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Purpose: Persistent deficits in knee flexor strength following harvest of semitendinosus and gracilis for anterior cruciate ligament reconstruction are inconsistent in the literature. Variation in methodology, including measuring torque at higher knee flexion angles may partially explain these discrepant findings. The objective of this study was to determine whether positioning (seated vs supine), consideration of peak or joint-angle-specific torque or device (Isokinetic Dynamometer vs NordBord Hamstring Dynamometer) impact the magnitude of knee flexor strength differences between limbs., Methods: Participants (n = 31, 44.2 ± 10.7 years,) who were at 14 ± 4.4 years follow-up for unilateral ACL reconstruction with semitendinosus/gracilis grafts completed the ACL Quality of Life outcome and an assessment including isokinetic concentric knee extensor and flexor strength in seated and supine with peak torque and torque at 60° (T60) and 75° (T75) knee flexion measured, followed by an eccentric Nordic Hamstring Curl., Results: Isokinetic concentric knee flexor torque was reduced in supine relative to seated, on the reconstructed limb against the unaffected, and at higher degrees of knee flexion relative to peak torque (T60 and T75 against peak torque). Limb symmetry varied by methodology (F (6,204)  = 8.506, p = 0.001) with reduced symmetry in supine T75 against all measures (71.1 ± 16.5%, p < 0.05), supine T60 against seated peak torque (82.7 ± 14.2%, p < 0.05), and the NordBord was lower than seated peak torque that was not statistically significant (83.9 ± 12.8%, n.s.). Knee extensor peak (r 2  = 0.167 (F (1,27)  = 5.3, p = 0.03) and Nordic curl eccentric torque (r 2  = 0.267, F (2,26)  = 4.736, p = 0.02) were predictors of ACL-QoL score, although a combined model did not improve over Nordic torque alone., Conclusion: Limb symmetry cannot be assumed in clinical practice across differing assessment methods for knee flexor strength as deficits are greatest in the supine position with torque measured at 75° knee flexion. Isokinetic knee extensor and eccentric knee flexor torque during the Nordic hamstring curl were predictors of ACL-QoL scoring and should be considered alongside patient-reported outcomes for patients following ACL reconstruction with hamstring grafts., Level of Evidence: Level IV., (© 2021. European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Purpose: Contralateral graft harvest in primary ACL reconstruction is relatively uncommon and the long-term comparative of this approach relative to ipsilateral harvest has not been described. The purpose of this study was to evaluate ACL graft and contralateral rupture following ipsilateral or contralateral semitendinosus and gracilis (STG) graft harvest at follow-up of a minimum 10 years post-reconstruction in the treatment of a complete ACL tear., Methods: Patients from a previous randomized trial were evaluated. The primary outcome measures were ipsilateral and contralateral reinjury as well as the International Knee Documentation Committee (IKDC) knee assessment form, the ACL Quality of Life questionnaire (ACL-QoL) and the Tegner activity scale. Participants completed four different single-leg hop tests and concentric knee flexion and extension strength were assessed on an isokinetic dynamometer., Results: Of the original 100 patients, 50 patients (41.3 ± 9.5 years of age, 31 males, 19 females) reported on re-injury at 12.6 ± 1.4 years post-operative. Thirty-eight patients returned for full assessment and 12 responded by mail or phone survey. There were no differences between groups for graft rupture, contralateral injury, ACL-QoL score, IKDC categorization, or anterior tibial translation, though both groups experienced a reduction in the Tegner Activity Scale from their preinjury scores. There was no difference in knee flexor and extensor isokinetic concentric strength, or single leg hop test performance. Knee flexor strength limb symmetry index was reduced when measured in the supine relative to the seated position in both groups, indicating persistent deficits in knee flexor strength when measured in the supine position., Conclusion: Contralateral hamstring harvest does not put patients at an increased risk of a contralateral ACL tear and long-term outcomes of ACL reconstruction do not differ based on the side of graft harvest. Contralateral STG harvest may provide a safe alternative surgical option for select patients., Level of Evidence: Level II., (© 2022. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Purpose: The anteromedial (AMP) portal technique was introduced to position the femoral tunnel in anterior cruciate ligament (ACL) reconstruction to more closely replicate the original ACL footprint compared to the transtibial (TT) approach. Few randomized trials have evaluated differences in these techniques with respect to clinical outcomes. The purpose of this study was to determine if there are any differences in clinical outcome between the AMP and TT approaches., Methods: This is a single-blinded, prospective, randomized controlled trial. Participants were randomized to undergo ACL reconstruction using the AMP or TT approach. The primary outcome measure was the ACL quality of life (ACL-QOL), and secondary outcomes were the IKDC knee assessment, side-to-side difference in anterior-posterior knee laxity (KT-1000) and tunnel orientation (X-ray findings) at preoperative, 3, 6, 12, and 24 months postoperative. Statistical comparisons were performed using a series of t tests for independent groups with equal variance., Results: Ninety-six participants were consented and randomized between 2007 and 2011 with eight excluded postrandomization. Mean (SD) preoperative ACL-QOL was 33 (13) for TT and 36 (17) for AMP and improved significantly (p < 0.001) in both groups to 79 (18) and 78 (18) at 24 months postoperative, respectively. The preoperative median IKDC grade for both groups was C and improved similarly in both groups at 24 months (n.s.). There was no side-to-side difference in knee laxity based on KT-1000 measurements with a mean (SD) 1 (3) mm between affected and unaffected limbs in the TT group compared to 1 (3) mm for the AMP group. A significant difference was found in femoral tunnel orientation with the AMP group at 43° (7) and the TT group 58° (8) in the coronal plane (p < 0.001)., Conclusion: No differences in clinical outcome were found when comparing AMP to TT in primary ACL reconstruction using a STG graft. This prospective randomized controlled trial suggests surgeons can use either method without significantly compromising clinical outcome., Level of Evidence: I.

Purpose: Large variation in tendon size between individuals makes hamstring graft diameter for anterior cruciate ligament (ACL) reconstruction unpredictable. Inadequate graft diameter may necessitate an alternative source of tissue requiring pre-operative planning. The purpose of this study was to determine whether magnetic resonance image (MRI) measurements and clinical anthropometric data are predictive of hamstring tendon graft diameter., Methods: Data from 109 patients having ACL reconstruction with semitendinosus-gracilis (STGT) autograft were retrospectively evaluated. Cross-sectional area (CSA) of the gracilis tendon (GT) and semitendinosus tendon (ST) were determined from pre-operative MRI scans. Variables included pre-operative height, weight, body mass index (BMI), age and gender; and intra-operative graft diameter., Results: Correlations between anthropometric variables, hamstring tendons CSA and intra-operative graft diameter were calculated. Multiple stepwise regression was performed to assess the predictive value of these variables to graft diameter. Sensitivity and specificity were calculated to evaluate the utility of MRI CSA measurements in accurately identifying inadequate graft diameter (<8 mm). All anthropometric variables were positively correlated with intraoperative graft diameter (p < 0.01). Semitendinosus-gracilis tendon CSA (p < 0.001) and STGT CSA and weight (p < 0.001) were significantly predictive models of graft diameter. Sensitivity and specificity were 79 and 74 %, respectively., Conclusion: The strongest indicators of a four-stranded STGT graft for primary ACL reconstruction were STGT CSA on MRI plus weight. Measurement of graft diameter can be performed pre-operatively via MRI to identify tendons that may be of inadequate size for ACL reconstruction. This can assist with surgical planning to determine the most appropriate graft choice., Level of Evidence: III.

Purpose: Electrothermal arthroscopic capsulorrhaphy (ETAC) was introduced as an adjunct to shoulder stabilization surgery to address capsular laxity in the treatment of traumatic anterior dislocation. No previous RCT has compared arthroscopic Bankart repair with ETAC of the medial glenohumeral ligament and anterior band of the inferior glenohumeral ligament versus undergoing arthroscopic Bankart repair alone. Our hypothesis was that there would be no difference in quality of life between these two groups. Complication/failure rates were also compared., Methods: Eighty-eight patients were randomly assigned to receive arthroscopic Bankart repair with (n = 44) or without ETAC (n = 44). Post-operative visits occurred at 3, 6, 12, and 24 months with WOSI, ASES, and Constant scores completed, and rates of dislocation/subluxation were determined., Results: Data on 74 patients were analysed, with the rest lost to follow-up. There were no differences between groups at any post-surgery time points for WOSI, ASES, or Constant scores (n.s.). Eight patients in the no-ETAC group and 7 in the ETAC group were considered failures (n.s.)., Conclusions: No benefits in patient-reported outcome or recurrence rates using ETAC were found. Mean WOSI scores 2 years post-surgery were virtually identical for the two groups. ETAC could not be shown to provide benefit or detriment when combined with arthroscopic labral repair for traumatic anterior instability of the shoulder., Level of Evidence: II.

Purpose: To investigate the differences in the incidence and severity of knee osteoarthritis (OA), joint space narrowing, knee laxity, and knee flexion and extension strength between an anterior cruciate ligament (ACL)-reconstructed knee and the contralateral non-reconstructed limb., Methods: Retrospective case series of patients from a single surgeon that had an ACL reconstruction with a semitendinosus/gracilis autograft more than 12 years ago. Outcome measures included radiographic analysis, International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), KT-1000, Tegner Activity Level Scale, Lysholm Knee Score, ACL quality of life score (ACL-QOL) and knee flexor/extensor strength., Results: Seventy-four patients consented and sixty-eight (43 male, 25 female) were included for analysis. Average age (SD) at the time of surgery was 31.2 (±9.1) years. At follow-up of 14.6 (1.9) years, 9% had re-ruptured their ACL, whereas 5% ruptured the contralateral ACL. Reconstructed knees had a greater incidence and severity of OA (P < 0.01). Medial meniscus surgery was a strong predictor of OA. Seventy-five per cent scored a normal or nearly normal knee on the IKDC. The mean Lysholm score was 75.8% and Tegner Activity Level Scale scores decreased (P < 0.001) from the time of surgery. Knee extension strength was greater in the contralateral knee at speeds of 60°/s (P = 0.014) and 150°/s (P = 0.012)., Conclusions: Reconstructed knees have a greater incidence and severity of OA than non-reconstructed knees, which suggests degenerative changes are secondary to ACL rupture. Medial meniscus surgery is a strong predictor of OA. Despite this, 75% of patients reported good outcomes.

Purpose: To compare the reliability of tibial tunnel position and angle produced with a standard ACL guide (two-dimensional guide) or Howell 65° Guide (three-dimensional guide) in the coronal and sagittal planes. In the sagittal plane, the dependent variables were the angle of the tibial tunnel relative to the tibial plateau and the position of the tibial tunnel with respect to the most posterior aspect of the tibia. In the coronal plane, the dependent variables were the angle of the tunnel with respect to the medial joint line of the tibia and the medial and lateral placement of the tibial tunnel relative to the most medial aspect of the tibia., Methods: The position and angle of the tibial tunnel in the coronal and sagittal planes were determined from anteroposterior and lateral radiographs, respectively, taken 2-6 months postoperatively. The two-dimensional and three-dimensional guide groups included 28 and 24 sets of radiographs, respectively. Tibial tunnel position was identified, and tunnel angle measurements were completed. Multiple investigators measured the position and angle of the tunnel 3 times, at least 7 days apart., Results: The angle of the tibial tunnel in the coronal plane using a two-dimensional guide (61.3 ± 4.8°) was more horizontal (P < 0.05) than tunnels drilled with a three-dimensional guide (64.7 ± 6.2°). The position of the tibial tunnel in the sagittal plane was more anterior (P < 0.05) in the two-dimensional (41.6 ± 2.5%) guide group compared to the three-dimensional guide group (43.3 ± 2.9%)., Conclusion: The Howell Tibial Guide allows for reliable placement of the tibial tunnel in the coronal plane at an angle of 65°. Tibial tunnels were within the anatomical footprint of the ACL with either technique. Future studies should investigate the effects of tibial tunnel angle on knee function and patient quality of life., Level of Evidence: Case-control retrospective comparative study, Level III.