Ligament reconstruction following multi-ligamentous knee injuries involves graft fixation in bone tunnels using interference screws (IS) or cortical suspensory systems. Risks of IS fixation include graft laceration, cortical fractures, prominent hardware, and inability to adjust tensioning once secured. Closed loop suspensory (CLS) fixation offers an alternative with fewer graft failures and improved graft-to-tunnel incorporation. However, graft tensioning cannot be modified to accommodate errors in tunnel length evaluation. Adjustable loop suspensory (ALS) devices (i.e., Smith & Nephew Ultrabutton) address these concerns and also offer the ability to sequentially tighten each graft, as needed. However, ALS devices may lead to increased graft displacement compared to CLS devices. Therefore, this study aims to report outcomes in a large clinical cohort of patients using both IS and CLS fixation. A retrospective review of radiographic, clinical, and patient-reported outcomes following ligament reconstruction from a Level 1 trauma centre was completed. Eligible patients were identified via electronic medical records using ICD-10 codes. Inclusion criteria were patients 18 years or older undergoing ACL, PCL, MCL, and/or LCL reconstruction between January 2018 and 2020 using IS and/or CLS fixation, with a minimum of six-month post-operative follow-up. Exclusion criteria were follow-up less than six months, incomplete radiographic imaging, and age less than 18 years. Knee dislocations (KD) were classified using the Schenck Classification. The primary outcome measure was implant removal rate. Secondary outcomes were revision surgery rate, deep infection rate, radiographic fixation failure rate, radiographic malposition, Lysholm and Tegner scores, clinical graft failure, and radiographic graft failure. Radiographic malposition was defined as implants over 5 mm off bone or intraosseous deployment of the suspensory fixation device. Clinical graft failure was defined as a grade II or greater Lachman, posterior drawer, varus opening at 20° of knee flexion, and/or valgus opening at 20° of knee flexion. Radiographic failure was defined when over 5 mm, 3.2 mm, and/or 2.7 mm of side-to-side difference occurred using PCL gravity stress views, valgus stress views, and/or varus stress views, respectively. Descriptive statistics were used. Sixty-three consecutive patients (mean age = 41 years, range = 19-58) were included. A total of 266 CLS fixation with Ultrabuttons and 135 IS were used. Mean follow-up duration was 383 days. Most injuries were KD type II and III. Graft revision surgery rate was 1.5%. Intraosseous deployment occurred in 6.2% and 17% had implants secured in soft tissue, rather than on bone. However, the implant removal rate was only 6.2%. Radiographic PCL gravity stress views demonstrated an average of 1.2 mm of side-to-side difference with 6.2% meeting criteria for radiographic failure. A single patient met radiographic failure criteria for collateral grafts. Mean Lysholm and Tegner scores were 87.3 and 4.4, respectively, with follow-up beyond one year. Both IS and CLS fixation demonstrate an extremely low revision surgery rate, a high rate of implant retention, excellent radiographic stability, and satisfactory patient-reported outcome scores. Incorrect implant deployment was seen in a total of 17% of patients, yet none required implant removal. A single patient required graft revision due to implant failure

Acromioclavicular joint is an integral component of Shoulder Complex and common site of injury particularly for athletes involved in sports such as Football, Cricket, Rugby and Shotput. Acromioclavicular Injuries are often neglected and goes untreated especially in low demand patients. Classic surgical techniques are associated with high complication rates. This is a prospective study from 2015–2017 wherein 32 patients with Acute grade 3, 4, 5, 6 Acromioclavicular joint dislocations, were operated with Minimally Invasive Double Tunnel Anatomical Coraco-clavicular Ligament Reconstruction (DT-ACCLR) with Tightrope Suspensory fixation. Clinical Outcomes were evaluated with Visual Analog Scale, Constant functional scale, Start of Movement, Return to Work, Satisfaction index and Coraco-clavicular distance over 12 months. Mean follow-up was 14 ± 3.8 months. Visual analog scale and Constant scores revealed significant advancements 0 ± 0.5 (range, 0–2) and 95 ± 3 (range, 92–98) scores at 12 months respectively. The coraco-clavicular distance significantly reduced from 23 ± 2.4 mm to 8 ± 0.5 mm. Mean return to work by 7 days. 98.6% patients were satisfied with surgical results. We conclude that DT-ACCLR is simple and creative surgical technique which provides stable, reliable and painless AC joint. The patients can move the shoulder same day and return to Work by 5–7days and Sports 3–4 weeks

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

Summary Statement

We evaluated the mechanical strength of two cortical suspension devices by reproducing clinical situation for ACL reconstruction. A most important factor affecting the displacement during cyclic load was the length of the tendon rather than the length of the device.

The optimal method of tibial fixation when using a hamstring tendon autograft in anterior cruciate ligament (ACL) reconstruction is unclear. This study aimed to compare the risk of revision ACL reconstruction between suspensory and interference devices on the tibial side.

Prospective data on primary ACL reconstructions recorded in the New Zealand ACL Registry between April 2014 and December 2019 were analyzed. Only patients with a hamstring tendon autograft fixed with a suspensory device on the femoral side were included. The rate of revision ACL reconstruction was compared between suspensory and interference devices on the tibial side. Univariate Chi-Square test and multivariate Cox regression was performed to compute hazard ratios (HR) and 95% confidence intervals (CI) with adjustment for age, gender, time-to-surgery, activity at the time of injury, number of graft strands and graft diameter.

6145 cases were analyzed, of which 59.6% were fixed with a suspensory device on the tibial side (n = 3662), 17.6% fixed with an interference screw with a sheath (n = 1079) and 22.8% fixed with an interference screw without a sheath (n = 1404). When compared to suspensory devices (revision rate = 3.4%), a higher risk of revision was observed when using an interference screw with a sheath (revision rate = 6.2%, adjusted HR = 2.05, 95% CI 1.20 – 3.52, p = 0.009) and without a sheath (revision rate = 4.6%, adjusted HR = 1.81, 95% CI 1.02 – 3.23, p = 0.044). The number of graft strands and a graft diameter of ≥8 mm did not influence the risk of revision.

When reconstructing the ACL with a hamstring tendon autograft, the use of an interference screw, with or without a sheath, on the tibial side has a higher risk of revision when compared to a suspensory device.

This prospective, randomized, controlled trial compares patient outcome after non-operative care versus open reduction and tunneled suspension device fixation (ORTSD) for grade III or IV acromioclavicular joint disruptions.

Sixty patients aged between sixteen and thirty-five years with an acute grade III or IV AC joint disruption were randomized to receive ORTSD fixation or non-operative treatment. Functional assessment was conducted at six weeks, three months, six months, and one year using the Disabilities of the Arm, Shoulder and Hands (DASH), Oxford Shoulder Scores (OSS) and Short Form (SF-12). Reduction was evaluated using radiographs. Complications were recorded, and an economic evaluation performed.

There was no significant difference in DASH or OSS at one year between non-operative and ORTSD groups (DASH score, 4.67 versus 5.63; OSS, 45.72 versus 45.63). Patients undergoing surgery had inferior DASH scores at 6 weeks (p<0.01). Five patients who failed non-operative management subsequently received surgery. Overall cost of treatment was significantly greater after ORTSD fixation (£796.22 vs £3359.73 (p<0.01)).

ORTSD fixation confers no functional benefit over non-operative treatment at one year. While patients managed non-operatively generally recover faster, a significant group remain dissatisfied following non-operative treatment requiring delayed surgical reconstruction.

Aims. To evaluate graft healing of decellularized porcine superflexor tendon (pSFT) xenograft in an ovine anterior cruciate ligament (ACL) reconstruction model using two femoral fixation devices. Also, to determine if pSFT allows functional recovery of gait as compared with the preoperative measurements. Methods. A total of 12 sheep underwent unilateral single-bundle ACL reconstruction using pSFT. Two femoral fixation devices were investigated: Group 1 (n = 6) used cortical suspensory fixation (Endobutton CL) and Group 2 (n = 6) used cross-pin fixation (Stratis ST). A soft screw was used for tibial fixation. Functional recovery was quantified using force plate analysis at weeks 5, 8, and 11. The sheep were euthanized after 12 weeks and comprehensive histological analysis characterized graft healing at the graft-bone interface and the intra-articular graft (ligamentization). Results. The pSFT remodelled into a ligament-like structure and no adverse inflammatory reaction was seen. The ground reaction force in the operated leg of the Endobutton group was higher at 11 weeks (p < 0.05). An indirect insertion was seen at the graft-bone interface characterized by Sharpey-like fibres. Qualitative differences in tendon remodelling were seen between the two groups, with greater crimp-like organization and more aligned collagen fibres seen with Endobutton fixation. One graft rupture occurred in the cross-pin group, which histologically showed low collagen organization. Conclusion. Decellularized pSFT xenograft remodels into a ligament-like structure after 12 weeks and regenerates an indirect-type insertion with Sharpey-like fibres. No adverse inflammatory reaction was observed. Cortical suspensory femoral fixation was associated with more enhanced graft remodelling and earlier functional recovery when compared with the stiffer cross-pin fixation

Poor availability of allografts in South Africa has led to an increased use of synthetic augmentation to stabilize knee joints in the treatment of knee dislocations. This study aims to evaluate multiligament knee injuries treated with a posterior cruciate ligament internal brace. The study included patients with knee dislocations who were treated with a PCL internal brace. The internal brace involved the insertion of a synthetic suture tape, which was drilled into the femoral and tibial footprint. Chronic injuries were excluded. Patient-reported outcome scores (PROMs), range of motion, stress X-Rays, and MRI scans were reviewed to assess outcomes. Acceptable outcomes were defined as a Lysholm score of 84 or more, with grade II laxity in no more than one ligament and a range of motion from full extension to 90° or more. The study included eight patients, with a median age of 42, of which five were female. None of the patients had knee flexion less than 90° or an extension deficit of more than 20°. PROMs indicated acceptable outcomes (EQ5D, Tegner Lysholm). Stress radiographs showed less than 7mm (Grade I) of posterior translation laxity in all patients. Four patients underwent MRI scans 1–2 years after the initial surgery, which revealed healing of the PCL in all patients. However, increased signal in a continuous ligament suggested only partial healing in two patients. Tunnel widening of 200% and 250% was noted around the tibial and femoral PCL footprints, respectively. All patients demonstrated stable knees and acceptable PROMs. Tunnel widening was observed in all patients who had MRI scans. Factors such as suspensory fixation, anisometric tunnel position, and the absence of PCL tear repair may have contributed to the tunnel widening

Introduction: After adopting a new low suspensory bio-absorbable femoral fixation technique for single bundle, four strand, hamstring Anterior Crutiate Ligament (ACL) in conjunction with a rapid rehabilitation program, we observed at routine follow up that there was no evidence of femoral tunnel widening, as often observed with conventional high suspensory fixation systems. Method: We conducted a retrospective observational cohort study to test the hypothesis that the Rigid-Fix (Mitek) system of femoral fixation, a low suspensory technique, is less prone to tunnel widening than traditional suspensory techniques. 14 subjects were recruited at routine follow up, and assessed by interview, clinical examination and plain digital raiodgraphs. All radiographs were taken under clinical supervision, with a scale reference, hence allowing digital rescaling. Results: All subjects had regained knee stability, and all but one had returned to their pre-injury level of sport. Clinically all knees were ligamentaly stable, exhibiting negative Luchman and pivot shift tests. Examination of the radiographs demonstrated only a 1.1mm (+/− 0.9mm) mean femoral tunnel widening, which represents a 12% increase in diameter (21% increase in area), and compares very favourably to the observed tunnel widening in high suspensory techniques, as cited in the literature. Conclusions: We conclude that the Rigid-Fix femoral ACL fixation system does not exhibit any evidence of clinically significant tunnel widening, even when used in conjunction with a rapid rehabilitation program. Systems of low suspension benefit from the advantage of not relying on interference fit which risks posterior cortical ‘Blow Out’. A shorter graft working length within the tunnel lessens graft micro-movement, making early low biological fixation within the femoral tunnel more likely, and reduces the amount of tunnel widening. These micro-movement have been described as the ‘Windscreen Wiper’ and ‘Bungee Cord’ effects, and are well documented in traditional high suspensory fixation

Introduction: The aim of this study was to compare two methods of femoral fixation for four strand Hamstring (4SH) primary ACL reconstruction: namely a recently introduced suspensory fixation using absorbable polylactic acid cross pins versus our traditional method of anchor fixation. Method: Forty-five consecutive patients, who had undergone primary ACL reconstruction using 4SH graft and the suspensory femoral fixation were prospectively evaluated by an independent observer. IKDC scores were recorded and laxity was assessed using cruciometer. These results were compared with a similar well-matched cohort of patients whose femoral fixation was with an anchor. Tibial fixation in both the groups was similar. Results: No significant difference was noted between the two groups on comparison of IKDC scores or cruciometer readings at a minimum one-year follow-up. Conclusions: This suspensory method of femoral fixation for a four-strand hamstring graft provided a secure fixation with satisfactory early clinical results. As this method of fixation is a new technique, further follow-up is needed for long-term validation

The purpose of this study was to describe our experience of the Calaxo Osteoconductive interference screw (Smith & Nephew) when used for both femoral and tibial graft fixation in Double Bundle ACL reconstruction. Since May 2006, all patients with an ACL deficient knee were reconstructed using the Double Bundle technique. All were followed prospectively and outcome data collected. Evidence of fixation failure was established subjectively by clinical examination (Lachman, Anterior Draw, Pivot Shift) and objectively via KT-1000 arthrometer. Following ethical approval, post-operative CT scans (immediate and 1 year) were performed on our first 10 patients allowing assessment of tunnel dimensions/fill. Thirty two patients (29 male, 3 female) with a mean age of 30 (range 18-46) were included. At last follow-up, no evidence of graft/fixation failure was found; KT-1000 mean side-side difference 1.4mm (range −3 to +6). All patients had a positive pivot shift preoperatively which was abolished postoperatively. One patient had a postoperative infection with no other complications reported. Radiologically the screws did not show complete resorption but areas of new bone were identified. We have shown satisfactory results with use of the Calaxo screw when used in Double Bundle Reconstruction. We have not had any cases of the adverse local soft tissue reaction, which has led to this screw being withdrawn from clinical use. Even when using a total of four screws in each knee. A previous study published by Seibold (2007) has shown tunnel widening and communication when suspensory fixation is used in Double Bundle reconstruction. This has the potential risk of leading to fracture between the tunnels. This has not been seen with the Calaxo screw which may be a result of the biological action of the screw which should ultimately lead to a reduction in these risks

Introduction: The purpose of this study was to describe our experience of the Calaxo Osteoconductive interference screw (Smith & Nephew) when used for both femoral and tibial graft fixation in Double Bundle ACL reconstruction. Methods: Since May 2006, all patients with an ACL deficient knee were reconstructed using the Double Bundle technique. All were followed prospectively and outcome data collected. Evidence of fixation failure was established subjectively by clinical examination (Lachman, Anterior Draw, Pivot Shift) and objectively via KT-1000 arthrometer. Following ethical approval, post-operative CT scans (immediate and 1 year) were performed on our first 10 patients allowing assessment of tunnel dimensions/fill. Results: Thirty two patients (29 male, 3 female) with a mean age of 30 (range 18–46) were included. At last follow-up, no evidence of graft/fixation failure was found; KT-1000 mean side-side difference 1.4mm (range −3 to +6). All patients had a positive pivot shift preoperatively which was abolished postoperatively. One patient had a postoperative infection with no other complications reported. Radiologically the screws did not show complete resorption but areas of new bone were identified. Discussion: We have shown satisfactory results with use of the Calaxo screw when used in Double Bundle Reconstruction. We have not had any cases of the adverse local soft tissue reaction, which has led to this screw being withdrawn from clinical use. Even when using a total of four screws in each knee. A previous study published by Seibold (2007) has shown tunnel widening and communication when suspensory fixation is used in Double Bundle reconstruction. This has the potential risk of leading to fracture between the tunnels. This has not been seen with the Calaxo screw which may be a result of the biological action of the screw which should ultimately lead to a reduction in these risks

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

Aims

MRI has been suggested as an objective method of assessing anterior crucate ligament (ACL) graft “ligamentization” after reconstruction. It has been proposed that the MRI appearances could be used as an indicator of graft maturity and used as part of a return-to-sport assessment. The aim of this study was to evaluate the correlation between MRI graft signal and postoperative functional scores, anterior knee laxity, and patient age at operation.

The August 2012 Knee Roundup³⁶⁰ looks at: meniscal defects and a polyurethane scaffold; which is best between a single or double bundle; OA of the knee; how to resolve anterior knee pain; whether yoga can be bad for your menisci; metal ions in the serum; whether ACI is any good; the ACL; whether hyaluronic acid delays collagen degradation; and hyaluronan and patellar tendinopathy.