Aims. Our purpose was to describe an unusual series of 21 patients with fungal osteomyelitis after an anterior cruciate ligament reconstruction (ACL-R). Methods. We present a case-series of consecutive patients treated at our institution due to a severe fungal osteomyelitis after an arthroscopic ACL-R from November 2005 to March 2015. Patients were referred to our institution from different areas of our country. We evaluated the amount of bone resection required, type of final reconstructive procedure performed, and Musculoskeletal Tumor Society (MSTS) functional score. Results. A total of 21 consecutive patients were included in the study; 19 were male with median age of 28 years (IQR 25 to 32). All ACL-R were performed with hamstrings autografts with different fixation techniques. An oncological-type debridement was needed to control persistent infection symptoms. There were no recurrences of fungal infection after median of four surgical debridements (IQR 3 to 6). Five patients underwent an extensive curettage due to the presence of large cavitary lesions and were reconstructed with hemicylindrical intercalary allografts (HIAs), preserving the epiphysis. An open surgical debridement was performed resecting the affected epiphysis in 15 patients, with a median bone loss of 11 cm (IQR 11.5 to 15.6). From these 15 cases, eight patients were reconstructed with allograft prosthesis composites (APC); six with tumour-type prosthesis (TTP) and one required a femoral TTP in combination with a tibial APC. One underwent an above-the-knee amputation. The median MSTS functional score was 20 points at a median of seven years (IQR 5 to 9) of follow-up. Conclusion. This study suggests that mucormycosis infection after an ACL-R is a serious complication. Diagnosis is usually delayed until major bone destructive lesions are present. This may originate additional massive reconstructive surgeries with severe functional limitations for the patients. Level of evidence: IV. Cite this article: Bone Joint Open 2020;2(1):3–8

Background. Surgical reconstruction of the anterior cruciate ligament is a common practice to treat the disability or chronic instability of the knee. Several factors associated with success or failure of the ACL reconstruction, including surgical technique and graft material and graft tension. We aimed to show how we can optimize the graft properties and achieve better post surgical outcomes during ACL reconstruction using 3-dimensional computational finite element simulation. Methods. In this paper, 3-dimensional model of the knee was constructed to investigate the effect of graft tensioning on the knee joint biomechanics. Four different grafts were compared: 1) bone-patellar tendon-bone graft (BPTB) 2) Hamstring tendon 3) BPTB and a band of gracilis 4) Hamstring and a band of gracilis. The initial graft tension was set as “0, 20, 40, or 60N”. The anterior loading was set to 134 N. Findings. Our study shows that the use of the discarded gracilis tendon, which usually excised after graft fixation, could be associated with a host of merits. Our results show that preserving this excess part of gracilis would decrease the required pretention load and, subsequently, could optimize biomechanical properties of the knee. Conclusion. Required pretension during surgery will have decreased significantly by adding a band of gracilis to the proper graft. Therefore, in addition to achieving normal stability of the knee, we can have lower risk of degradation

Cite this article: Bone Joint Open 2020;1-11:706–708.

Objectives

Our aim was to assess the use of intra-operative fluoroscopy in the assessment of the position of the tibial tunnel during reconstruction of the anterior cruciate ligament (ACL).

To address the current challenge of anterior cruciate ligament (ACL) reconstruction, this study is the first to fabricate a braided collagen rope (BCR) which mimics native hamstring for ACL reconstruction. The study aims to evaluate the biological and biomechanical properties of BCR both in vivo and vitro. Rabbit ACL reconstruction model using collagen rope and autograft (hamstring tendon) was conducted. The histological and biomechanical evaluations were conducted at 6-, 12-, 18, 26-week post-operation. In vitro study included cell morphology analysis, cell function evaluation and RNA sequencing of the tenocytes cultured on BCR. A cadaver study was also conducted to verify the feasibility of BCR for ACL reconstruction. BCR displays satisfactory mechanical strength similar to hamstring graft for ACL reconstruction in rabbit. Histological assessment showed BCR restore ACL morphology at 26 weeks similar to native ACL. The superior dynamic ligamentization in BCR over autograft group was evidenced by assessment of cell and collagen morphology and orientation. The in vitro study showed that the natural collagen fibres within BCR enables to signal the morphology adaptation and orientation of human tenocytes in bioreactor. BCR enables to enhance cell proliferation and tenogenic expression of tenocytes as compared to hydrolysed collagen. We performed an RNA-Sequencing (RNA-seq) experiment where RNA was extracted from tenocyte seeded with BCR. Analysis of enriched pathways of the up-regulated genes revealed that the most enriched pathways were the Hypoxia-inducible factor 1-alpha (HIF1A) regulated networks, implicating the possible mechanism BCR induced ACL regeneration. The subsequent cadaver study was conducted to proof the feasibility of BCR for ACL reconstruction. This study demonstrated the proof-of-concept of bio-textile braided collagen rope for ACL reconstruction, and the mechanism by which BCR induces natural collagen fibres that positively regulate morphology and function of tenocytes

The purpose of this study is to assess the long term results of combined ACL reconstruction and unicompartmental knee replacements (UKR). These patients have been selected for this combined operation due to their combination of instability symptoms from an absent ACL and unicompartmental arthritis. Retrospective review of 44 combined UKR and ACL reconstruction by a single surgeon. Surgeries included both medial and lateral UKR combined with either revision ACL reconstruction or primary ACL reconstruction. Patient reported outcomes were obtained preoperatively, at one year, 5 years and 10 years. Revision rate was followed up over 13 years for a mean of 7.4 years post-surgery. The average Oxford score at one year was 43 with an average increase from pre-operation to 1 year post operation of 15. For the 7 patients with 10 year follow up average oxford score was 42 at 1 year, 43 at 5 years and 45 at 10 years. There were 5 reoperations. 2 for revision to total knee arthroplasty and 1 for an exchange of bearing due to wear. The other 2 were the addition of another UKR. For those requiring reoperation the average time was 8 years. Younger more active patients presenting with ACL deficiency causing instability and unicompartmental arthritis are a difficult group to manage. Combining UKR and ACL reconstruction has scant evidence in regard to long term follow up but is a viable option for this select group. This paper has one of the largest cohorts with a reasonable follow up averaging 7.4 years and a revision rate of 11 percent. Combined unilateral knee replacements and ACL reconstruction can be a successful operation for patients with ACL rupture causing instability and unicompartmental arthritis

Arthrofibrosis is a less common complication following anterior cruciate ligament (ACL) reconstruction and there are concerns that undergoing early surgery may be associated with arthrofibrosis. The aim of this study was to identify the patient and surgical risk factors for arthrofibrosis following primary ACL reconstruction. Primary ACL reconstructions prospectively recorded in the New Zealand ACL Registry between April 2014 and December 2019 were analyzed. The Accident Compensation Corporation (ACC) database was used to identify patients who underwent a subsequent reoperation with review of operation notes to identify those who had a reoperation for “arthrofibrosis” or “stiffness”. Univariate Chi-Square test and multivariate Cox regression analysis was performed. Hazard ratios (HR) with 95% confidence intervals (CI) were computed to identify the risk factors for arthrofibrosis. 9617 primary ACL reconstructions were analyzed, of which 215 patients underwent a subsequent reoperation for arthrofibrosis (2.2%). A higher risk of arthrofibrosis was observed in female patients (adjusted HR = 1.67, 95% CI 1.22 – 2.27, p = 0.001), patients with a history of previous knee surgery (adjusted HR = 1.97, 95% CI 1.11 – 3.50, p = 0.021) and when a transtibial femoral tunnel drilling technique was used (adjusted HR = 1.55, 95% CI 1.06 – 2.28, p = 0.024). Patients who underwent early ACL reconstruction within 6 weeks of their injury did not have a higher risk of arthrofibrosis when compared to patients who underwent surgery more than 6 weeks after their injury (3.5% versus 2.1%, adjusted HR = 1.56, 95% CI 0.97 – 2.50, p = 0.07). Age, graft type and concomitant meniscal injury did not influence the rate of arthrofibrosis. Female sex, a history of previous knee surgery and a transtibial femoral tunnel drilling technique are risk factors for arthrofibrosis following primary ACL reconstruction

Abstract. Aims. Growth disturbances after transphyseal paediatric ACL reconstruction have led to the development of physeal-sparing techniques. However, evidence in their favour remains weak. This study reviews the literature to identify factors associated with growth disturbances in paediatric ACL reconstructions. Materials and Methods. Web of Science, Scopus and Pubmed were searched for case series studying paediatric ACL reconstructions. Titles, abstracts, text, results and references were examined for documentation of growth disturbances. Incidences of graft failures were also studied in these selected studies. Results. 78 studies with 2693 paediatric ACL reconstructions had 70 growth disturbances (2.6%). Of these 17 were varus, 26 valgus, 13 shortening, 14 lengthening and 5 patients had reduced tibial slope. Coronal plane deformities were seen more frequently with eccentric physeal arrest and lengthening with intraepiphyseal tunnelling. Shortening and reduced tibial slope were related to large central physeal arrest and anterior tibial physeal arrest respectively. Extraphyseal technique were least likely to have growth disturbances. 62 studies documented 166 graft failures in 2120 patients (7.83%). Conclusion. Growth disturbances resulting from transphyseal ACL reconstruction can be minimised by keeping drill size small, drilling steep and away from the physeal periphery. Insertion of bone plug, hardware or synthetic material through the drilled physis should be avoided. The evidence to accurately quantify such growth disturbances till skeletal maturity remains weak. Robust long term studies such as national ligament registries may standardise preoperative and postoperative outcome assessment to further characterise the risk of growth disturbance and re-ruptures

The principal of “function priority, early rehabilitation, and return to sports” is now the goal for sports injury rehabilitation. Neuromuscular electrical stimulation for anterior cruciate ligament (ACL) reconstruction is a rising procedure for early rehabilitation. This paper systematically assessed the effects of neuromuscular electrical stimulation on postoperative ACL reconstruction to provide guidance for physiotherapist and patient when designing a suitable rehabilitation protocol. To evaluate the interventional outcomes of neuromuscular electrical stimulation following ACL reconstruction, we searched PubMed, EMbase, the Cochrane Library, Web of Science and CNKI to collect all randomized controlled trials (RCTs) comparing the effects with neuromuscular electrical stimulation and without intervention on rehabilitation after ACL reconstruction up to January 30, 2022. Two investigators independently performed literature screening, data extraction, bias assessment of risk, and used RevMan 5.3 software to conduct a meta-analysis. A total of six RCTs were included, and the results showed that the use of neuromuscular electrical stimulation after anterior cruciate ligament reconstruction significantly improved the International Knee Documentation Committee (IKDC) scores (MD 6.33, 95% CI [-0.43, 12.22]; I2 = 66%; p = 0.040), the Lysholm score (MD 7.94, 95% CI [6.49, 9.39]; I2 = 89%; p < 0.001), and the range of motion (ROM) (MD 9.99, 95% CI [7.97, 12.02]; I2 = 81%; p < 0.001) in the knees when compared to the control group without using neuromuscular electrical stimulation. Existing evidence show that neuromuscular electrical stimulation is beneficial for early rehabilitation after ACL reconstruction. The use of neuromuscular electrical stimulation is encouraged in the design of rehabilitation protocol. However, due to the limited number of RCT studies and the small sample size, further multi-center RCTs with more participants are needed for a higher-level evidence

Aims. To verify whether secretory leucocyte protease inhibitor (SLPI) can promote early tendon-to-bone healing after anterior cruciate ligament (ACL) reconstruction. Methods. In vitro: the mobility of the rat bone mesenchymal stem cells (BMSCs) treated with SLPI was evaluated by scratch assay. Then the expression levels of osteogenic differentiation-related genes were analyzed by real-time quantitative PCR (qPCR) to determine the osteogenic effect of SLPI on BMSCs. In vivo: a rat model of ACL reconstruction was used to verify the effect of SLPI on tendon-to-bone healing. All the animals of the SLPI group and the negative control (NC) group were euthanized for histological evaluation, micro-CT scanning, and biomechanical testing. Results. SLPI improved the migration ability of BMSCs and upregulated the expression of genes related to osteogenic differentiation of BMSCs in vitro. In vivo, the SLPI group had higher histological scores at the tendon-bone interface by histological evaluation. Micro-CT showed more new bone formation and bone ingrowth around the grafted tendon in the SLPI group. Evaluation of the healing strength of the tendon-bone connection showed that the SLPI group had a higher maximum failure force and stiffness. Conclusion. SLPI can effectively promote early tendon-to-bone healing after ACL reconstruction via enhancing the migration and osteogenic differentiation of BMSCs. Cite this article: Bone Joint Res 2022;11(7):503–512

The bone-patellar tendon-bone (BTB) autograft has a lower rate of graft failure but a higher rate of contralateral anterior cruciate ligament (ACL) injury after primary ACL reconstruction. Subsequent contralateral injury may be a marker of success of the BTB graft, but it is unclear whether the type of graft influences the rate of return to sport. This study aimed to compare the rates of return to weekly sport and return to preinjury activity levels between the BTB and hamstring tendon autografts following primary ACL reconstruction. Prospective data on primary ACL reconstructions recorded in the New Zealand ACL Registry between April 2014-November 2019 were analyzed. The primary outcome was return to weekly sport, defined as a Marx activity score of 8, at 2-year follow-up. The secondary outcome was return to preinjury activity level, defined as a post-operative Marx activity score that was equal or greater to the patient's preinjury Marx score. Return to sport was compared between the BTB and hamstring tendon autografts via multivariate binary logistic regression with adjustment for patient demographics. 4259 patients were analyzed, of which 50.3% were playing weekly sport (n = 2144) and 28.4% had returned to their preinjury activity level (n = 1211) at 2-year follow-up. A higher rate of return to weekly sport was observed with the BTB autograft compared to the hamstring tendon autograft (58.7% versus 47.9%, adjusted odds ratio = 1.23, p = 0.009). Furthermore, the BTB autograft had a higher rate of return to preinjury activity levels (31.5% versus 27.5%, adjusted odds ratio = 1.21, p = 0.025). The BTB autograft is associated with a higher return to sport and may explain the higher rate of contralateral ACL injury following primary ACL reconstruction

Meniscal repairs are commonly performed during anterior cruciate ligament (ACL) reconstruction. This study aimed to identify the risk factors for meniscal repair failure following concurrent primary ACL reconstruction. Primary ACL reconstructions with a concurrent repair of a meniscal tear recorded in the New Zealand ACL Registry between April 2014 and December 2018 were analyzed. Meniscal repair failure was defined as a patient who underwent subsequent meniscectomy, and was identified after cross-referencing data from the ACL Registry with the national database of the Accident Compensation Corporation (ACC). Multivariate Cox regression was performed to produce hazard ratios (HR) with 95% confidence intervals (CI) to identify the patient and surgical risk factors for meniscal repair failure. 2041 meniscal repairs were analyzed (medial = 1235 and lateral = 806). The overall failure rate was 9.4% (n = 192). Failure occurred in 11.1% of medial (137/1235) and 6.8% of lateral (55/806) meniscal repairs. The risk of medial failure was higher with hamstring tendon autografts (adjusted HR = 2.00, 95% CI 1.23 – 3.26, p = 0.006) and in patients with cartilage injury in the medial compartment (adjusted HR = 1.56, 95% CI 1.09 – 2.23, p = 0.015). The risk of lateral failure was higher when the procedure was performed by a surgeon with an annual case volume of less than 30 ACL reconstructions (adjusted HR = 1.92, 95% CI 1.10 – 3.33, p = 0.021). Age, gender, time from injury-to-surgery and femoral tunnel drilling technique did not influence the risk of meniscal repair failure. When repairing a meniscal tear during ACL reconstruction, the use of a hamstring tendon autograft or the presence of cartilage injury in the medial compartment increases the risk of medial meniscal repair failure. Lower surgeon case volume increases the risk of lateral meniscal repair failure

Screw fixation is an established method for anterior cruciate ligament (ACL) reconstruction, although with a high rate of implant-related complications. An allograft system for implant fixation in ACL reconstruction, the Shark Screw ACL (surgebright GmbH) could overcome some of the shortcomings of bioabsorbable screws, such as foreign body reaction, need for implant removal and imaging artefacts. However, it needs to provide sufficient mechanical stability. Therefore, the aim of this study was to investigate the biomechanical stability, especially graft slippage, of the novel allograft system versus a conventional bioabsorbable interference screw (BioComposite Interference Screw; Arthrex Inc.) for tibial implant fixation in ACL reconstruction. Twenty-four paired human proximal tibiae (3 female, 9 male, 72.7 ± 5.6 years) underwent ACL reconstruction. The quadrupled semitendinosus and gracilis tendon graft were fixed in one specimen of each pair using the allograft fixation system Shak Screw ACL and the contralateral one using an interference screw. All specimens were cyclically loaded at 1 Hz with peak load levels monotonically increased from 50 N at a rate of 0.1 N/cycle until catastrophic failure. Relative movements of the graft versus the tibia were captured with a stereographic optical motion tracking system (Aramis SRX; GOM GmbH). The two fixation methods did not demonstrate any statistical difference in ultimate load at graft slippage (p = 0.24) or estimated survival at slippage (p = 0.06). Both, the ultimate load and estimated survival until failure were higher in the interference screw (p = 0.04, and p = 0.018, respectively). Graft displacement at ultimate load reached values of up to 7.2 mm (interference screw) and 11.3 mm (Shark Screw ACL). The allograft screw for implant fixation in ACL reconstruction showed similar behavior in terms of graft slippage compared to the conventional metal interference screw but underperformed in terms of ultimate load. However, the ultimate load may not be considered a direct indicator of clinical failure

Background. Anterior cruciate ligament (ACL) reconstruction with concomitant meniscal injury occurs frequently. Meniscal repair is associated with improved long-term outcomes compared to resection but is also associated with a higher reoperation rate. Knowledge of the risk factors for repair failure may be important in optimizing patient outcomes. Purpose. This study aimed to identify the patient and surgical risk factors for meniscal repair failure, defined as a subsequent meniscectomy, following concurrent primary ACL reconstruction. Methods. Data recorded by the New Zealand ACL Registry and the Accident Compensation Corporation, the New Zealand Government's sole funder of ACL reconstructions and any subsequent surgery, was reviewed. Meniscal repairs performed with concurrent primary ACL reconstruction was included. Root repairs were excluded. Univariate and multivariate survival analysis was performed to identify the patient and surgical risk factors for meniscal repair failure. Results. Between 2014 and 2020, a total of 3,024 meniscal repairs were performed during concurrent primary ACL reconstruction (medial repair = 1,814 and lateral repair = 1,210). The overall failure rate was 6.6% (n = 201) at a mean follow-up of 2.9 years, with a failure occurring in 7.8% of medial meniscal repairs (142 out of 1,814) and 4.9% of lateral meniscal repairs (59 out of 1,210). The risk of medial failure was higher in patients with a hamstring tendon autograft (adjusted HR = 2.20, p = 0.001), patients aged 21–30 years (adjusted HR = 1.60, p = 0.037) and in those with cartilage injury in the medial compartment (adjusted HR = 1.75, p = 0.002). The risk of lateral failure was higher in patients aged ≤ 20 years (adjusted HR = 2.79, p = 0.021) and when the procedure was performed by a surgeon with an annual ACL reconstruction case volume of less than 30 (adjusted HR = 1.84, p = 0.026). Conclusion. When performing meniscal repair during a primary ACL reconstruction, the use of a hamstring tendon autograft, younger age and the presence of concomitant cartilage injury in the medial compartment increases the risk of medial meniscal repair failure, whereas younger age and low surgeon volume increases the risk of lateral meniscal repair failure

Anterior cruciate ligament (ACL) injuries have been increasing, especially amongst adolescents. These injuries can increase the risk for early-onset knee osteoarthritis (OA). The consequences of late-stage knee OA include structural joint change, functional limitations and persistent pain. Interleukin-6 (IL-6) is a pro-inflammatory biomarker reflecting knee joint healing, and increasing evidence suggests that IL-6 may play a critical role in the development of pathological pain. The purpose of this study was to determine the relationship between subjective knee joint pain and function, and synovial fluid concentrations of the pro-inflammatory cytokine IL-6, in adolescents undergoing anterior cruciate ligament reconstruction surgery. Seven youth (12-17 yrs.) undergoing anterior cruciate ligament (ACL) reconstruction surgery participated in this study. They completed the Pedi International Knee Documentation Committee (Pedi-IKDC) questionnaire on knee joint pain and function. At the time of their ACL reconstruction surgery, synovial fluid samples were collected through aspiration to dryness with a syringe without saline flushing. IL-6 levels in synovial fluid (sf) were measured using enzyme linked immunosorbent assay. Spearman's rho correlation coefficient was used to determine the correlation between IL-6 levels and scores from the Pedi-IKDC questionnaire. There was a statistically significant correlation between sfIL-6 levels and the Pedi-IKDC Symptoms score (-.929, p=0.003). The correlations between sfIL-6 and Pedi-IKDC activity score (.546, p = .234) and between sfIL-6 and total Pedi-IKDC score (-.536, p = .215) were not statistically significant. This is the first study to evaluate IL-6 as a biomarker of knee joint healing in an adolescent population, reported a very strong correlation (-.929, p=0.003) between IL-6 in knee joint synovial fluid and a subjective questionnaire on knee joint pain. These findings provide preliminary scientific evidence regarding the relationship between knee joint pain, as determined by a validated questionnaire and the inflammatory and healing status of the patient's knee. This study provides a basis and justification for future longitudinal research on biomarkers of knee joint healing in patients throughout their recovery and rehabilitation process. Incorporating physiological and psychosocial variables to current return-to-activity (RTA) criteria has the potential to improve decision making for adolescents following ACL reconstruction to reduce premature RTA thereby reducing the risk of re-injury and risk of early-onset knee OA in adolescents

Anterior cruciate ligament (ACL) injuries are among the most common and debilitating knee injuries in professional athletes with an incidence in females up to eight-times higher than their male counterparts. ACL injuries can be career-threatening and are associated with increased risk of developing knee osteoarthritis in future life. The increased risk of ACL injury in females has been attributed to various anatomical, developmental, neuromuscular, and hormonal factors. Anatomical and hormonal factors have been identified and investigated as significant contributors including osseous anatomy, ligament laxity, and hamstring muscular recruitment. Postural stability and impact absorption are associated with the stabilizing effort and stress on the ACL during sport activity, increasing the risk of noncontact pivot injury. Female patients have smaller diameter hamstring autografts than males, which may predispose to increased risk of re-rupture following ACL reconstruction and to an increased risk of chondral and meniscal injuries. The addition of an extra-articular tenodesis can reduce the risk of failure; therefore, it should routinely be considered in young elite athletes. Prevention programs target key aspects of training including plyometrics, strengthening, balance, endurance and stability, and neuromuscular training, reducing the risk of ACL injuries in female athletes by up to 90%. Sex disparities in access to training facilities may also play an important role in the risk of ACL injuries between males and females. Similarly, football boots, pitches quality, and football size and weight should be considered and tailored around females’ characteristics. Finally, high levels of personal and sport-related stress have been shown to increase the risk of ACL injury which may be related to alterations in attention and coordination, together with increased muscular tension, and compromise the return to sport after ACL injury. Further investigations are still necessary to better understand and address the risk factors involved in ACL injuries in female athletes. Cite this article: Bone Jt Open 2024;5(2):94–100

Surgery performed in low-volume centres has been associated with longer operating time, longer hospital stays, lower functional outcomes, and higher rates of revision surgery, complications, and mortality. This has been reported consistently in the arthroplasty literature, but there is a paucity of data regarding the relationship between surgical volume and outcome following anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to compare the ACL reconstruction failure rate between hospitals performing different annual surgical volumes. The hypothesis was that ACL reconstructions performed at low-volume hospitals would be associated with higher failure rates than those performed at high-volume centres. This level-II cohort study included all patients from the Norwegian Knee Ligament Registry that underwent isolated primary autograft ACL reconstruction between 2004 and 2016. Hospital volume was divided into quintiles based on the number of ACL reconstructions performed annually, defined arbitrarily as: 1–12 (V1), 13–24 (V2), 25–49 (V3), 50–99 (V4), and ≥100 (V5) annual procedures. Kaplan-Meier estimated survival curves and survival percentages were calculated with revision ACL reconstruction as the end point. Mean change in Knee Injury and Osteoarthritis Outcome Score (KOOS) Quality of Life and Sport subsections from pre-operative to two-year follow-up were compared using t-test. 19,204 patients met the inclusion criteria and 1,103 (5.7%) underwent subsequent revision ACL reconstruction over the study period. Patients in the lower volume categories (V1-3) were more often male (58–59% vs. 54–55% p=<0.001) and older (27 years vs. 24–25 years, p=<0.001) compared to the higher volume hospitals (V4-5). Concomitant meniscal injuries (52% vs. 40%) and participation in pivoting sports (63% vs. 56%) were most common in V5 compared with V1 (p=<0.001). Median operative time decreased as hospital volume increased, ranging from 90 minutes at V1 hospitals to 56 minutes at V5 hospitals (p=<0.005). Complications occurred at a rate of 3.8% at low-volume (V1) hospitals versus 1.9% at high-volume (V5) hospitals (p=<0.001). Unadjusted 10-year survival with 95% confidence intervals for each hospital volume category were: V1 – 95.1% (93.7–96.5%), V2 – 94.1% (93.1–95.1%), V3 – 94.2% (93.6–94.8%), V4 – 92.6% (91.8–93.4%), and V5 – 91.9% (90.9–92.9%). There was no difference in improvement between pre-operative and two-year follow-up KOOS scores between hospital volume categories. Patients having ACL reconstruction at lower volume hospitals did not have inferior clinical or patient reported outcomes, and actually demonstrated a lower revision rate. Complications occurred more frequently however, and operative duration was longer. The decreased revision rate is an interesting finding that may be partly explained by the fact that patients being treated in these small, often rural hospitals, may be of lower demand as suggested by the increased age and decreased participation in pivoting sports. In addition, patients with more complicated pathology such as meniscal tears were more commonly treated in the larger volume hospitals. The most significant limitation of this study is that provider volume was not assessed, and the number of surgeons dividing up the surgical volume at each hospital is not known

Summary:. Hamstring tendons (HT) represent a widely used autograft for ACL reconstruction. Harvesting, processing and pretensioning procedures together with the time out of the joint could theoretically hamper tendon cells (TCs) viability. The authors hypothesize that HT cells are not impaired at the end of the surgical procedures and their tenogenic phenotype may be strongly improved by exposure to PEMF. Methods. Remnants of semitendinosus and gracilis tendons were collected at the end of the surgical procedures before skin closure from 15 healthy donors who underwent ACL reconstruction with autologous hamstring tendons. To isolate TCs, the tendon was minced and digested with 0.3 % type I collagenase and the nucleated cells were plated at a density 5x10E3 cells/cm2 and cultured in chamber slides in differentiation medium composed of DMEM + 5ng/ml basic fibroblast growth factor (b-FGF) for 7, 14, 21 days. The following cell cultures were set up:. -. TCs cultured with differentiation medium + exposure to PEMF 8 h/day (PEMF generator system IGEA, intensity of magnetic field = 1.5 mT, frequency = 75 Hz). -. TCs cultured with differentiation medium without exposure to PEMF. At day 0, day 7, day 14 and day 21, immunofluorescence analysis was performed to evaluate the expression of collagen type I, collagen type VI, scleraxis and PCNA (proliferative marker). Subsequently, tendon explant cultures were set up to verify, at day 21, explant viability and the expression of collagen type I, collagen type VI, beta-catenin and PCNA. Results. The TCs from the tendon fragments at the end of the ACL reconstruction were alive and they expressed markers of proliferation and tendon phenotype at the end of the culture periods. The TCs in the presence PEMF 8h/day showed greater production of collagen type I, collagen type VI and scleraxis than that of TCs cultured without PEMF (p<0,05): the expression of this markers increased from 7 to 21 days of culture. The expression of PCNA, in the presence of PEMF stimulus, was significantly lower (p<0,05) than that of TCs cultured without PEMF. A similar behavior was surprisingly observed in tendon explant cultures. Conclusions. Hamstring tendons used for ACL reconstruction are not simple autologous tenoconductive scaffold but are a biologic structure rich in progenitor cells that show tenogenic behavior. Their tenogenic phenotype may be strongly improved by exposure to PEMF. In a future clinical perspective, the postoperative use of PEMF could be used to enhance the ligamentization processes of autologous hamstring tendons, when used as autografts for ACL reconstructions

Objectives. To compare the effect of femoral bone tunnel configuration on tendon-bone healing in an anterior cruciate ligament (ACL) reconstruction animal model. Methods. Anterior cruciate ligament reconstruction using the plantaris tendon as graft material was performed on both knees of 24 rabbits (48 knees) to mimic ACL reconstruction by two different suspensory fixation devices for graft fixation. For the adjustable fixation device model (Socket group; group S), a 5 mm deep socket was created in the lateral femoral condyle (LFC) of the right knee. For the fixed-loop model (Tunnel group; group T), a femoral tunnel penetrating the LFC was created in the left knee. Animals were sacrificed at four and eight weeks after surgery for histological evaluation and biomechanical testing. Results. Histologically, both groups showed a mixture of direct and indirect healing patterns at four weeks, whereas only indirect healing patterns were observed in both groups at eight weeks. No significant histological differences were seen between the two groups at four and eight weeks in the roof zone (four weeks, S: mean 4.8 . sd. 1.7, T: mean 4.5 . sd. 0.5, p = 0.14; eight weeks, S: mean 5.8 . sd. 0.8, T: mean 4.8 . sd. 1.8, p = 0.88, Mann-Whitney U test) or side zone (four weeks, S: mean 5.0 . sd. 1.2, T: mean 4.8 . sd. 0.4, p = 0.43; eight weeks, S: mean 5.3 . sd. 0.8,T: mean 5.5 . sd. 0.8, p = 0.61, Mann-Whitney U test) . Similarly, no significant difference was seen in the maximum failure load between group S and group T at four (15.6 . sd. 9.0N and 13.1 . sd. 5.6N) or eight weeks (12.6 . sd. 3.6N and 17.1 . sd. 6.4N, respectively). Conclusion. Regardless of bone tunnel configuration, tendon-bone healing after ACL reconstruction primarily occurred through indirect healing. No significant histological or mechanical differences were observed between adjustable and fixed-loop femoral cortical suspension methods. Cite this article: Y. Sato, R. Akagi, Y. Akatsu, Y. Matsuura, S. Takahashi, S. Yamaguchi, T. Enomoto, R. Nakagawa, H. Hoshi, T. Sasaki, S. Kimura, Y. Ogawa, A. Sadamasu, S. Ohtori, T. Sasho. The effect of femoral bone tunnel configuration on tendon-bone healing in an anterior cruciate ligament reconstruction: An animal study. Bone Joint Res 2018;7:327–335. DOI: 10.1302/2046-3758.75.BJR-2017-0238.R2

Abstract. Methodology. Prospective single-surgeon case-series evaluating patients undergoing surgery by this technique. 76 cases (mean age of 33.2 years) who had primary ACL reconstruction with BTB or quadriceps tendon with bone block, were divided into 2 matched groups (age, sex and type of graft) of 38 each based on the method of femoral fixation used (interference screw or adjustable cortical suspension). Patients were followed up clinically and using PROMS from NLR with EQ-5D, KOOS, IKDC and Tegner scores. Complications and return to theatre were noted. Paired two-tailed student t-tests and Chi-square tests were employed for statistical analysis. Results. At a mean follow-up of 82 months, peri-operative mean EQ-5D VAS, EQ-5D Index, KOOS, IKDC and Tegner activity scores showed significant improvement (p<0.05), but no significant difference between the two groups (p>0.05). Mean graft length and diameter was 77mm and 9.3 respectively. Mean interval from injury to surgery was 10.5 months. 18(23.7%) patients had associated meniscal tear with 73.3 % undergoing repair. 10 cases (13.2 %) returned to theatre including, MUA for arthrofibrosis (n=2) and intra-substance graft failure (n=2). 3 cases had to be converted to interference screw fixation due to the tightrope cutting through from the femoral bone block as a result of a technical pitfall. Conclusion. Primary ACL reconstruction using adjustable cortical suspension on femoral side for BTB or quadriceps bone-block tendon graft is a safe technique with added advantages of 360 degree bone ingrowth and no screw in the femoral tunnel