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Purpose The purpose of this study was to evaluate whether harvesting a second graft from the ipsilateral extensor mechanism adversely affects clinical outcomes in revision anterior cruciate ligament (ACL) reconstruction. Methods A retrospective review of 34 patients undergoing revision anterior cruciate ligament (ACL) reconstruction with either quadriceps tendon (QT) autograft or bone–tendon–bone (BTB) autograft was conducted. Patients with two grafts (BTB+QT) from the extensor mechanism were matched based on age, laterality, and sex to patients who had primary reconstruction with hamstring (HS) autograft followed by revision with either BTB or QT autograft (HS+QT/BTB). Return of quadriceps function was assessed with time to return to jogging in a standardized rehab protocol or time to regain 80% quadriceps strength. Secondary outcomes included International Knee Documentation Committee (IKDC) and Marx scores at 12-month follow-up and return to sport. Results There were no significant differences in return to jogging or 80% quadriceps strength (HS 149.5 ± 38.2 days, BTB+QT 131.7 ± 40.1 days, n.s.), number able to return to sport (HS 62%, BTB+QT 93%, n.s.), months to return to sport (HS 10.6 ± 1.4, BTB+QT 10.5 ± 2.3, n.s.), return to pre-injury level of competition (HS 62%, BTB+QT 73%, n.s.), or IKDC (HS 77.2 ± 16.4, BTB+QT 74.8 ± 23.9, n.s.) and Marx scores (HS 9.2 ± 5.3, BTB+QT 8.0 ± 3.7, n.s.) at one-year follow-up. Conclusion The main finding of the present study was that outcomes for patients who underwent revision ACL reconstruction with a second extensor mechanism autograft were comparable to those seen for patients who underwent revision ACL reconstruction with extensor mechanism autograft after primary ACL reconstruction with hamstring autograft. By better understanding the consequences of harvesting a second graft from the extensor mechanism, surgeons can better decide what graft to use in revision ACL reconstruction. Level of evidence Level III.

Purpose To evaluate the effect of posterior tibial slope (PTS) on patient-reported outcomes (PROs) and posterior cruciate ligament (PCL) graft failure after PCL reconstruction. Methods Patients undergoing PCL reconstruction with a minimum 2-year follow-up were included in this retrospective cohort study. A chart review was performed to collect patient-, injury-, and surgery-related data. Medial PTS was measured on preoperative lateral radiographs. Validated PROs, including the International Knee Documentation Committee Subjective Knee Form, Knee injury and Osteoarthritis Outcome Score, Lysholm Score, Tegner Activity Scale, and Visual Analogue Scale for pain, were collected at final follow-up. A correlation analysis was conducted to assess the relationship between PTS and PROs. A logistic regression model was performed to evaluate if PTS could predict PCL graft failure. Results Overall, 79 patients with a mean age of 28.6 ± 11.7 years and a mean follow-up of 5.7 ± 3.3 years were included. After a median time from injury of 4.0 months, isolated and combined PCL reconstruction was performed in 22 (28%) and 57 (72%) patients, respectively. There were no statistically significant differences in PROs and PTS between patients undergoing isolated and combined PCL reconstruction (non-significant [n.s.]). There were no significant correlations between PTS and PROs (n.s.). In total, 14 (18%) patients experienced PCL graft failure after a median time of 17.5 months following PCL reconstruction. Patients with PCL graft failure were found to have statistically significantly lower PTS than patients without graft failure (7.0 ± 2.3° vs. 9.2 ± 3.3°, p  < 0.05), while no differences were found in PROs (n.s.). PTS was shown to be a significant predictor of PCL graft failure, with a 1.3-fold increase in the odds of graft failure for each one-degree reduction in PTS ( p  < 0.05). Conclusions This study showed that PTS does not affect PROs after PCL reconstruction, but that PTS represents a surgically modifiable predictor of PCL graft failure. Level of evidence III.

Background: The quadriceps tendon is a versatile graft option, and the clinical implications of a quadriceps tendon harvest need to be further defined. Purpose: To review surgical considerations for the safe harvest of a quadriceps tendon autograft for anterior cruciate ligament (ACL) reconstruction, with a focus on the risk of patellar fractures. Study Design: Case series; Level of evidence, 4. Methods: A series of 57 patients underwent ACL reconstruction with a quadriceps tendon autograft with a patellar bone block from March 2011 to December 2012 at a single institution. Patients who sustained a patellar fracture were identified. The clinical course for each patient was reviewed with International Knee Documentation Committee (IKDC) subjective knee form scores through 2-year follow-up. Results: The incidence of patellar fractures was 3.5% intraoperatively and 8.8% at 2 years. This included 2 intraoperative fractures, 1 fracture during strength testing, and 2 occult fractures detected on computed tomography (CT) performed 6 months postoperatively for research purposes in asymptomatic participants. For the 5 patients with a patellar fracture with 24-month follow-up, the IKDC scores were 91.95, 91.95, 100.00, 100.00, and 64.37. Conclusion: Careful consideration of the quadriceps tendon and patellar anatomy is needed to safely harvest the bone plug from the superior pole of the patella. The consequences of a quadriceps tendon autograft harvest, specifically with regard to the risks associated with fractures of the patella during the harvest, demand full consideration. Postoperative imaging with CT may identify abnormalities in patients who are otherwise asymptomatic.

A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sport and their previous activity level. The aim of the Panther Symposium ACL Injury Return to Sport Consensus Group was to provide a clear definition of RTS after ACL injury and a description of the RTS continuum as well as provide clinical guidance on RTS testing and decision-making. Consensus statement. An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence. Key points include that RTS is characterized by achievement of the preinjury level of sport and involves a criteria-based progression from return to participation to RTS and, ultimately, return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along an RTS continuum, with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors, and concomitant injuries. The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing, and methods for the biological assessment of healing and recovery.

Purpose The goal of individualized anatomic anterior cruciate ligament reconstruction (ACL-R) is to reproduce each patient’s native insertion site as closely as possible. The amount of the native insertion site that is recreated by the tunnel aperture area is currently unknown, as are the implications of the degree of coverage. As such, the goals of this study are to determine whether individualized anatomic ACL-R techniques can maximally fill the native insertion site and to attempt to establish a crude measure to evaluate the percentage of reconstructed area as a first step towards elucidating the implications of complete footprint restoration. Methods This is a prospective pilot study of 45 patients who underwent primary single-bundle anatomic ACL-R from May 2011 to April 2012. Length and width of the native insertion site were measured intraoperatively. Using published guidelines, reconstruction technique and graft choice were determined to maximize the percentage of reconstructed area. Native femoral and tibial insertion site area and femoral tunnel aperture area were calculated using the formula for area of an ellipse. On the tibial side, tunnel aperture area was calculated with respect to drill diameter and drill guide angle. Percentage of reconstructed area was calculated by dividing total tunnel aperture area by the native insertion site area. Results The mean areas for the native femoral and tibial insertion sites were 83 ± 20 and 125 ± 20 mm 2 , respectively. The mean tunnel aperture area for the femoral side was 65 ± 17, and 86 ± 17 mm 2 for the tibial tunnel aperture area. On average, percentage of reconstructed area was 79 ± 13 % for the femoral side, and 70 ± 12 % for the tibial side. Conclusion Anatomic ACL-R does not restore the native insertion site in its entirety. Percentage of reconstructed area serves as a rudimentary tool for evaluating the degree of native insertion site coverage using current individualized anatomic techniques and provides a starting point from which to evaluate the clinical significance of complete footprint restoration. Level of evidence IV.