MORPHOLOGICAL AND METRIC STUDY OF THE PES ANSERINUS TENDONS IN HUMAN FETUSES

Measurement Validation of Navigation During the Pivot-Shift Test

Objectives:Over recent years, there has been growing interest in utilizing surgical sutures and Fibertape as internal braces or augmentations during anterior cruciate ligament (ACL) reconstruction procedures. This systematic review aims to critically evaluate the comparative effectiveness of surgical sutures versus Fibertape in ACL reconstruction as internal braces or augmentations.Methods:We conducted a systematic review and meta-analysis to compare the biomechanical properties of surgical sutures and Fibertape in ACL surgery. A comprehensive search was conducted across PubMed/MEDLINE, SCOPUS, and Europe PMC for studies published up to July 4th, 2024. The systematic review was structured around the PICO framework, focusing on patients who had undergone ACL reconstruction surgery (P), comparing the use of surgical sutures (I) versus Fibertape (C), and evaluating outcomes related to elasticity, strength, and graft stability (O). Only peer-reviewed papers published in English were included. Meta-analysis was performed using RStudio. Quality assessment of the included studies was conducted using the JBI checklist.Results:We included a total of 14 studies involving in vivo ACL reconstructions. ACL reconstruction with an Fibertape demonstrated significantly greater strength (standard mean difference [SMD]: 2.47, 95% CI: 1.26 to 3.68; p < 0.01) and decreases elasticity (SMD: 2.22, 95% CI: 0.93 to 3.51; p < 0.001) compared to traditional surgical sutures, but not strength of the construct (SMD: 0.43, 95% CI: -0.11 to 0.97; p = 0.42). EAll included studies were of lower risk of bias.Conclusion:We suggest that ACL reconstruction using Fibertape provides significantly enhanced strength and stiffness compared to surgical sutures. Given the lower risk of bias across all included studies, adopting Fibertape in ACL surgeries may offer improved biomechanical outcomes.

To determine the long-term risk of osteoarthritis following combined anterior cruciate ligament reconstruction (ACLR) and lateral extra-articular procedures (LEAP). A comprehensive search of multiple databases (EMBASE, OVID Medline, PubMed, Cochrane, and Scopus) was independently conducted by two reviewers according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies reporting on the rates of osteoarthritis following primary, arthroscopic ACLR combined with LEAP and a minimum 5-year follow-up were eligible for inclusion. The primary outcome was the prevalence of moderate to severe radiographic arthritis defined as International Knee Documentation Committee (IKDC) grades C or D, Ahlback grades 1-5, or Kellgren-Lawrence grades 3 or 4. A comparative meta-analysis of ACLR with and without LEAP was also performed. A total of eight studies were included, comprising 849 patients who underwent ACLR with LEAP, and 164 who underwent isolated ACLR. Cumulative meta-analysis showed a 4% prevalence of moderate to severe osteoarthritis across all studies after ACLR with LEAP. Subgroup analysis demonstrated a prevalence of 3% in the 5-to-10-year follow-up group and 6% in the 10+ year follow-up group. In the three comparative cohort studies, meta-analysis revealed no statistically significant difference in moderate to severe osteoarthritis rates between ACLR with LEAP and ACLR alone. This study demonstrates that long-term prevalence of moderate to severe osteoarthritis following combined ACLR with LEAP is low, and that the addition of LEAP does not increase the incidence compared to ACLR alone. These findings support the use of LEAP in selected patients, without concern for increased long-term joint degeneration. Level III, meta-analysis and systematic review.

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

IntroductionThe number of anterior cruciate ligament reconstruction (ACLR) procedures is increasing. However, the likelihood of not allocating sufficient funds for the ACLR procedure in a developing country, especially in Indonesia, is high. This study aimed to analyze costs for ACLR procedures in Indonesia’s resource-limited context, determine the burden of ACLR, and propose national prices for ACLR reimbursement.MethodsA retrospective observational study was conducted on the cost of ACLR from a payer perspective using inpatient billing records from 1 January 2019 to 31 December 2019 from four hospitals. The national burden of ACLR was calculated and national prices for reimbursement were developed.ResultsOf the 80 ACLRs performed, 53 (66%) were isolated ACLRs and 27 (34%) were combined with meniscus treatment. The mean hospital costs incurred per ACLR procedure were USD 2,853 (IDR 40.4 million), which was mainly attributed to the orthopedic implants (USD 1,387; IDR 19.6 million). The costs of ACLR with combined meniscus treatment were estimated to be 35 percent higher than for isolated ACLR. The national burden of ACLR revealed a total budget of USD 367.4 million (IDR 5.2 trillion) per 100,000 patients for ACLR with additional meniscus treatment and USD 271.3 million (IDR 3.8 trillion) per 100,000 patients for the isolated ACLR procedure.ConclusionsACLR procedures in Indonesia are underbudgeted. Adjustment of reimbursement prices for ACLR procedures is needed to facilitate access for the Indonesian people. This study showed varying cost estimates for ACLR in Indonesia, necessitating a new reimbursement system that takes various clinical and patient factors into account.

Modified Lemaire Lateral Extra-Articular Tenodesis Using an Inlay Technique and All-Suture Knotless Anchor Fixation

Background:In several anatomic single-bundle anterior cruciate ligament (ACL) reconstruction (ASB-ACLR) procedures, the femoral and tibial tunnel apertures are created at different locations within the native ACL attachment area.Hypothesis:Graft length changes during knee motion will be different among ASB-ACLR procedures with different femoral and tibial tunnel aperture locations.Study Design:Controlled laboratory study.Methods:A total of 12 cadaveric knees were used in this study. In each knee, 4 and 3 thin tunnels were created within the ACL attachment area on the femur and the tibia, respectively. Using 1 of 5 different combinations of femoral and tibial tunnel aperture location, 5 ASB-ACLRs were performed on each knee. In each reconstruction approach, a strong thread was used in place of the tendon graft, and the tibial graft end was tethered to a custom-made isometric positioner at 0° of knee flexion, with an approximately 12-N load applied to the thread. Then, each specimen underwent 5 cycles of knee flexion-extension motion in a range between 0° and 120°, and graft length changes were determined for each SB-ACLR approach.Results:The length changes of the graft were significantly different among the 5 ASB-ACLRs. The maximum length change values of the 3 grafts that were implanted between the femoral and tibial centers of the posterolateral bundle attachments or implanted into the femoral tunnel created at the center of the fanlike extension fiber attachment were significantly greater than those of the graft implanted between the centers of the anteromedial bundle attachments (P < .0001) and of the graft implanted between the centers of the whole ACL attachments (P < .0001).Conclusion:The length changes of the graft during knee motion were significantly different among the 5 ASB-ACLR approaches, even though all of the tunnel apertures were created within the femoral and tibial attachments of the native ACL.Clinical Relevance:The grafts in the first 3 graft locations may be so relaxed during knee flexion that they cannot resist anterior drawer loads exerted on the tibia.

How to Avoid Knee Tunnel Convergence When Performing a Modified Lemaire Extra-Articular Tenodesis

Objectives:Graft choice for anterior cruciate ligament (ACL) reconstruction remains controversial. Quadriceps autograft has emerged as an alternative graft choice. However, there remains a paucity of comparative outcomes. Our purpose is to compare subjective outcomes and complications of ACL reconstruction using either BTB or quadriceps autograft. Our hypothesis is that there will be no difference in subjective outcome or complications between groups.Methods:Following IRB approval, retrospective review of prospectively collected data identified consecutive cohorts of patients undergoing ACL reconstruction with either BTB or quadriceps autograft. Surgery was performed by a single sports fellowship trained surgeon between 2011-2019. Patients undergoing concomitant osteotomies, cartilage restoration, and other ligament reconstruction procedures were excluded. Pre- and post-surgical patient reported outcomes (PROs) including IKDC, KOOS, PROMIS, SANE, Tegner, and Marx were compared between groups. Complications requiring re-operation (infection, stiffness, reconstruction failure) were recorded. Results were analyzed statistically.Results:141 patients met inclusion criteria. There were 72 BTB and 69 quadriceps autografts. Mean age was 20.5 years in the BTB group and 20.7 years in the quadriceps group (p=0.9). 28 of 69 (40.6%) BTB and 34 of 72 (47.2%) quadriceps were female. Pre-operative KOOS Pain (64.5, 78.0, p=0.0007), KOOS QOL (29.6, 37.7, p=0.05), IKDC (44.5, 52.6, p=0.05), and PROMIS Physical Function (39.0, 42.7 p=0.04) scores were significantly higher in the BTB cohort. There were no differences in other baseline PROs. At minimum 6-month follow-up (range 6 - 57 months), patients in both quadriceps and BTB autograft cohorts reported statistically significant improvements in all KOOS domains, Tegner (76.4%, p=0.0002; 94.0%, p=0.000000003), IKDC (67.3%, p=0.0000009; 54.0%, p=0.000000009), SANE (69.4%, p=0.0000001; 70.7%, p=0.000000002), PROMIS Mobility T-Score (30.6%, p=0.0000003; 24.6%, p=0.000002), PROMIS Global Physical Health (15.3%, p=0.00002; 14.3%, p=0.00004), PROMIS Physical Function (33.2%, p=0.0000000008; 29.6%, p=0.00000002), PROMIS Pain Interference (-17.9%, p=0.00000002; -20.8%, p=0.00000000007). Post-operative Tegner (4.7, 6.0, p=0.04) and Global Mental Health (55.7, 60.1, p=0.008) scores were significantly higher in the BTB cohort. Complications were low and not significant between groups. Both quadriceps and BTB autograft cohorts required post-operative re-operations (4.4% and 6.9%, p=0.5). Quadriceps had 2 ligament reconstructions (2.9%) and 1 surgery for stiffness (1.4%). BTB group had 3 ligament reconstructions (4.2%) and 2 surgeries for stiffness (2.8%).Conclusion:Patients undergoing either BTB and quadriceps autograft ACL reconstruction demonstrated significant subjective improvements and low rates of complications requiring re-operation. At mid-term follow-up, the BTB cohort had higher activity and mental health scores.

The autologous semitendinosus-gracilis graft is the first choice of many orthopaedic surgeons when reconstructing the anterior cruciate ligament. The effect that graft harvest has on muscle and tendon morphology remains unclear. The purpose of this study was to describe these effects more completely. Magnetic resonance images were acquired from eight patients before the anterior cruciate ligament reconstruction with semitendinosus-gracilis autograft and then again postoperatively after they had returned to sports. Muscle and tendon morphology was described by determining the volume and peak cross-sectional area of each structure on digitally reconstructed images. The effects that the procedure had on muscle and tendon length were evaluated separately and then together as a muscle-tendon complex. Anterior cruciate ligament reconstruction with semitendinosus-gracilis autograft resulted in a marked decrease in volume, cross-sectional area, and length of the semitendinosus and gracilis muscles. Tendon regeneration occurred in varying degrees in nearly all subjects. The morphology of the biceps femoris and semimembranosus muscles suggested that they had been compensating for the reduced semitendinosus and gracilis muscle function. Although semitendinosus and gracilis muscle retraction occurred following tendon stripping, nearly all of the subjects displayed evidence of at least partial tendon regeneration. Anterior cruciate ligament reconstruction with semitendinosus-gracilis autograft had a marked impact on semitendinosus and gracilis muscle morphology. However, this altered muscle morphology did not appear to have a clinically important impact on short-term outcomes. The biceps femoris and semimembranosus muscles appear to compensate for reduced semitendinosus and gracilis function. Tendon regeneration is observed in most people, but it is often incomplete at six months.

Objectives: To determine rates of perioperative opioid use and characterize associations between preoperative depression and chronic and cumulative opioid consumption after ACL reconstruction. Methods: Using insurance claims data, we identified 48,657 adults who underwent ACL reconstruction from 2010 to 2015, had prescription drug insurance, and had ≥1 year of continuous insurance enrollment postoperatively. Chronic opioid use was defined as filling ≥120 days’ supply from 3 to 12 months postoperatively. Logistic and linear regression, controlled for age, sex, and Charlson Comorbidity Index value, were used to determine associations of preoperative depression with binary and continuous outcomes, respectively. Results: Preoperatively, 2,237 patients (4.6%) had depression and 2,387 (4.9%) were taking opioids; patients with depression had 6.5 times the odds (95% confidence interval [CI]: 5.8, 7.3) of taking opioids than patients without depression. Postoperatively, 25% of the patients filled ≥1 opioid prescription; mean duration of use was 13 ± 11 days, and 362 patients (0.7%) had chronic use. Patients with preoperative depression were less likely than patients without depression to fill an opioid prescription postoperatively (OR 0.2, 95% CI: 0.2, 0.2). Of patients who filled opioid prescriptions postoperatively, those with preoperative depression were more likely to refill that prescription at least once (OR 2.0, 95% CI: 1.9, 2.2) but did not have greater odds of chronic use (OR 0.9, 95% CI: 0.5, 1.5). Preoperative depression was not associated with greater cumulative opioid consumption from 3 to 12 months postoperatively (β = −40, 95% CI: −226, 146). Conclusion: Although patients with preoperative depression were more likely to take opioids preoperatively and to obtain ≥1 opioid refill postoperatively, they did not have greater odds of chronic postoperative opioid use or greater cumulative opioid consumption after ACL reconstruction.

Objective postoperative knee stability after 1-stage and 2-stage revision anterior cruciate ligament reconstruction

Anterior cruciate ligament reconstruction with hamstring tendons

AimArthroscopic interventions have revolutionized the treatment of joint pathologies. The appropriate diagnostics and treatment are required for infections after ligament reconstructions using non-resorbable material such as tendon grafts, anchors, and sutures, prone to biofilm formation. The infection rate is around 1% for knee and shoulder, while up to 4% for Achilles tendon reconstructions. Despite high number of these procedures worldwide, there is limited evidence about the best treatment protocol. Our study aimed to provide a general protocol for the treatment of small implants for soft tissue reconstruction.MethodBetween 2019 and 2023, we treated 48 infections of ligament, meniscus, and tendon reconstructions out of 7291 related procedures performed in the same time period. Early infection (&lt;30 days) were treated with an arthroscopic debridement and implant retention (DAIR), except Achilles tendons had open DAIR, while those with delayed or chronic infection (&gt;30 days) were treated with extensive debridement and lavage combined with one-stage exchange (OSE) or implant removal. During surgery, at least 5 microbiological s and samples for histopathology were obtained. The removed material was sonicated. After surgery, all patients were one week on iv. antibiotics, followed by oral antibiofilm antibiotics for 6 weeks including rifampicin and/or a quinolone. All patients were followed for at least 1 year. Failure was defined as the need for additional revision surgery after finished iv. antibiotic treatment.ResultsAmong 48 patients, 38 were early and 10 were late acute or chronic infections. The incidence of infection for our cohort was 0.7%. We observed 27 infections after ligament reconstruction of the knee, 15 of the shoulder, 5 of the ankle, and 1 infection of the elbow joint. 40 patients were treated with DAIR, 5 with OSE, and 3 with implant removal. We had 11 C. acnes, 10 S. aureus, 6 S. epidermidis, 2 P. aeruginosa, 2 S. lugdunensis, 10 mixed flora, and 3 culture-negative infections. 12 patients received antibiotics before surgery, and all culture-negative infections were related to this subgroup. We observed 2 failures, both in a combination of proximal tibial osteotomy and ligament reconstruction of the knee joint. The success rate of our protocol was 96%.ConclusionsPrompt surgical treatment followed by 6 weeks of antibiotic treatment cured 96% of infections of small implants after reconstruction procedures of knee, shoulder, and ankle joints. Our study is the first to provide a treatment protocol for infections of small implants after ligament reconstruction procedures

Editorial Commentary: Return to Sport Following Extra-Articular Augmentation of Anterior Cruciate Ligament Reconstruction—Let the LET (Lateral Extra-Articular Tenodesis) Games Commence!