Extensor Mechanism Disruption After Contralateral Middle Third Patellar Tendon Harvest for Anterior Cruciate Ligament Revision Reconstruction

The contralateral central third patellar tendon autograft is a reliable graft choice for revision, and recently, for primary reconstruction of the anterior cruciate ligament (ACL). We report 2 complications including a lateral third tibial tuberosity fracture and a distal patellar tendon avulsion with contralateral patellar tendon autograft with disruption of the extensor mechanism of the donor knee. A patient sustained a lateral tibial tuberosity fracture of the donor knee and underwent open reduction and internal fixation. At 1-year follow-up, she had no extensor lag and full range of motion. Another patient sustained a distal patellar tendon avulsion of the donor knee and underwent primary repair. Three years postoperatively, she had a full range of motion and no extensor lag. Although contralateral middle third patellar tendon autograft for primary and revision ACL reconstruction is established in the literature, extensor mechanism complications can occur. Technical considerations are important to avoid weakening the remaining patellar tendon insertion. Postoperative nerve blocks or local anesthetics may alter pain feedback for regulation of weight bearing and contribute to overload of the donor knee.     

Flipped patellar tendon autograft anterior cruciate ligament reconstruction.

To determine the efficacy of an anterior cruciate ligament (ACL) graft that customizes length and facilitates anatomic outlet fixation, a prospective study of the "flipped" patellar tendon autograft ACL reconstruction began in 1995. This technique shortens the tendon portion to match the intra-articular length by rotating 1 bone plug 180 degrees proximally onto the tendon, thus flipping the bone plug over its ligamentous insertion. Bioscrews (poly L-lactic acid; Linvatec, Largo, FL) secured the grafts. All patients undergoing this procedure with a minimum 21 months follow-up were reviewed. Preoperative and postoperative Tegner, Lysholm, and IKDC activity scores, and Lachman and pivot shift tests were obtained. Postoperative KT testing and radiographs were obtained. Fifty patients were followed-up for an average of 28 months (range, 21 to 39 months). Average patient age was 34 years (range, 16 to 52 years). Tegner scores increased from 2.0 preoperatively to 6.0 postoperatively. Lysholm scores increased from 46 preoperatively to 93 at follow-up, with 86% excellent (66%) or good (20%). IKDC activity scores increased from 3.1 preoperatively to 1.7 postoperatively. KT manual-maximum difference at follow-up averaged 0.7 mm, with 74% less than 3-mm, 18% 3- to 5-mm, and 8% greater than 5-mm difference. Postoperative Lachman results were 0 in 45 patients and 1+ in 5 patients. Postoperative pivot shift was absent in all but 1 patient. Full extension was achieved in all cases and flexion averaged 136 degrees with no patient having less than 120 degrees flexion. No lytic bone changes or tunnel widening were seen. The flipped patellar tendon autograft reduces graft length to its intra-articular portion, increasing graft stability, isometry, and stiffness, and avoiding tunnel graft mismatch with clinically excellent results.     

Anterolateral rotatory instability of the knee. Cadaver study of extraarticular patellar-tendon transposition

A cadaver knee-testing system was used to analyze the effect of an extraarticular reconstruction for anterolateral rotatory instability in which the lateral one third of the patellar tendon with a patellar bone block was transposed to the lateral femoral condyle. Ligament and reconstruction tendon forces were measured using buckle transducers, and joint motion was measured using an instrumented spatial linkage as 90 N anteriorly directed tibial loads were applied to seven knee specimens at 0 degree, 30 degrees, 60 degrees, and 90 degrees of flexion by a pneumatic load apparatus. This was done for each knee with first an intact, then an excised anterior cruciate ligament, and finally the extraarticular reconstruction. Forces in the transposed graft exhibited an isotonic pattern over the flexion range, unlike the intact anterior cruciate ligament, which was more highly loaded in extension than in flexion. The transposition of the patellar tendon led to external rotation of the tibia in both unloaded and anterior load conditions throughout flexion. Collateral ligament forces increased with anterior cruciate ligament excision, with the force in the medial ligament remaining higher than normal with the reconstruction, while the lateral forces became lower than normal.     

Does harvesting the medial third of the patellar tendon cause lateral shift of the patella after ACL reconstruction?

Many centers do not use the medial third of the patellar tendon as a graft for ACL reconstruction due to the apprehension that there may be post harvest maltracking of the patella towards the lateral side. We undertook a prospective study to evaluate patellar alignment in 30 patients in whom ACL reconstruction was done using the medial third of the patellar tendon. Q-angle assessment was the rough clinical parameter, and the Merchant view, Laurin views, and CT scans were used for radiological assessment. The assessment was done preoperatively and at six months post surgery, and the contralateral normal knees were used as controls. We observed no significant changes in the congruence angle (pre-op -13.86 degrees, postop -12 degrees) or the lateral patellofemoral angles in the pre-operative and postoperative knees as compared to the controls. CT scans were more sensitive for evaluating the congruence angles, and picked up an insignificant abnormal lateralisation of the patella in four cases. None of these patients however had any postoperative symptoms of misalignment. Although medial third graft harvesting did have a 13% change in patellar alignment, this was not statistically significant. Post harvesting local problems are inherent to the procedure, and are independent of the site of harvesting, as they were also seen in cases with no evidence of misalignment.     

Biomechanical effect of a two-segment anterior cruciate ligament graft with separate femoral attachments and differing levels of prescribed load sharing.

The objective of this study was to analyze the biomechanical effect of varying the level of prescribed load sharing between two segments of an anterior cruciate ligament (ACL) graft, and of separating the femoral attachments of these segments. Total anterior-posterior (AP) laxity was measured using an instrumented spatial linkage. Forces in graft segments were measured using buckle transducers. The two-segment graft was formed using the middle third of the patellar tendon with bone blocks and a synthetic augmentation device. Proximal fixation was obtained using a fixture which allowed changing the individual locations of the femoral attachments of the tendon and augmentation segments. Distal fixation was achieved using a force-setting device which allowed the loads in each segment to be set to prescribed levels. Total graft force, load sharing, and total AP laxity were recorded during the application of 100-N AP tibial loads at 0 degrees, 30 degrees, 60 degrees, 90 degrees, and 110 degrees flexion, for various combinations of load sharing set at extension and locations of femoral attachment sites. The load sharing, total graft force, and AP laxity during AP loading at the five test flexion angles were not significantly affected by changing the prescribed level of load sharing set at extension for a given femoral attachment configuration. However, varying the separate hole locations of the graft segments for a given level of load sharing significantly affected load sharing, total graft force, and AP laxity. If the tendon graft was located posteriorly (on the medial surface of the lateral femoral condyle) and the augmentation segment proximally, the augmentation carried a greater portion of the total force in flexion. If the augmentation segment was changed to a more posterosuperior location and the tendon posteroinferior, the tendon carried a higher percentage of the total force in flexion. AP laxity in most reconstruction states was significantly greater than in the normal joint with an intact ACL. The nature of the load sharing between the graft segments under AP tibial load over the flexion range can be controlled by the appropriate choice of the segments' femoral attachment locations.     

Revision of anterior cruciate ligament reconstruction with patellar tendon allograft and autograft: 2- and 5-year results

Introduction

The most common failure reasons of an anterior cruciate ligament (ACL) graft are incorrect positioning of the drill channels and insufficient fixation. In many cases, one-stage revision with patellar tendon graft and the appropriate corrections are possible. For previous use of the ipsilateral patellar tendon third, an allograft seems favorable for reconstruction. So far, no study compared the results of revision surgery of autologous versus allogenous patellar tendon grafts for revision surgery of the ACL in a 5-year follow-up.

Materials and methods

A retrospective study was conducted to analyze the clinical outcome and stability results 2?years (19.2?±?5.8?months) and 5?years (68.8?±?6.8?months) after revision of ACL reconstruction using middle-third patellar tendon allografts and autografts. The allografts were cleansed by mechanical means only. There were 15 patients in the allograft group and 14 in the autograft group. Patients with isolated re-rupture of the ACL graft were included in the study. Clinical results were evaluated by International Knee Documentation Committee 2000 forms (IKDC), Lysholm score, Tegner activity score, and visual analog scale. Stability was evaluated by means of KT-1000 arthrometer, Lachman test, and pivot-shift test. Location of drill holes was evaluated radiologically. Gonarthritis was graded according to Kellgren and Lawrence on the basis of radiographs.

Results

There were no significant differences between the two groups in anterior translation, manual examination for stability, IKDC 2000 findings, Tegner activity score, or Lysholm score. Extension deficits were more frequent in the autograft group at the first follow-up (P?=?0.010). Lateral gonarthritis and femoral tunnel widening were more common in the allograft group at the second follow-up (P?=?0.049 and P?=?0.023, respectively). Pain on walking downhill was significantly more frequent in the allograft group at the second follow-up (P?=?0.027).

Conclusions

The functional results with allografts that had not undergone irradiation or chemical sterilization were comparable to those with autografts in ACL revision surgery. Allografts represent a good alternative to autogenous patellar tendons in revision surgery.     

The comparison of functional results of anterior cruciate ligament injuries treated with semitendinosus tendon and central one-third of patellar tendon autografts

The results of ACL reconstructions with autologus grafts taken from semitendinosus tendon and patellar ligament are presented. There were 78 patients in four groups. Patient age ranged from 15 to 47 years. The period of observation varied from 1 to 10 years, average 3.5. The first group consisted of 28 people treated with single semitendinosus tendon graft. In the second group there were 12 patients with acute ACL injuries treated by reinsertion of torn ligament attachment augmented by semitendinosus tendon. The third group of 18 persons had an ACL reconstruction with central one-third of patellar ligament fastened with thread loops on bone screws or staples. The last group of 20 patients had ACL reconstruction with central one-third of patellar ligament autograft. All patients were prospectively evaluated according to the Hospital for Special Surgery and the Lysholm and Gillquist scales. The statistical analysis clearly reveals the best results in the fourth group of patients, who had graft fixation with interference screws. Received: 4 April 2001/Accepted: 23 April 2001     

Reconstruction of the anterior cruciate ligament in patients over 50 years

The records of patients aged 50 years or over who underwent primary reconstruction of the anterior cruciate ligament between 1990 and 2002 were reviewed. There were 35 knees in 34 patients that met the inclusion criteria. The mean age of the patients was 57 years (50 to 66) and the mean clinical follow-up was for 72 months (25 to 173). A total of 23 knees were reconstructed with patellar tendon allograft, and 12 with patellar tendon autograft. The mean pre-operative knee extension was 1 degrees (-5 degrees to 10 degrees) and flexion was 129 degrees (125 degrees to 150 degrees) and at follow-up these values were 0 degrees (-5 degrees to 5 degrees) and 135 degrees (120 degrees to 150 degrees), respectively. Pre-operatively there were 31 knees (89%) with a Lachman grade 2+ or 3+. Post-operatively, 33 knees (94%) were Lachman grade 0 or 1+. The mean pre- and post-operative International Knee Documentation Committee scores were 39 (23 to 72) and 90 (33 to 100) respectively. The mean pre- and post-operative Lysholm scores were 50 (18 to 68) and 92 (28 to 100) respectively and the mean University of California Los Angeles activity scores were 8.5 before injury (4 to 10), 4.3 (3 to 6) after injury and 8.3 (4 to 10) post-operatively. There were three graft failures (8.6%) requiring revision. We conclude that reconstruction of the anterior cruciate ligament in carefully-selected patients aged 50 years or over can achieve similar results to those in younger patients, with no increased risk of complications.     

Isokinetic evaluation of anterior cruciate ligament reconstruction: hamstring versus patellar tendon.

The purpose of the study was to compare the hamstring and quadriceps isokinetic results 6 months postoperatively in patients having patellar tendon or hamstring anterior cruciate ligament (ACL) reconstruction. The study group was comprised of 106 randomly selected patients who had ACL reconstruction with either autogenous patellar tendon (PT), semitendinosus (ST), or semitendinosus and gracilis (ST/G). Hamstring and quadriceps isokinetic strength were assessed at 180 degrees/sec and 300 degrees/sec with the results of the operatively treated leg expressed as a percent compared with the nonoperative leg. The mean results for knee extension at 180 degrees/sec were 68.3%, 74.3%, and 78.1%; and at 300 degrees/sec were 70.7%, 76.7%, and 81.7% for PT, ST, and ST/G, respectively. The mean results for knee flexion at 180 degrees/sec were 86.1%, 80.6%, and 81.7%; and at 300 degrees/sec were 77.6%, 79.1%, and 75.6% for PT, ST, and ST/G, respectively. No statistically significant differences were found in regard to knee extension or flexion strength when evaluating the different tissue sources. The results show that selection of autogenous hamstring or PT used for ACL reconstruction should not be based solely on the assumption of the tissue source altering the recovery of quadriceps and/or hamstring strength. In addition, a majority of the patients had not achieved adequate strength to safely partake in unlimited activities at 6 months postoperatively.     

Cyclops syndrome: loss of extension following intra-articular anterior cruciate ligament reconstruction

Arthrofibrosis is one of the recognized complications following traditional anterior cruciate ligament (ACL) reconstruction. With the advent of arthroscopic assisted ACL reconstructions, the extent of potential arthrofibrosis appeared to be less. However, 13 patients after intra-articular ACL reconstruction using a patella tendon autograft developed a similar symptom complex. In addition to postoperative loss of full extension, there was an audible and palpable clunk with terminal extension. These patients had similar arthroscopic findings of a nodule that formed anterolateral to the tibial tunnel placement of the graft. The arthroscopic appearance of the soft tissue mass with its surface vessels was reminiscent of a "cyclops." After arthroscopy with debridement and manipulation of the knee, extension was improved in all cases. The average range of motion immediately after the procedure was 6.0-130 degrees, compared with 16-103 degrees preoperatively. The range of motion at last follow-up averaged 3.8 degrees of extension and 138 degrees of flexion. All patients had greater than 130 degrees of flexion. There were no complications attributed to the manipulation and arthroscopic lysis of adhesions, and no patient experienced loss of graft integrity or knee stability. The "cyclops" nodule was examined grossly and microscopically and demonstrated peripheral fibrous tissue with a central region of granulation tissue in all specimens. In addition, two specimens were noted to include bony fragments and three specimens contained cartilaginous tissue.     

Shortening of the patellar tendon after anterior cruciate ligament reconstruction

In this prospective study, patellar height changes were investigated after anterior cruciate ligament (ACL) reconstruction with a mean follow-up of 22.4 months. A total of 114 patients were included. Fifty- two patients (group A) were treated by multiple suture repair, 27 patients (group B) underwent acute ACL reconstruction, and 35 patients (group C) underwent ACL reconstruction > or =6 weeks after injury with a patellar tendon graft. The patellar vertical height ratios (VHR) were evaluated preoperatively (VHR 1), 6 months postoperatively (VHR 2), and at follow-up (VHR 3). For the studied questions, the following answers were obtained: (1) The change of the patella height was the same in all three groups (i.e., disregarding the different surgical procedures). (2) The time elapsed between injury and ACL reconstruction did not influence the shortening of the patellar tendon. (3) Women showed a more pronounced shortening of the patellar tendon than did men. (4) A significant shortening of the patellar tendon occurred in 30% of our patients, and the process of shortening was finished 6 months postoperatively. (5) Anterior knee pain was present in 27.2% of our patients and occurred significantly more often after patellar tendon graftings. (6) Age had no influence on the changes of the patellar height.Arthroscopy 1998 Sep;14(6):592-6     

Method for setting total graft force and load sharing in augmented ACL grafts

The objective of this study was to develop a method for obtaining a controllable and reproducible immediate postoperative mechanical state in a knee with an anterior cruciate ligament (ACL) reconstruction. This method, called the force-setting technique, was demonstrated using a composite graft consisting of the middle third of the patellar tendon with bone blocks (PT) and the ligament augmentation device (LAD). The total graft force was set to match the force in the intact ACL at 30 degrees flexion with the knee under the same standardized external load, while at the same time the load sharing between the biologic and augmentation components was controlled. The total graft force was set to match the ACL force three separate times in each knee, with ratios of load sharing set at the following levels: 50% PT-50% LAD, 25% PT-75% LAD, and 75% PT-25% LAD. ACL, PT, LAD, and collateral forces were measured using buckle transducers, and three-dimensional knee motion was measured using an instrumented spatial linkage as 90 N anteriorly directed tibial loads were applied to eight specimens at 0 degree, 30 degrees, 60 degrees, and 90 degrees flexion with an intact ACL, an excised ACL, and the three load-sharing reconstruction states. The total graft force could be consistently set to within an average of 2% of the intact ACL force at 30 degrees flexion, and load sharing between the graft segments could be set to within an average of 5.1% of the desired ratio at 30 degrees.(ABSTRACT TRUNCATED AT 250 WORDS)     

Reconstruction of a ruptured patellar tendon with achilles tendon allograft following total knee arthroplasty

BACKGROUND: Rupture of the patellar tendon after total knee arthroplasty is a rare and debilitating complication. Proper surgical management of this condition remains controversial. The purpose of this study was to review the results of reconstruction of a ruptured patellar tendon with an Achilles tendon allograft following total knee arthroplasty. METHODS: We reviewed our experience with the use of a fresh-frozen Achilles tendon allograft with an attached calcaneal bone graft to restore extensor function in nine patients with patellar tendon rupture following total knee arthroplasty (five primary and four revision). All patients were examined clinically and radiographically at an average of twenty-eight months. RESULTS: The average knee and functional scores improved from 26 and 14 points, respectively, before the surgery to 81 and 53 points after the surgery. The average extensor lag decreased from 44 degrees preoperatively to 3 degrees postoperatively, and the average range of motion of the knee increased from 88 degrees to 107 degrees. Two grafts failed in the early postoperative period. Both were repaired successfully. Radiographs showed an average proximal patellar migration of 17.8 mm, which did not appear to affect extensor function. CONCLUSIONS: This short-term follow-up study showed that once an Achilles allograft has healed, it can serve as a reliable reconstruction of a ruptured patellar tendon following total knee arthroplasty. This technique may be particularly suited for patients in whom the extensor mechanism was compromised by multiple prior operations. Continued follow-up is necessary to determine the long-term durability of these results.     

RETRACTED ARTICLE: The effect of graft choice on functional outcome in anterior cruciate ligament reconstruction

A prospective, randomised, 5-year follow-up study was designed to compare the functional results between patellar tendon and hamstring tendon autografts after anterior cruciate ligament reconstruction. Primary reconstruction was performed in 32 patients using the central third of the patellar ligament and in 32 patients using double-looped semitendinosus and gracilis tendons. All reconstructions were performed by a single surgeon, with identical surgical technique and rehabilitation protocol. Of the total 64 patients in the study, 54 (85%) were available for the 5-year follow-up. No statistically significant differences were seen with respect to Lysholm score, International Knee Documentation Committee (IKDC) classification, clinical and KT-2000 arthrometer laxity testing, single-legged hop test and anterior knee pain. Graft rupture occurred in two patients (8%) in the patellar tendon group and in two patients (7%) in the hamstring tendon group; 23 patients (88%) in the patellar tendon group and 23 patients (82%) in the hamstring tendon group returned to their pre-injury activity level. Good subjective outcome and stability can be obtained by using either graft; no statistically significant differences were found in functional outcome between the grafts.     

Anterior cruciate ligament reconstruction stability with continuous passive motion. The role of isometric graft placement.

A comparison was made of the stability of isometric versus nonisometric anterior cruciate ligament (ACL) reconstructions when subjected to immediate postoperative continuous passive motion (CPM). Anterior cruciate ligament reconstructions were performed on 13 anatomic specimen knees using bone/patellar tendon/bone grafts. Nine ACL substitutions were considered isometric with maximum graft length changes of less than 1 mm. Four ACL substitutions were nonisometric with graft length changes of 3 mm or greater resulting from tightening in flexion. The specimens were subjected to CPM through 0 degrees-95 degrees knee flexion. Knee stability was remeasured with a knee arthrometer at three and 14 days after beginning CPM. All four nonisometric specimens had failed within three days, with increased anterior laxity of 2-9 mm in both the Lachman (20 degrees) and anterior drawer (90 degrees) positions. All nine isometric reconstructions successfully retained pre-CPM anterior stability within 1 mm after 14 days of CPM. This investigation illustrates the importance of isometric graft placement for ACL reconstruction success. Continuous passive motion does not appear to adversely affect immediate ACL-substitute integrity or fixation if graft placement is isometric (less than 1 mm of graft excursion through 0 degrees-110 degrees of knee motion). Continuous passive motion may cause graft deformation, fixation failure, or both, with resultant loss of knee stability if the graft is not isometrically positioned (greater than 3 mm of graft excursion resulting from tightening in flexion).     

Anterolateral rotatory instability of the knee: Cadaver study of extraarticular patellar-tendon transposition

A cadaver knee-testing system was used to analyze the effect of an extraarticular reconstruction for anterolateral rotatory instability in which the lateral one third of the patellar tendon with a patellar bone block was transposed to the lateral femoral condyle. Ligament and reconstruction tendon forces were measured using buckle transducers, and joint motion was measured using an instrumented spatial linkage as 90 N anteriorly directed tibial loads were applied to seven knee specimens at 0°, 30°, 60°, and 90° of flexion by a pneumatic load apparatus. This was done for each knee with first an intact, then an excised anterior cruciate ligament, and finally the extraarticular reconstruction.

Forces in the transposed graft exhibited an isotonic pattern over the flexion range, unlike the intact anterior cruciate ligament, which was more highly loaded in extension than in flexion. The transposition of the patellar tendon led to external rotation of the tibia In both unloaded and anterior load conditions throughout flexion. Collateral ligament forces increased with anterior cruciate ligament excision, with the force in the medial ligament remaining higher than normal with the reconstruction, while the lateral forces became lower than normal.     

Implant-free press-fit fixation for bone–patellar tendon–bone ACL reconstruction: 10-year results

Objective

The aim of this study is to determine the outcome of anterior cruciate ligament (ACL) reconstruction without foreign material with patellar tendon bone graft in the fixation with bone dowels near the native insertion.

Materials and methods

Between 1998 and 1999, 189 patients were operated with ACL reconstruction with BTB patellar tendon graft. In a prospective study, 148 (78%) (91M, 57F) patients could be seen for a mean follow-up of 10.3 years. All had foreign material-free press-fit and a bottom-to-top (BTT) fixation in 120° knee flexion. All patients were evaluated with detailed history, clinical examinations, radiographic examination with weight bearing which could be compared to the time of surgery in 64 (43%) patients. Laxity testing was performed in Lachman position with the Rolimeter and pivot shift. All patients were graded according to the IKDC and Tegner activity score.

Results

87% of the patients achieved an IKDC score of A/B. The subjective IKDC score was A/B in 94.6% of the subjects. The average side-to-side difference was 1.42 ± 0.88 mm for the Lachman test, 97% of the patients were rated between 0 and 2 mm. The pivot-shift test was negative in 90% and was observed with a glide in 7% of the patients. Radiological joint space narrowing was found in the medial compartment in 8 (12.4%) cases, and laterally in 9 (14.1%) cases. All these patients had partial or total meniscus resections. The patello-femoral joint space was reduced in 21 (23%) cases. The Tegner activity score changed from 6.9 pre-injury to 5.0 at the 10-year follow-up.

Conclusion

The implant-free fixation of the graft with bone dowels and BTT implantation has good and excellent results after 10 years in more than 80% of the patients. Loss of the meniscus is a main factor contributing to osteoarthritis. Advantages of patellar tendon bone press-fit fixation include anatomical positioning and fast bone-to-bone healing, ease for revision surgery and cost effectiveness.     

Anterior cruciate ligament reconstruction in adolescents: a survivorship analysis

There are few reports on the longevity of anterior cruciate ligament (ACL) reconstruction in adolescents. In the study reported here, we performed a survivorship analysis of our experience with ACL reconstructions in adolescents. We retrospectively reviewed the cases of 276 consecutive patients (girls' bone age, > 13 years; boys' bone age, > 14 years; chronological age, < 18 years) who underwent primary ACL reconstruction. All patients underwent transphyseal ACL reconstruction with Achilles tendon soft-tissue allograft using the same technique. Twenty-nine patients (10.5%) were excluded or lost to follow-up. Mean follow-up of the remaining 247 patients was 6.3 years (range, 2-10 years). Data were collected from charts and telephone interviews. Failure was defined as the report of symptomatic knee instability and/or revision ACL surgery. The Kaplan-Meier method showed that 1-year survivorship of ACL reconstruction was 96.4% and 5-year survivorship was 93.1%.     

A comparison of quadruple semitendinosus and patellar tendon grafts in reconstruction of the anterior cruciate ligament

In a two-centre study, 164 patients with unilateral instability of the anterior cruciate ligament were prospectively randomised to arthroscopic reconstruction with either a patellar tendon graft using interference screw fixation or a quadruple semitendinosus graft using an endobutton fixation technique. The same postoperative rehabilitation protocol was used for all patients and follow-up at a median of 31 months (24 to 59) was carried out by independent observers. Four patients (2%) were lost to follow-up. No significant differences were found between the groups regarding the Stryker laxity test, one-leg hop test, Tegner activity level, Lysholm score, patellofemoral pain score, International Knee Documentation Committee (IKDC) score or visual analogue scale, reflecting patient satisfaction and knee function. Slightly decreased extension, compared with the non-operated side, was found in the patellar tendon group (p < 0.05). Patients with associated meniscal injuries had lower IKDC, visual analogue (p < 0.01) and Lysholm scores (p < 0.05) than those without such injuries. Patients in whom reconstruction had been carried out less than five months after the injury had better final IKDC scores than the more chronic cases (p < 0.05). We conclude that patellar tendon and quadruple semitendinous tendon grafts have similar outcomes in the medium term. Associated meniscal pathology significantly affects the final outcome and early reconstruction seems to be beneficial.     

Quadriceps tendon-patellar bone autograft for anterior cruciate ligament reconstruction: a technical note

The quadriceps tendon autograft can be used for primary and revision anterior cruciate ligament (ACL) reconstruction. Despite several successful clinical reports, graft fixation issues remain, and the ideal technique for fixation continues to be controversial. We present a technique of ACL reconstruction with quadriceps tendon autograft (QTA) using a patellar bone block. The tendon end is fixed in the femoral tunnel and the bone plug in the tibial tunnel using reabsorbable interference screws. The advantages of this technique are related to the increase in stiffness of the graft, the achievement of a more anatomic fixation, and a reduction in synovial fluid leakage.