTB or HT had high rates of return to play. This was seen in both subgroups with 13–15-year-olds mostly receiving a HT graft repair and 16–18-year-olds mainly receiving a BTB repair. A moderate re-rupture rate was seen at 24-months. However longer follow up is needed to truly see the long-term impact of such an injury at such a young age.     

Arthroscopic BPTB graft reconstruction in ACL ruptures: 15-year results and survival

PurposeThe aim of this study is to investigate the 15-year results and survival of arthroscopic ACL reconstruction using the central-third patellar bone–tendon–bone (BPTB) autograft.MethodsACL BPTB reconstruction was performed in 250 consecutive patients. Of these patients, 88% returned for a follow-up examination at 15 years after reconstruction. Therefore, 220 patients were studied. Mean time from injury to intervention was 3.4 months (range 2 to 16). The parameters for assessment of results were subjective satisfaction, clinical examination (pivot-shift test, Lachman test with KT-1000), recovery of pre-injury activity level, and long-leg standing radiographs. We also evaluated the presence of meniscal and/or chondral injuries during the procedure. Failure rates were also evaluated. We defined a failure as severe instability not compatible with the activities of daily living (ADL) due to graft rupture.Results8.2% of patients required a revision procedure because of graft rupture. In subjective terms, 98.1% of patients said that they were satisfied with the surgical outcomes after 15 years. Pivot shift test was normal in 93.5% at 15 years. Lachman test (KT-1000) was normal in 95.4% at 15 years. Fifteen years after surgery, 90% of patients recovered their pre-injury activity level. In 25.4% of patients symptomatic osteoarthritic changes in the knee were found at 15 years.ConclusionsThe survival prevalence of arthroscopic ACL reconstruction using the central-third patellar bone–tendon–bone (BPTB) autograft at 15 years was 94.8%. Fifteen years after surgery, 90% of patients recovered their pre-injury activity level. In 25.4% of patients symptomatic osteoarthritic changes in the knee were found at 15 years.Level of evidenceLevel IV.     

Factors associated with revision following anterior cruciate ligament reconstruction: A systematic review of registry data

BackgroundTo identify the patient and surgical factors associated with revision anterior cruciate ligament (ACL) reconstruction as reported by all national and community ACL registries.MethodsA systematic review was performed on the MEDLINE, Embase and Cochrane Library databases. Eligibility criteria included English studies published by national or community ACL registries reporting on primary ACL reconstruction and risk factors associated with revision ACL reconstruction.ResultsThirty-three studies from the Swedish, Norwegian, Danish and Kaiser Permanente registries were included for review. Fourteen studies from all four registries reported younger age as a risk factor for revision ACL reconstruction. In addition, the Swedish registry reported concomitant medial collateral ligament (MCL) injury, undergoing earlier surgery, lower Knee Injury and Osteoarthritis Outcome Score (KOOS), smaller graft diameter and an anteromedial portal drilling technique as risk factors for revision. The risk factors reported by the Norwegian registry included lower body mass index (BMI), lower KOOS, hamstring tendon grafts and suspensory fixation. The Danish registry reported hamstring tendon grafts, anteromedial portal drilling and suspensory fixation as risk factors. The Kaiser Permanente registry reported male sex, lower BMI, ethnicity, hamstring tendon grafts, allografts, smaller graft diameter and an anteromedial portal technique as risk factors for revision.ConclusionMultiple patient and surgical factors were associated with increased risk of revision ACL reconstruction in registries. Younger age and the use of hamstring tendon grafts were consistently reported as risk factors for failure.     

Passing return to sports tests after ACL reconstruction is associated with greater likelihood for return to sport but fail to identify second injury risk

BackgroundA limited number of patients return to sport (RTS) after an anterior cruciate ligament reconstruction (ACLR) and patients who RTS have a relatively high risk for second ACL injury. The purpose of the current study was to compare the results of a test battery between patients who returned to the pre-injury level of sport (RTS group) and patients who did not (NO-RTS group).It was hypothesized that the RTS group showed better test results.MethodsSixty-four patients (age 27.8 ± 8.8 years) were included. The results of a multicomponent test battery (jump-landing task assessed with the Landing Error Scoring System (LESS), three hop tests, isokinetic strength test for quadriceps and hamstring) were compared between groups with a 2 × 2 ANOVA.ResultsThe RTS group showed a significantly lower LESS score (p = 0.010), significantly higher absolute scores on hop tests with both legs (injured leg: single leg hop test p = 0.013, triple leg hop test p = 0.024, side hop test p = 0.021; non-injured leg: single leg hop test p = 0.011, triple leg hop test p = 0.023, side hop test p = 0.032) and significantly greater hamstring strength in the injured leg (p = 0.009 at 60°/s, p = 0.012 at 180°/s and p = 0.013 at 300°/s). No differences in test results were identified between patients who sustained a second ACL injury and patients who did not.ConclusionPatients after ACLR with better jump-landing patterns, hop performance and greater hamstring strength have greater likelihood for RTS. However, our findings show that RTS criteria fail to identify patients who are at risk for a second ACL injury.     

Failure rate analysis and clinical outcomes of two different femoral tunnel positions using anteromedial portal technique in anterior cruciate ligament reconstruction

AimTo analyze two different femoral tunnel positions and to evaluate their correlation with clinical, functional outcomes and surgical revision rate in patients who underwent primary arthroscopic anterior cruciate ligament (ACL) reconstruction with anteromedial (AM) portal technique.MethodsFrom January 2015 to October 2018, we recruited 244 patients that underwent primary single-bundle ACL reconstruction, using four strand-semitendinosus graft and AM portal technique for femoral tunnel placement. Patients were divided into two groups based on the different femoral tunnel positions: 117 patients of group A had ACL footprint center femoral tunnel position compared with 127 patients of group B, with femoral tunnel placement close to the AM bundle footprint. Preoperatively and at last follow up, all patients were assessed subjectively by Lysholm, Tegner, and International Knee Documentation Committee (IKDC) scores, while Lachman, Pivot-shift, and KT-1000 tests were performed to evaluate knee joint stability.ResultsGroup B patients showed significantly better results in Lysholm, objective, and subjective IKDC scores compared with patients of group A (P < 0.001). A significantly higher surgical failure rate was found in group A than in group B (10.26% vs. 2.3%; P < 0.001). A higher anterior knee laxity was recorded in patients of group A than in patients of group B (1.9 ± 1.1 vs. 1.3 ± 1 mm; P < 0.001); a reduction in mean anterior tibial translation from preoperative to final follow up was found in group B compared with group A (3.5 ± 1.2 vs. 2.7 ± 1.1 mm; P < 0.001). No significant differences in the Tegner scale were found between the two groups.ConclusionACL reconstruction performed using the AM portal technique showed better and more satisfactory clinical and functional outcomes associated with a lower failure rate when the femoral tunnel had been placed more eccentrically in the footprint, in the AM bundle center position.     

Bone plug fixation in anterior cruciate ligament reconstruction: A clinical and radiological assessment of graft-tunnel integration

BackgroundThe decision regarding graft choice and fixation in anterior cruciate ligament (ACL) reconstruction remains controversial. Free cylindrical bone plugs have been used successfully as graft fixation method. However, some concerns continue to exist regarding how well these plugs integrate with the bony walls of the tunnel. The aim of this study was to assess osteo-integration of free cylindrical bone plugs and to evaluate its effect on the clinical outcomes of the procedure.MethodsFrom January 2015 to December 2017, 30 patients (21–40 years old) with torn ACL were operated on and followed up for 24 months after surgery. All patients were assessed clinically (International Knee Documentation Committee score (IKDC) and Tegner–Lysholm knee scoring system), instrumentally (KT 1000 and Rolimeter), and radiologically (X-ray, computed tomography and magnetic resonance imaging). Young active patients with torn ACL were included while those with previous ligamentous injury and/or surgery were excluded.ResultsAll bone grafts showed solid bone healing after 6 months of surgery; incorporation was ‘good to excellent’ (tibial side: 66.6%; femoral side: 86.6%). There was no correlation between age or time interval and graft incorporation. Positive correlation was shown between tibial and femoral graft incorporation within the same patient. Only one patient was abnormal in our final objective IKDC scores (graded C). The mean side-to-side difference with KT 1000 and Rolimeter was 1.9 and 1.8, respectively.ConclusionFree cylindrical bone plugs could be used safely for hamstring tendon graft fixation; it enhances graft tunnel integration within the first 6 months and yields comparable clinical outcomes whilst avoiding the potential hazards of foreign hardware implants.     

Sciatic nerve injury following hamstring harvest

Injury to the sciatic nerve following harvesting of the medial hamstring tendons is a complication that has not been described. I report a unique case of sciatic nerve injury above the level of its bifurcation into its terminal branches following hamstring graft harvest for use in ACL reconstruction. The sciatic nerve anatomy and technique of graft harvest is briefly described.     

Anterior cruciate ligament graft forces are sensitive to fixation angle and tunnel position within the native femoral footprint during passive flexion

BackgroundAnterior cruciate ligament (ACL) graft position within the anatomic femoral footprint of the native ACL and the flexion angle at which the graft is fixed (i.e., fixation angle) are important considerations in ACL reconstruction surgery. However, their combined effect on ACL graft force remains less well understood.HypothesisDuring passive flexion, grafts placed high within the femoral footprint carry lower forces than grafts placed low within the femoral footprint (i.e., high and low grafts, respectively). Forces carried by high grafts are independent of fixation angle. All reconstructions impart higher forces on the graft than those carried by the native ACL.Study DesignControlled laboratory study.MethodsFive fresh-frozen cadaveric knees were mounted to a robotic manipulator and flexed from full extension to 90° of flexion. The ACL was sectioned and ACL force was calculated via superposition. ACL reconstructions were then performed using a patellar tendon autograft. For each knee, four different reconstruction permutations were tested: high and low femoral graft positions fixed at 15° and at 30° of flexion. Graft forces were calculated from full extension to 90° of flexion for each combination of femoral graft position and fixation angle again via superposition. Native ACL and ACL graft forces were compared through early flexion (by averaging tissue force from 0 to 30° of flexion) and in 5° increments from full extension to 90° of flexion.ResultsWhen fixed at 30° of flexion, high grafts carried less force than low grafts through early flexion bearing a respective 64 ± 19 N and 88 ± 11 N (p = 0.02). Increasing fixation angle from 15° to 30° caused graft forces through early flexion to increase 40 ± 13 N in low grafts and 23 ± 6 N in high grafts (p < 0.001). Low grafts fixed at 30° of flexion differed most from the native ACL, carrying 67 ± 9 N more force through early flexion (p < 0.001).ConclusionACL grafts placed high within the femoral footprint and fixed at a lower flexion angle carried less force through passive flexion compared to grafts placed lower within the femoral footprint and fixed at a higher flexion angle. At the prescribed pretensions, all grafts carried higher forces than the native ACL through passive flexion.Clinical RelevanceBoth fixation angle and femoral graft location within the anatomic ACL footprint influence graft forces and, therefore, should be considered when performing ACL reconstruction.     

Radiodense ligament markers for radiographic evaluation of anterior cruciate ligament reconstruction

IntroductionEarly clinical and radiographic diagnosis of failed or loosened anterior cruciate ligament (ACL) reconstructions can be challenging. The aim of the present study is to retrospectively evaluate the use of radiologically visible markers in the ACL graft, serving as a potential diagnostic tool in ACL graft rupture and insufficiency.MethodsTwenty patients were included in the study. ACL reconstruction was performed with use of a hamstring autograft in hybrid fixation technique. The graft was marked with two radiodense suture knots, one at the tibial and femoral tunnel openings. Radiographs were performed postoperatively, after 6 weeks and 12 months. Four distances between markers and landmarks were measured in anteroposterior and three in lateral radiographic views and the positional change between the timepoints of measurement was calculated.ResultsMeasurements of the marker distances on radiographs showed an excellent interobserver reliability (κ = 0.97).In two measured distal anteroposterior distances statistically significant changes could be detected between 6 weeks and 12 months postoperatively in one patient with MRI-documented ACL rerupture and in five patients with ACL elongation defined as anteroposterior-translation with side-to-side difference of ≥ 3 mm measured with a Rolimeter device. On lateral radiographs, marker distances were highly variable and did not correlate with clinical ACL elongation.ConclusionThe application of radiodense ACL graft markers is a straight-forward, non-expensive and potentially useful diagnostic tool to identify the position of the transplant and for diagnosis of graft elongation or failure. However, the method is sensitive to the radiological projection, which should be further studied and optimized.     

The relationship between a Segond fracture and meniscus injury in patients with anterior cruciate ligament tears

BackgroundSegond fracture may be identified when an anterior cruciate ligament (ACL) tear is diagnosed, and it has historically been considered a sign of significant knee trauma indicating intra-articular injury. There are few studies on the correlation between a Segond fracture and meniscus injury. The purpose of this study was to evaluate the relationship between a Segond fracture and meniscus injury in patients with ACL tears.MethodsA retrospective review of all patients undergoing acute ACL reconstruction (less than 1 month from the time of injury) between 2013 and 2020 was performed. The absence or presence of a Segond fracture was confirmed using preoperative radiographs. Demographic data (age, sex and body mass index), injury variables (time from injury and mechanism of injury) and arthroscopic features (meniscal or chondral injury) were analysed to investigate the relationship between a Segond fracture and meniscus injury.ResultsA total of 427 patients were included in the study. The incidence of Segond fractures was 12.4%. Among the patients with a Segond fracture, 15 patients were injured playing soccer (28.3%), 11 patients were injured playing basketball (20.8%), eight patients sustained the injury during racquet sports (15.1%), five patients (9.4%) were injured during less popular sports (such as skiing, ice-skating and boxing), and 14 patients (26.4%) were injured by contact mode of injury. A Segond fracture was a significant risk factor for lateral meniscus tears in patients with ACL tears (adjusted odds ratio, 1.938; 95% confidence interval, 1.078–3.481; P = 0.027).ConclusionThe incidence of Segond fractures in patients with acute ACL tears was higher than that reported in previous studies. A Segond fracture could increase the risk of a lateral meniscus tear in patients with an ACL tear.     

Improvement of primary stability in ACL reconstruction by mesh augmentation of an established method of free tendon graft fixation. A biomechanical study on a porcine model

PurposeThe aim of the present study was to compare primary stability in ACL reconstruction and ultimate load to failure of a mesh augmented hamstring tendon graft fixed with two cross pins to established hamstrings and bone-patellar-tendon-bone (BTB) graft fixation methods.MethodsForty fresh porcine femora were divided into four groups: (A): BTB graft fixed with two RigidFix® pins, (B): hamstring tendon graft fixed with a Milagro® interference screw, (C): hamstring tendon graft fixed with two RigidFix® pins, and (D): hamstring tendon graft augmented with Ultrapro® mesh fixed with two RigidFix® pins. Each graft underwent cyclic loading in tension and load to failure. Elastic and plastic displacements were measured by 3-dimensional digital image correlation. Groups were compared by one-way ANOVA and Tukey–Kramer post-hoc tests.ResultsAfter 1000 cycles, the mean plastic displacement was lowest in the BTB graft (p < 0.001). Plastic displacement was significantly lower in the mesh augmented group compared to the plain hamstring graft and the Milagro screw group (p < 0.05). Load to failure was highest in the mesh-augmented group; significant to the hamstring tendon (p = 0.023).ConclusionAlthough the BTB-graft represented the most stable construct against plastic displacement in our study, mesh augmentation of free tendon grafts significantly increased primary stability and reduced plastic displacement of femoral cross pin fixation. This new augmentation device may better protect the hamstrings graft from secondary elongation during postoperative rehabilitation.Clinical relevanceMesh augmentation seems to be an effective technique to stabilise free hamstring tendon autografts during postoperative rehabilitation with significant reduction of graft slippage.     

Anterior cruciate ligament reconstruction with ultrasound-guided femoral nerve block does not adversely affect knee extensor strength beyond that seen with intravenous patient-controlled analgesia at 3 and 6 months postoperatively

BackgroundThis study aimed to investigate the effect of anterior cruciate ligament (ACL) reconstruction with an ultrasound-guided femoral nerve block (FNB) on knee extensor strength weakness 3 and 6 months, and graft rupture in the 1 year following ACL reconstruction.MethodsOne hundred and seven patients who underwent ACL reconstruction were included in this retrospective study. The patients were divided into two groups stratified by the method of postoperative pain management. The FNB group included 66 patients, and there were 41 patients in the intravenous patient-controlled analgesia (iv-PCA) group. The isokinetic peak torque of knee flexor and extensor was measured preoperative, 3 and 6 months after ACL reconstruction. Muscle strength measurements were performed using the BIODEX dynamometer at a velocity of 60°/s and 180°/s. Peak torque of knee extensor and flexor strength, estimated pre-injury capacity (EPIC), body weight ratio (BW), and graft rupture incidence were compared between the two groups.ResultsThere were no statistically significant differences in the knee extensor and flexor strength for all items at 3 and 6 months after ACL reconstruction. There was also not a statistically significant difference in the graft rupture incidence between the two groups: FNB group was two patients, 3.0% vs. iv-PCA group was one patient, 2.4% (p = 0.86).ConclusionACL reconstruction with ultrasound-guided FNB does not affect knee extensor strength at 6 months, nor graft rupture at 1 year postoperatively.     

Association between time from anterior cruciate ligament injury to reconstruction and morphological changes of the intercondylar notch using MRI and arthroscopy

BackgroundFew studies have measured the dimensions of intercondylar notch under direct arthroscopic visualization. The purpose of our study was to analyse the association between time from anterior cruciate ligament (ACL) injury to reconstruction and the morphological changes of intercondylar notch using magnetic resonance imaging (MRI) and arthroscopy.MethodsData was collected for patients who received knee arthroscopic surgery during 2014–2015. According to the time from ACL injury to reconstruction, these patients were divided into five groupsACL non-injured group (NI), acute rupture group (AR, <3 months), chronic rupture group 1 (CR1, 3–12 months), 2 (CR2, 1–5 years) and 3 (CR3, >5 years). MRI measurements of femoral condylar width (FCW) and intercondylar width (ICW) were undertaken before surgery. The widths at the base, middle and top of the intercondylar notch (ICWb, ICWm, ICWt, respectively) and the intercondylar notch height (ICH) were measured during arthroscopy. Intercondylar notch width index (NWI) and notch shape index (NSI) were then calculated and analysed among groups.ResultsA total of 272 patients were allocated to groups NI (n = 89), AR (n = 84), CR1 (n = 51), CR2 (n = 30) or CR3 (n = 18). Statistical analysis showed significant differences in ICW, ICWb, ICH, NWI and NSI between groups NI and AR. Among the groups with ACL-injury, ICWb and ICWt and NWI in group CR3 were statistically smaller than the other three groups (P = 0.004, 0.016, and 0.005, respectively).ConclusionsThe width of intercondylar notch had a negative correlation with time from ACL injury to reconstruction. Significant secondary notch stenosis was observed over 5 years after ACL rupture.