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Remnant always exists following injuries of the posterior cruciate ligament (PCL). To improve the clinical outcomes of PCL reconstruction, preservation of the remnant has long been a consideration. However, how to make the remnant-preservation technique simple and more effective is of concern. We describe a single-bundle anatomical PCL reconstruction technique with remnant preservation in which the posteromedial and posterolateral portals are used, the graft is placed at the lateral side of the remnant, and pulleys are used to facilitate graft passage at the 2 killer turns of the grafting routes. We consider introduction of this technique will provide reasonable choices in PCL reconstruction., Technique Video Video 1 Single-bundle posterior cruciate ligament reconstruction with remnant preservation. This procedure is performed in the right knee. The arthroscope is placed into the posteromedial (PM) compartment through the anterolateral (AL) portal. The PM portal is created. The arthroscope is placed into the PM compartment through the PM portal, across the posterior septum to the posterolateral (PL) compartment. The PL portal is created. A shaver is placed into the PL compartment through the PL portal and into the posterior septum. Part of the posterior septum is removed to expose the PCL remnant and its tibial insertion. The arthroscope is placed in through the anterolateral (AL) portal. A tibial tunnel locator is placed from the anteromedial (AM) portal, through the lateral side of the PCL remnant, to the posterior compartments. The arthroscope is placed into the PM compartment. The tibial tunnel locator is placed along the PCL tibial insertion down to against the posterior capsule. attachment, just lateral to the midline of the PCL insertion. A K-wire is drilled in. The arthroscope is placed in through the AM portal. The femoral tunnel is created sequentially with a K-wire and a drill to expected size and depth. The arthroscope is placed into the posterior compartments through the PM portal. The switching stick is placed in through the PL portal to lever the posterior capsule posteriorly. The K-wire is over drilled to create the tibial tunnel to expected size. The arthroscope is placed in through the AM portal. A guide suture is placed in through the AL portal, passed through the lateral side of the PCL remnant to the posterior compartments. The arthroscope is placed in through the PM portal. The guide suture is retrieved through the tibial tunnel. A 2-cm long medial incision is made over the medial femoral epicondyle. The arthroscope is placed in through the AM portal. A guide pin tailed with a suture loop is placed in through the AL portal and passed through the femoral tunnel. The guide suture is passed through the femoral tunnel with the suture loop tailing the guide pin and out of the medial incision. The arthroscope is placed in through the PM portal. A switching stick is placed in through the PL portal to the anterior inferior side of the guide suture and used as a pulley and a lever. With the guide suture, the fixing sutures at the proximal end of the graft is pulled in through the tibial tunnel and out through the femoral tunnel. With constant pulling of the fixing sutures, the graft is pried into the joint through the tibial tunnel with repeated maneuver of the switching stick. The arthroscope is placed in through the AL portal. An obturator is placed at the turning point of the fixing sutures at the inner orifice of the femoral tunnel as a pulley. The graft is pulled into the femoral tunnel. The proximal fixing sutures are tied on a cortical fixation button over the outer orifice of the femoral tunnel. With constant pulling of the distal end of the graft, the knee is flexed several times to pull back and tension the graft. At full extension of the knee, an interference screw is placed into the tibial tunnel for primary fixation. A transtibial ridge tunnel is created. A set of cortical suspensory fixation device with an adjustable loop is pulled through this tunnel from the medial to the lateral side. The sutures from the distal end of the graft are fixed at the adjustable loop.

The clinical results of posterior cruciate ligament reconstruction (PCL) still leave much room for improvement. To get better knee stability, the double-bundle reconstruction, the use of strong grafts, and the preservation of the remnant have been applied. However, the combination of the 3 measures has seldom been reported. Thus I introduce a 4-tunnel double-bundle PCL reconstruction technique, in which I combine the use of strong grafts and preservation of the remnant. The critical point of this technique is manipulating skillfully across the femoral notch with the preservation, as well as the hindrance to operation of the PCL remnant. My clinical experience indicates this technique is somewhat complicated but most effective. I believe the introduction of this technique will provide an additional choice when PCL reconstruction is to be performed., Technique Video Video 1 Four-tunnel double-bundle posterior cruciate ligament (PCL) reconstruction with remnant preservation. This procedure is performed in the right knee. The semitendinosus tendon (ST), the gracilis tendon (GT) and the anterior half of the peroneus longus tendon (AHPLT) are harvested to make two grafts. The anterolateral (AL) and anteromedial (AM) portals are fashioned, and combined lesions are treated. The posteromedial and the posterolateral (PL) portals are created. The posterior septum at the tibial insertion site of the PCL is removed to expose the PCL. A PCL tibial tunnel locator is placed through the AM portal and the lateral side of the PCL remnant to the posterior compartments. The PCL tibial tunnel locator is set at the AL part of the PCL tibial insertion site. A K wire is drilled in. The PCL tibial tunnel locator is placed through the AM portal and the medial side of the PCL remnant to the posterior compartments. The tibial tunnel locator is set at the PM part of the PCL tibial insertion site. Another K wire is drilled in. A switching stick is placed through the PL portal to push the posterior capsule backwards to increase the buffer space for the drilling. The tibial tunnels are created with corresponding cannulated drills over the K wires. One guide suture loop is placed through the AL portal and the lateral side of the PCL remnant to the posterior compartments and pulled through the AL-bundle tibial tunnel. Another guide suture loop is placed through the AL portal and the medial side of the PCL remnant to the posterior compartments and pulled through the PM-bundle tibial tunnel. An incision is made over the medial femoral epicondyle. The proximal end of the guide suture loop for the AL bundle is passed through the AL-bundle femoral tunnel. The proximal end of the guide suture loop for the PM bundle is passed through the PM-bundle femoral tunnel. A switching stick is placed through the PL portal to the anterior inferior side of the guide suture loop for the PM bundle. The fixing sutures from the proximal end of the PM-bundle graft are pulled through the tibial and the femoral tunnels. The PM-bundle graft is levered into the posterior compartments and pulled to the femoral tunnel. An obturator is placed at the inferior posterior side of the proximal fixing sutures at the inner orifice of the PM-bundle femoral tunnel. The PM-bundle graft is pulled into the femoral tunnel. The proximal fixing sutures from the PM-bundle graft are fixed onto a cortical fixation button. A switching stick is placed through the PL portal to the anterior inferior side of the guide suture loop for the AL bundle. The fixing sutures on the proximal end of the AL-bundle graft are pulled through the tibial and the femoral tunnels. The AL-bundle graft is levered into the posterior compartments and pulled to the femoral tunnel. An obturator is placed at the inferior posterior side of the proximal fixing sutures at the inner orifice of the AL-bundle femoral tunnel. The AL-bundle graft is pulled into the femoral tunnel. The proximal fixing sutures from the AL-bundle graft are fixed onto a cortical fixation button. Interference screws are placed into the tibial tunnels to the inner orifices for primary fixation at knee extension. A transtibial ridge tunnel is created at a plane distal to the outer orifices of the tibial tunnels. A cortical suspensory fixation device with an adjustable loop is set through this transtibial ridge tunnel. The sutures from the distal ends of the graft are fixed at the adjustable loop.

Double-bundle posterior cruciate ligament (PCL) reconstruction has long been attempted to obtain better clinical results than single-bundle PCL reconstruction. In most previous reports regarding double-bundle PCL reconstruction, one tibial tunnel and various kinds of grafts were used. We introduce a two-tibial tunnel, double-bundle PCL reconstruction technique with ultra-strong grafts. The critical points of this technique are proper creation of the tibial tunnels and the protection of the posterior neurovascular structures. Our clinical experience indicates this technique can lead to satisfactory stable outcomes. We believe that this technique will provide a reasonable choice for PCL reconstruction without remnant preservation., Technique Video Video 1 Four-tunnel, double-bundle anatomical posterior cruciate ligament reconstruction without remnant preservation is performed in the following steps: 1. This procedure is performed in the left knee. The arthroscope is inserted through the anterolateral (AL) portal to the posteromedial (PM) compartment, and the PM portal is created. 2. The arthroscope is inserted into the PM compartment through the PM portal and then passed through the posterior septum to the posterolateral (PL) compartment. The PL portal is created. A shaver is inserted into the posterior septum through the PL portal. Part of the posterior septum is removed to connect the posterior compartments. The PCL remnant at the tibial insertion is removed to leave a 2-3-mm stump. 3. The arthroscope is inserted through the AL portal, and a PCL tibial tunnel locator is inserted through the anteromedial (AM) portal to the posterior compartments. The arthroscope is inserted into the PM compartment through the PM portal. The PCL tibial tunnel locator is set at the AL part of the PCL tibial attachment site. A K wire is drilled in from the medial edge of the tibial tubercle. The tibial tunnel locator is set at the PM part of the PCL tibial insertion site. Another K wire is drilled in paralleling the former K wire. 4. The arthroscope is inserted through the AL portal; the locations of the femoral tunnels are marked with a radiofrequency probe. The arthroscope is inserted through the AM portal, and the femoral tunnels are created. 5. The arthroscope is inserted through the PM portal. A switching stick is inserted through the PL portal to elevate the posterior capsule from the PCL tibial insertion to increase the buffer space for the drilling. The tibial tunnels are created with corresponding cannulated drills over the K wires. One guide suture loop is passed through each tibial tunnel into the posterior compartments and pulled to the anterior compartment. 6. An incision is made over the medial femoral epicondyle. The arthroscope is inserted through the AM portal, the proximal ends of the guide suture loops are passed through the corresponding femoral tunnels, with a suture loop tailing a guide pin, out of the medial incision. 7. With the guide suture loop, the fixing sutures on the proximal end of the PM-bundle graft are pulled through the tibial tunnel into the joint and through the femoral tunnel out. A switching stick is inserted through the PM portal to the anterior inferior side of the fixing sutures at the inner orifice of the tibial tunnel. With constant pulling of the fixing sutures, the graft is moved into the posterior compartments and pulled to the femoral tunnel with repeated maneuvers. 8. The arthroscope is inserted through the AL portal. The PM-bundle graft is pulled into the femoral tunnel. The proximal fixing sutures are attached to a cortical fixation button. 9. The arthroscope is inserted through the PM portal. A switching stick is inserted through the PL portal to the anterior inferior side of the guide suture loop for the AL-bundle graft at the inner orifice of the tibial tunnel. With the guide suture loop, the fixing sutures on the proximal end of the AL-bundle graft are pulled through the tibial tunnel into the joint and through the femoral tunnel out. 10. The AL-bundle graft is pulled through the tibial tunnel into the femoral tunnel and affixed to a cortical fixation button.

Purpose The aim of this study was to determine the anatomic, operative and biological factors that influenced graft healing after single-bundle anterior cruciate ligament (ACL) reconstruction. Methods One hundred fourteen consecutive patients who underwent anatomic single-bundle ACL reconstruction with quadrupled hamstring tendon autografts between 2016 and 2019 were retrospectively analyzed. Ninety-four patients met the inclusion criteria with minimum follow-up of 12 months. Patients were evaluated with multiple clinical measurements, including International Knee Documentation Committee Subjective Knee Form (IKDC-SKF), Lyshom Scores, and Marx activity scale. To evaluate graft healing, the signal-to-noise quotient (SNQ) was measured at intra-articular graft and intra-tunnel integration were evaluated on magnetic resonance imaging (MRI) at one year after surgery. Potential factors affecting graft healing, including age, sex, body mass index, time from injury to surgery, posterior tibial slope, lateral femoral condyle ratio, notch width index, meniscal injury, remnant preservation, tunnel aperture locations, graft size, graft bending angle, graft/remaining notch volume ratio were evaluated for their association with graft SNQ value by stepwise regression analysis. Results A total of 94 patients were evaluated with mean follow-up 28.5 +/- 9 months. Univariate regression analysis showed that posterior tibial slope, notch width index, remnant preserving procedure, high femoral tunnel, anterior tibial tunnel, graft bending angle, and graft/remaining notch volume ratio significantly associated with graft SNQ values. Multivariate regression analysis showed that lateral tibial slope, remnant preservation, and graft/remaining notch volume ratio were independent factors correlated with graft SNQ values. Also, the graft SNQ values was weakly correlated with femoral tunnel integration and Marx activity scale at one year. There was no correlation between graft SNQ values and IKDC-SKF and Lysholm scores. There was no correlation between graft SNQ values and International Knee Documentation Committee and Lysholm scores. Conclusions Tibial slope, remnant preservation and graft/remaining notch volume ratio were significant independent associated factors of graft SNQ value at one year. The graft SNQ values were also weakly correlated with femoral tunnel integration and the Marx activity scale. These factors should be taken into account for ensuring the ideal graft healing and for the return to sport decision-making.

Purpose The aim of this study was to verify the effects of a new remnant augmentation technique with anatomical double-bundle anterior cruciate ligament (ACL) reconstruction for postoperative clinical scores, anterior stability and frequency of complications compared to remnant removal and cases with remnant defects. Methods The 105 patients who underwent anatomical double-bundle ACL reconstruction were divided into three groups. If the remnant was a Crain I-III type, remnant-preserving bone tunnel creation was attempted. After the creation of the bone tunnel, good continuity was maintained in 34 patients (preserved group). Due to lost continuity, the remnant was resected in 26 patients (resected group). No identifiable remnant continuity remained (Crain IV) in 45 patients (absent group). The Lysholm knee score, Tegner activity scale, International Knee Documentation Committee (IKDC) subjective score, anterior stability measured using the KT-1000 arthrometer at 2 years postoperatively, and frequency of complications were compared among the three groups. Univariate and multiple linear regression analysis were performed to clarify the factors affecting postoperative anterior stability. Results The Lysholm knee score, Tegner activity scale, IKDC subjective score, and frequency of complications were not significantly different among the groups. The mean side-to-side difference of anterior stability was significantly better in the preserved group (0.3 ± 1.6 mm) compared to the resected group (1.6 ± 2.3 mm, p = 0.003) and absent group (1.6 mm ± 1.7, p = 0.009). The multiple linear regression analysis showed remnant preservation significantly related to postoperative anterior stability. Conclusion Although there were no differences in clinical scores, the ACL reconstruction with new preservation technique showed good anterior stability and no difference in the frequency of complications.

Various degree of remnant tissues exists following anterior cruciate ligament (ACL) injury. Making use of these tissues may be helpful for the reconstructed ACL from many aspects. There are many methods of remnant preservation and use, as well as many types of combined ACL reconstruction. However, the most effective methods of remnant reuse as well as ACL reconstruction are still being pursued. We introduce an anatomical double-bundle transtibial ACL reconstruction with in-between remnant preservation technique named sandwich-style ACL reconstruction. The indication of this technique is complete ACL tear with a large volume of connectable remnant. The main tricks of this technique are proper ligation of the remnant, proper location of the anteromedial-bundle tibial tunnels, and passing the anteromedial bundle through the shallow side of the remnant. We believe the introduction of this technique will provide more options for remnant preservation and ACL reconstruction., Technique Video Video 1 Sandwich-style ACL reconstruction. This procedure is performed in the right knee. The semitendinosus tendon and the gracilis tendon are harvested. A 4-stranded graft is made from each tendon. The ACL remnant is ligated with 2 polydioxanone sutures. Femoral notch plasty is performed. The femoral tunnels are located and marked with a radiofrequency probe. The tibial tunnels are located and marked with a radiofrequency probe. The projection of the AM-bundle tibial tunnel is defined. The AM-bundle tibial tunnel is created. The projection of the PL-bundle tibial tunnel is defined. The PL-bundle tibial tunnel is created. A K wire is drilled to the marked point of the PL-bundle femoral tunnel through the PL-bundle tibial tunnel. The PL-bundle femoral tunnel is created. A K wire is drilled to the marked point of the AM-bundle femoral tunnel through the AM-bundle tibial tunnel. The AM-bundle femoral tunnel is created. An incision is made on the lateral midline of the thigh to reach the anterolateral femur through the underside of the quadriceps. The ligating sutures and the remnant are pulled into the AM-bundle femoral tunnel. The fixation sutures on the PL-bundle graft are pulled into the PL-bundle femoral tunnel through the PL-bundle tibial tunnel. The fixation sutures on the AM-bundle graft are pulled into the AM-bundle femoral tunnel through the AM-bundle tibial tunnel and the superior side of the remnant. The AM- and the PL-bundle grafts are placed in sequentially. Proximal suspension fixation is completed by tying the sutures on a mini plate over each orifice. The sutures from the distal graft ends are tied at an adjustable loop which is set through a transtibial ridge tunnel. (ACL, anterior cruciate ligament; AM, anteromedial; PL, posterolateral.)

Dois casos clínicos são apresentados para explorar as diferenças técnicas e discutir as vantagens e desvantagens do uso de zircônia folheada ou monolítica para confeccionar coroas únicas posteriores. O primeiro caso descreve as etapas clínicas na fabricação de uma coroa monolítica em um segundo pré-molar inferior esquerdo usando zircônia de alta translucidez. Mostra a utilização de um preparo dentário conservador baseado nas propriedades mecânicas superiores que este material apresenta, bem como nas características ópticas finais alcançadas pelo sombreamento e coloração. No segundo caso, foi realizado um tratamento restaurador convencional em bicamada com estrutura de zircônia seguida de estratificação com cerâmica de feldspato no primeiro molar inferior esquerdo. A literatura recente indica que cada uma dessas alternativas restauradoras apresenta vantagens e desvantagens específicas. Fatores como desempenho mecânico, fratura, características estéticas, sucesso clínico, taxas de complicações, desempenho de adesão e desgaste do antagonista são discutidos comparando os dois conjuntos restauradores. Os dados destacam que as coroas monolíticas evitam um grande problema relatado nas restaurações de duas camadas: o lascamento da cerâmica de recobrimento. As coroas monolíticas também permitem preparações dentárias minimamente invasivas, aumentando assim a preservação do remanescente dentário. No entanto, faltam dados que sustentem a similaridade do desempenho estético entre as montagens monolítica e bicamada, sendo a previsibilidade de uso restrita para a região posterior, pois casos que demandam alto apelo estético continuam a utilizar fundamentalmente as restaurações bicamada. Não foram encontradas falhas, e a satisfação do paciente foi relatada em ambas as técnicas após o acompanhamento de 12 meses.

Anatomic tunnel formation and remnant preservation are the recent trends in posterior cruciate ligament (PCL) reconstruction. However, it is difficult to observe the anatomical PCL footprint and perform the operation in the process of remnant‐preserving PCL reconstruction. This study describes a single‐bundle, transtibial PCL reconstruction technique with anatomic graft passage over the remnant PCL fibers. A femoral tunnel of PCL is created at 2 mm medial to the roof of the intercondylar notch and 3 mm proximal to the margin of the articular cartilage. The tibial insertion of PCL is observed using a figure‐of‐four position through a posterior trans‐septal portal. A tibial bone tunnel is made below the distal center portion of the tibial insertion of residual PCL fibers. The graft is passed over the PCL through the tibial bone tunnel, the space between the anterior cruciate ligament (ACL) and the residual PCL fibers, to the femoral socket and is fixed by the EndoButton and screw. This technique is able to ensure a reasonable intra‐articular length and optimal isometry. It has been applied in patients with PCL rupture and posterior instability of the knee joint, and no intraoperative or postoperative complications occurred. Our technology provides a valuable new treatment option for PCL rupture. Future comparative studies are needed to further clarify its beneficial effect.

Remnant preservation, in anterior cruciate ligament (ACL) reconstruction, has potential biological advantages. However, graft positioning remains vital to functional outcome and the prevention of failure. The aim of this study was to investigate the accuracy and precision of tibial tunnel positioning in remnant preservation single-bundle hamstring reconstruction. Fifty consecutive adult patients, with isolated ACL rupture, were recruited to a prospective study. Remnant preservation was performed in all cases where > 25% of the native ACL was present. Three-dimensional computer tomography was preformed 3–6 months post-operatively to assess tibial tunnel position (using a grid-based measurement). Accuracy and precision of this technique were assessed against published anatomical data in direct comparison with the group where remnant preservation could not be performed. Two patients withdrew following surgery. In the remaining groups (31 remnant preservation; 17 non-remnant preservation), no difference was demonstrated in tunnel position (40.4 ± 6.7% (anterior-to-posterior) and 47.4 ± 1.5% (medial-to-lateral) vs. 38.8 ± 4.9% and 46.7 ± 1.5%, respectively; n.s.), accuracy (6.1% vs. 4.8%; n.s.) or precision (3.9% vs. 2.8%; n.s.). Remnant preservation can be safely performed without compromising tunnel position. Therefore, the potential benefits of this technique can be utilised, in clinical practice, without sacrificing the ability to optimize tibial tunnel positioning. III.

Anterior cruciate ligament (ACL) tears are a common knee injury, and anatomic ACL reconstruction (ACLR) is now the standard of care to restore knee stability. Nevertheless, re-tear rates exceeding 5% are commonly reported, with an even higher percentage of patients unable to achieve preinjury knee function. As the torn ACL remnant contains elements (eg, cells, blood vessels and mechanoreceptors) essential to ACL function, it has been hypothesised that ACLR with remnant preservation may improve graft remodelling, in turn more quickly and completely restoring ACL structure and function. In this Current Concepts review, we summarise the present understanding of ACLR with remnant preservation, which includes selective bundle reconstruction of partial (one-bundle) ACL tears and single- and double-bundle ACLR with minimal to partial debridement of the torn ACL stump. Reported benefits of remnant preservation include accelerated graft revascularisation and remodelling, improved proprioception, decreased bone tunnel enlargement, individualised anatomic bone tunnel placement, improved objective knee stability and early mechanical support (with selective bundle reconstruction) to healing tissues. However, clinical studies of ACLR with remnant preservation are heterogeneous in the description of remnant characteristics and surgical technique. Presently, there is insufficient evidence to support the superiority of ACLR with remnant preservation over the standard technique. Future studies should better describe the ACL tear pattern, remnant volume, remnant quality and surgical technique. Progress made in understanding and applying remnant preservation may inform, and be reciprocally guided by, ongoing research on ACL repair. The goal of research on ACLR with remnant preservation is not only to achieve anatomic structural restoration of the ACL but also to facilitate biologic healing and regeneration to ensure a more robust and functional graft.

Resumo Objetivo Analisar os resultados da reconstrução do ligamento cruzado anterior (LCA) com preservação do remanescente, comparada à técnica convencional, no retorno do paciente ao nível de atividade física pré-lesão. Métodos Estudo transversal retrospectivo, que avaliou indivíduos adultos submetidos à reconstrução anatômica do LCA no período de 2010 a 2014. Os desfechos analisados foram: nível de atividade física, taxa retorno ao esporte, relesão do LCA definida como lesão documentada que necessite de nova reconstrução ligamentar, e dor pela escala numérica de dor (EVN). Resultados Foram incluídos 83 indivíduos com média de 31,8 anos de idade e seguimento médio de 4,2 anos após a cirurgia, 34 submetidos à reconstrução do LCA com preservação do remanescente, e 49 à convencional. Não houve diferença estatisticamente significativa entre os grupos na frequência de atividade física pré-lesão e pós-operatória, na taxa de relesão do LCA reconstruído e na intensidade da dor no pós-operatório. Na análise intragrupos, houve uma queda estatisticamente significativa na frequência da prática de atividade física pós-operatória para ambos os grupos em comparação ao nível pré-lesão. O tipo de esporte mais praticado foi o futebol, onde 72% pacientes do grupo remanescente retornaram ao esporte comparado a 52,6% do grupo controle; porém, essa diferença não foi estatisticamente significante. Conclusão Não foi possível observar diferenças entre os pacientes submetidos às técnicas cirúrgicas de reconstrução LCA com e sem a preservação do remanescente em relação ao retorno ao esporte, frequência de atividade física e intensidade da dor. Estudos futuros prospectivos são necessários.

Purpose To analyze differences in clinical outcomes of arthroscopic anterior cruciate ligament reconstruction between remnant-preserving and non-preserving methods. Methods International electronical databases PubMed, Embase, and the Cochrane central database from January 1966 to December 2017 were searched for randomized controlled trials (RCTs) and observational studies that compared differences of clinical outcomes of ACL reconstruction with and without remnant preservation. A meta-analysis of these studies was performed to compare clinical outcomes. Subgroup analyses were conducted to evaluate the role of methodological quality in primary meta-analysis estimates. Results Five RCTs and six observational studies were included in this meta-analysis and subgroup analysis. The remnant-preserving method in arthroscopic ACL reconstruction showed a statistically significant difference compared to the non-preserving method regarding arthrometric evaluation (side-to-side difference). Lachman test, Lysholm scores, and IKDC subjective scores showed statistically minor difference in meta-analysis, but showed no significant difference in subgroup analysis. Remained parameters including pivot shift test, IKDC grades, incidence of cyclops lesion showed no statistically differences in meta-analysis or subgroup analysis. Conclusions This meta-analysis with subgroup analysis showed that arthroscopic remnant-preserving ACL reconstruction provided statistically significant but limited clinical relevance in terms of arthrometric evaluation. Results of Lachman test, Lysholm scores, and IKDC subjective scores demonstrated statistically minor differences.

Purpose We studied the effect of interleukin-8 (IL-8) as the factor for angiogenesis in the joint fluid of remnant-preserved anterior cruciate ligament reconstruction (RP-ACLR). Materials and methods We measured 12 cytokines in joint fluid by multiplex assay and assessed the relationship between IL-8 and vascular endothelial growth factor (VEGF) concentrations. The signal intensity and mean sagittal diameter via postoperative magnetic resonance imaging (MRI) scans were evaluated and the stress X-ray image was analyzed at 3, 6, and 12 months after operation. Results The IL-8 concentration was highest 3 months postoperatively in those patients who underwent RP-ACLR. Clinical data also showed that the signal intensity and stress radiography of the knee graft were significantly better at the early postoperative stage. Discussion Our results show that IL-8 plays an important role in angiogenesis within 3 months after RP-ACLR. This effect yields better recovery after operation. RP-ACLR patients with high knee stability in clinical data were identical to those with high expression of IL-8 in experimental data. Therefore, IL-8 has been shown to help revascularization and ligamentization of the grafted tendon. These results indicate that IL-8 in RP-ACLR is an important factor for angiogenesis after operation. Unfortunately, the relationship of IL-8 and VEGF in vivo has not been studied. Conclusion Our results showed that the IL-8 concentration was very high within 3 months after RP-ACLR operation. The increase in concentration of IL-8 over time was consistent with the increase in VEGF concentration. In the IL-8 clinical setting, MRI analysis showed that ACL synovialization and tension were better in patients who underwent the remnant preservation method. In addition, it was shown that RP-ACLR may be advantageous for early anterior stability within 1 year post operation and beneficial for tendon graft in the early stage post operation. Taken together, our findings suggest that IL-8 may contribute to angiogenesis which is helpful for revascularization and ligamentization of the graft tendon in the early stages of RP-ACLR.

Background: Grade 3 Posterior Cruciate Ligament (PCL) injury needs surgical intervention, but there is no consensus on the optimal technique in PCL reconstruction. The old technique always removes the remnant for good visualization of tunnel replacement. Recently, many studies proposed the concept of the preservation of PCL remnant with achieving good visualization. The aim of the study is to evaluate PCL reconstruction with remnant preservation using the standard anterior and posteromedial portal at 2-years follow-up. Methods: We conducted a cohort retrospective study between January 2013 to December 2015. In this study, 25 patients underwent PCL reconstruction using standard anterior and posteromedial portal with remnant preservation. We used quadrupled hamstring autograft. The patients were assessed using the International Knee Documentation Committee (IKDC) score, Lysholm knee score, Modified Cincinnati Score, and Knee Society Score (KSS) at pre-operative and 2-years post-operative. Range of Motion (ROM) and complication were evaluated post-operatively. Results: The mean diameter of the quadruple hamstring graft was 8 mm. Clinical outcomes enhanced significantly (p Conclusion: PCL reconstruction using standard anterior and posteromedial portal with remnant preservation at 2 years follow up resulted in satisfactory clinical and functional outcomes.

Arthroscopic techniques for anterior talofibular ligament (ATFL) repair and reconstruction have been developed in recent years. We simultaneously performed anatomical arthroscopic ATFL repair and reconstruction using a free tendon graft. The ATFL remnant is carefully dissected only at the footprint of the superior limb of the ATFL, and a bone tunnel is created on each side of the fibula and talus. A soft suture anchor with 2 sets of threads is inserted into the fibular tunnel. One set of threads is used to grab the ATFL remnant via a lasso-loop technique, whereas the other set of threads is used to introduce the ATFL graft. The graft is first fixed with a screw in the talar tunnel. Subsequently, the ATFL remnant and the graft are tightened simultaneously by pulling the 2 sets of suture anchor threads at the fibular tunnel and are fixed with a screw. This technique provides the possible advantages of remnant preservation and promotion of load sharing by the repaired ATFL remnant and the reconstructed ATFL graft.

Purpose We aimed to evaluate surgical outcomes of high-grade bursal rotator cuff-tear repairs. Methods This systematic review was performed in May 2020 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed. Inclusion criteria were English-language studies reporting the results of pain improvement, functional outcome scores, and radiographic examinations after repair of bursal side partial rotator-cuff tears at any time point in patients of any age and with all levels of evidence. Exclusion criteria were articles not in English, in vitro or animal studies, epidemiological studies, and such article types as technical notes or narrative reviews. Results Of 58 articles, five were included in this study, of which three and two had level III and IV evidence, respectively, four were comparative studies, and one was a case series. Visual analogue scales were used in four of the five studies, all showing improvement in pain assessment from 5.87 preoperatively to 1.02 postoperatively. All five studies showed significant improvement on each functional outcome score at the final follow-up. The retear rate for all studies was 10.97% (27 of 246). Conclusion High-grade bursal side partial-thickness rotator cuff-tear repair gave satisfactory results in terms of pain scores, range of motion, and functional outcomes. The retear rate was still considerably high (10.9%), necessitating better understanding of the basic science, such as molecular mechanisms during adaptation, to improve the surgical technique.

To examine the role of the posterior fan-like extension of the ACL’s femoral footprint on the ACL failure load. Sixteen (n = 16) fresh frozen, mature porcine knees were used in this study and randomized into two groups (n = 8): intact femoral ACL insertion (ACL intact group) and cut posterior fan-like extension of the ACL (ACL cut group). In the ACL cut group, flexing the knees to 90°, created a folded border between the posterior fan-like extension and the midsubstance insertion of the femoral ACL footprint and the posterior fan-like extension was dissected and both areas were measured. Specimens were placed in a testing machine at 30° of flexion and subjected to anterior tibial loading (60 mm/min) until ACL failure. The intact ACL group had a femoral insertion area of 182.1 ± 17.1 mm2. In the ACL cut group, the midsubstance insertion area was 113.3 ± 16.6 mm2, and the cut posterior fan-like extension portion area was 67.1 ± 8.3 mm2. The failure load of the ACL intact group was 3599 ± 457 N and was significantly higher (p

Background Anatomic tunnel formation and remnant preservation are valuable aspects of anterior cruciate ligament (ACL) reconstruction. However, anatomic landmarks are difficult to observe during remnant-preserving ACL reconstruction (ACLR). The aims of this study were to evaluate the: 1) femoral tunnel location created with guidance from the apex of the deep cartilage margin (ADC) and footprint compared to anatomical reference; and 2) relationship between femoral tunnel location and outcomes of ACLR. Methods A total of 109 ACLR patients without revision ACLR, multi-ligament reconstruction, peri-knee fracture, and osteotomy were included. The femoral tunnel was formed at the most proximal corner of the femoral footprint using a posterior trans-septal portal as the viewing portal. The distance from the tunnel center to ADC was measured by computed tomography and arthroscopy. The two measurements were then compared. Finally, femoral tunnel location was compared to the anatomic reference and correlated with the outcomes. Results The average distance from ADC to the femoral tunnel center was 7.0 ± 1.4 mm as measured by arthroscopy, and 7.2 ± 2.0 mm using three-dimensional computed tomography. There was no statistically significant difference between the two methods (P = 0.420). Clinical and stability outcomes were significantly improved postoperatively. Clinical outcome was not related to femoral tunnel location; however, stability outcome was related to femoral tunnel location: the more proximally located femoral tunnels showed better stability. Conclusion The ADC can be a possible landmark in remnant-preserving ACLR using a trans-septal portal. A more proximal femoral tunnel, which is located at the proximal corner of the ACL remnant, can provide stability advantage during remnant-preserving ACLR.

The purpose of this study was to find the most suitable and safe position of the transseptal portal in anatomic anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstructions. The hypothesis of this study was that area and position of the transseptal portal are different between ACL and PCL reconstructions for the observation of native footprint. A matched-pair comparison study was conducted on the arthroscopic images of 100 consecutive patients who underwent ACL reconstruction and 50 consecutive patients who underwent PCL reconstruction. The transseptum was divided into six compartments. The opened compartments for each surgery were then evaluated to find which anatomical structures are well seen. The anterior middle and upper parts were necessary for the ACL reconstruction, whereas middle and lower portions of the anterior and posterior compartments were necessary for the PCL reconstruction. A larger opening was necessary for PCL reconstruction than that for ACL reconstruction. The ACL posterior one-third, ACL femoral attachment, and apex of the deep cartilage margin (DCM) were viewed in 100% of the patients during ACL reconstruction. The PCL posterior one-third, PCL tibial attachment, PCL fovea margin, and medial meniscus around posterior margin were always viewed during PCL reconstruction. The anterior part of the septum, from the middle to the upper portions of the transseptum, was necessary to be opened for visualization of the femoral footprint and DCM of the lateral femoral condyle during ACL reconstruction. The anterior and posterior parts of the septum, from the middle to the lower portions of the transseptum, were necessary for excellent visualization of the PCL tibial footprint during PCL reconstruction. These paths of the transseptal portal for each surgery will help surgeons obtain both anatomic footprint restoration and maximal remnant preservation through the most suitable and safe means. This is a case–control study; level of evidence is 3.

Background: Remnant preservation during anterior cruciate ligament (ACL) reconstruction (ACLR) is controversial, and it is unclear whether the stump aids or obscures tibial tunnel positioning. Purpose/Hypothesis: The aim of this study was to determine whether the rate of tibial tunnel malposition is influenced by remnant preservation. The hypothesis was that using a remnant-preserving technique to drill entirely within the tibial stump would result in a significant reduction in tibial tunnel malposition as determined by postoperative 3-dimensional computed tomography (3D-CT). Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing ACLR between October 2018 and December 2019 underwent surgery with a remnant-preserving technique (RP group) if they had a large stump present (>50% of the native ACL length) or if there was no remnant or if it was Results: Overall, 52 patients were included in the study (26 in each group). The mean tunnel positions were 36.8% ± 5.5% AP and 46.7% ± 2.9% ML in the RP group and 35.6% ± 4.8% AP and 47.3% ± 2.3% ML in the RA group. There were no significant differences in the mean AP ( P = .134) and ML ( P = .098) tunnel positions between the groups. Inter- and intraobserver reliability varied between fair to excellent and good to excellent, respectively. There was no significant difference in the rate of malposition between groups (RP group, 7.7%; RA group, 11.5%; P ≥ .999). Conclusion: Drilling entirely within the ACL tibial stump using a remnant-preserving reconstruction technique did not significantly change the rate of tunnel malposition when compared with stump ablation and utilization of standard landmarks.

Background: High-grade acromioclavicular (AC) joint separation injuries (Rockwood type IV or V) are surgically indicated because of complete disruption of the AC and coracoclavicular (CC) ligaments, leading to instability and pain. In surgical techniques that require a suspensory system, coracoid tunnel-related complications are not uncommon. Purpose: To report subjective and objective clinical outcomes and complication rates of a modified coracoid tunnel-free CC sling technique combined with CC ligament remnant preservation for a minimum 2-year follow-up. Study Design: Case series; Level of evidence, 4. Methods: Between January 2014 and January 2017, we prospectively enrolled patients who underwent a modified CC sling technique performed by 1 senior surgeon using the AC TightRope System in a coracoid tunnel-free fashion. The CC distance (CCD) and Rockwood AC joint classification were evaluated on radiographs preoperatively, immediately postoperatively, and at the final follow-up. The visual analog pain score, range of motion, American Shoulder and Elbow Surgeons score, Constant-Murley score, and University of California Los Angeles score were recorded preoperatively and at the final follow-up. Results: In total, 48 of 54 patients (88.9%) were included for the evaluation with a mean ± SD follow-up of 39.3 ± 8.9 months (range, 24.7-64.3 months). The CCD was significantly decreased from 22.7 ± 4.2 to 9.8 ± 2.3 mm ( P < .01) immediately after surgery and to 11.2 ± 1.8 mm ( P < .01) at final follow-up. At the final follow-up, the side-to-side difference of CCD was 3.5 ± 0.6 mm. Compared with the preoperative level, all subjective evaluations were significantly improved at the final follow-up. We observed that 4 of the 48 patients (8.3%) had a loss of reduction at the final follow-up, but no pain or instability was documented. Further, no coracoid-related complication or other complications were recorded. Conclusion: The coracoid tunnel-free CC sling technique using the AC TightRope System combined with CC ligament remnant preservation demonstrated significant improvement regarding both clinical and radiological outcomes, with a reduction loss rate of 8.3%. It is a safe method that could achieve satisfactory result without any coracoid drilling-related complications.

Background: Preservation of the tibial stump during anterior cruciate ligament reconstruction (ACLR) is controversial. While proposed benefits include enhanced graft revascularization, improved proprioception, and decreased graft rupture rates, a potential complication is the development of a symptomatic cyclops lesion. It is therefore important to determine whether any benefits outweigh potential complications. Purpose: To determine whether greater preservation of the tibial stump remnant would be associated with a decreased graft rupture rate without a concomitant increase in the rate of surgery for symptomatic cyclops lesions at 2 years after ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: A cohort of 658 patients in whom the amount of tibial stump preserved was classified as no stump (n = 228), 50% (n = 88) was followed up for 2 years, with graft ruptures and surgical treatment for cyclops lesions recorded. Contingency and Kaplan-Meier survival analyses were used to determine trends among the 3 remnant preservation groups in terms of graft rupture rates and surgery for cyclops lesions. Subgroup analysis was also conducted to examine sex-based differences. Results: There was no significant association between graft rupture rates and remnant preservation. There was a significant trend for fewer operations for symptomatic cyclops lesions with greater remnant preservation when the entire cohort was analyzed ( P = .04) and also when only female patients were analyzed ( P = .04). Conclusion: Although preservation of the tibial stump remnant was not associated with a reduced graft rupture rate, it was also not associated with increased rates of surgery for symptomatic cyclops lesions.

Outside-in technique is used popular nowadays as tibia tunnel-independent techniques ACL reconstruction along with transportal technique. Moreover, outside-in technique facilitates placement of the femoral tunnel in a center of the anatomic femoral origin of ACL. Recently, there has been growing interest in the substantial roles of the remnant of the ACL after a tear and attempts have been made to preserve remnant of the ACL after a tear. Among them, outside-in technique seems to be a more reliable and precise technique to achieve anatomic femoral origin of ACL with preserving the remnant bundle. In this chapter, the surgical technique and outcomes of ACL reconstruction using outside-in technique with/without remnant preservation are reviewed.

Background: Mechanoreceptor is a subtype of somatosensory receptor. It conveys extracellular stimuli through intracellular signal conduction via mechanically gated ion channel. It conveys not only kinetic stimuli but also pressure, stretching, touch, and even sound wave. Few studies have determined whether mechanoreceptors are present in Achilles tendon allografts used during remnant-preserving posterior cruciate ligament (PCL) reconstruction (PCLR). Purpose/Hypothesis: The purpose was to investigate whether mechanoreceptors are present in remnant tissues of the PCL and allograft tissues after PCLR. It was hypothesized that mechanoreceptors may be present in the remnant PCL tissue of the patients who underwent remnant PCLR technique. Study Design: Controlled laboratory study. Methods: Tissue samples were obtained from 14 participants who had undergone PCLR by means of Achilles tendon allografts (PCLR group) and from 4 healthy controls (control group). Among the PCLR group, 12 patients had undergone a remnant PCLR technique and the remaining 2 patients had undergone a nonremnant PCLR technique. In the PCLR group, we obtained samples during second-look arthroscopy or total knee arthroplasty after PCLR. In the control group, 4 biopsy specimens of normal PCL tissues were obtained from patients who had undergone other arthroscopic procedures. To check the presence of mechanoreceptors, immunohistochemical studies were performed on all biopsy specimens to identify neuronal and neurocytic markers by using monoclonal antibodies against glial fibrillary acidic protein, neuron-specific enolase, neurofilament, and S-100 protein. Only 1 of these markers needed to be positive to prove the presence of mechanoreceptors. Results: Neural tissue analogs, confirmed to be mechanoreceptors with monoclonal antibodies by the Ultraview DAB detection kit, were found in all specimens obtained from the control group. Mechanoreceptors were not found in the allograft specimens. However, remnant PCL tissues were found to have mechanoreceptors in 11 of 12 samples (91.7%). Conclusion: The results demonstrate that Achilles tendon allografts lack mechanoreceptors. This study can be used as histological evidence to support the advantage of remnant-preserving techniques for PCLR because they preserve proprioception. Clinical Relevance: To preserve proprioception, which leads to better functional outcome, using the remnant technique is a better procedure for PCL reconstruction.

Objective To assess the clinical results of the remnant‐preserving and I.D.E.A.L. femoral tunnel technique in the arthroscopic treatment of anterior cruciate ligament (ACL) injuries. Methods This was a retrospective single‐center, single‐surgeon study reviewing data from November 2016 to March 2019. Based on our inclusion/exclusion criteria, a total of 31 patients (18 males, 13 females; mean age, 23.6 years) who underwent arthroscopic ACL reconstruction with the remnant preservation and I.D.E.A.L. femoral tunnel technique were recruited and had a minimum follow‐up of 12 months. Clinical data and status of knee stability were recorded. The International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity scale were collected both preoperatively and at a minimum of 1‐year follow‐up. Results Statistically significant differences were detected between the preoperative and postoperative values for Lachman test and pivot‐shift test (P, (A) MRI of the right knee showed rupture of the femoral end of ACL. (B) A routine arthroscopic examination was performed using a probe with a 30° oblique arthroscope in the anterolateral (AL) portal and another probe in the anteromedial (AM) portal. ACL avulsion from femoral insertion was observed. (C) Position of the I.D.E.A.L. femoral tunnel (arthroscopic view). A guide PDS was placed through the femoral bone tunnel. (D) The tibial tunnel (the position of the Kirschner wire) was located at the center of ACL remnant. (E) The position of ACL graft in the joint after fixation through the tibial and femoral tunnels. (F) The ACL graft and ACL remnant were sutured together with PDS suture. (G,H) Postoperative anteroposterior and lateral plain radiographs showed the correct position of the titanium plate. (I) Volumetrically rendered image from sagittal CT taken after primary ACLR showed that the tunnels were located at the anatomic position. (J) 3D CT scan reconstruction with a femoral tunnel position. (K) 3D CT scan reconstruction with a tibial tunnel position.

To evaluate the clinical outcomes and graft maturation following posterior cruciate ligament reconstruction (PCLR) with preserved remnant and further analyze the correlated factors affecting graft maturation.Consecutive patients who underwent unilateral single-bundle PCLR with remnant preservation from January 2011 to October 2014 by the same senior doctor using tibialis anterior allografts and same surgical technique were included. At a follow-up of more than 2 years, range of motion (ROM) and posterior laxity assessed by posterior drawer test and the KT-1000 arthrometer were examined. Tegner, Lysholm, and International Knee Documentation Committee scores were evaluated. The graft maturation was assessed by a 3.0-T magnetic resonance imaging. Overall correlation analyses and multivariate regression analysis were performed to identify correlated factors of graft maturation, and then subgroups were divided and analyzed according to significant risk factor.Forty-three (84.3%) of 51 enrolled patients were successfully followed up (38.4 months, 24-54 months). All clinical scores improved significantly, and there were no complications. The results of KT-1000 difference revealed significant decline of posterior laxity (9.4 ± 1.5 vs 2.2 ± 1.5 mm; P.001). The MRI evaluation confirmed no ligament retears. Both correlation and regression analyses showed time from injury to surgery had a positive, statistically significant weak correlation with the signal intensity score (R = 0.38, P = .012; coefficient = 0.10; P = .036). Subgroup (group 1: time from injury to surgery3 months; group 2: 3-6 months; group 3: 6-12 months; group 4: ≥12 months) analysis showed there were no significant differences of clinical outcomes between subgroups, while MRI signal intensity was significantly lower in the group with shorter time from injury to surgery (P = .02).The remnant-preserved PCLR resulted in satisfactory clinical outcomes and graft maturation at a mean follow-up of 38.4 months. The time from injury to surgery showed a weak positive correlation with postoperative graft signal intensity on MRI.Level III, retrospective comparative study.

Background: Anterior cruciate ligament (ACL) reconstruction is one of the most common procedures in orthopaedics. Orthopaedic surgery is vastly evolving to give better functional outcome. Apart from stability, proprioception, ligament healing are important factors for return to sports. The presence of remnant containing mechanoreceptors and free neural endings can help reinnervate the ACL auto graft. Aims and objectives were to evaluate clinical outcomes in patients undergoing ACL reconstruction with remnant preservation.Methods: One hundred and six patients who underwent ACL reconstruction between April 2014 and March 2020. Among these 80 patients underwent remnant preservation. Analysis is done based on international knee documentation committee score (IKDC), modified Cincinnati knee rating system (MCKRS) and Tegner-Lysholm scoring system. Other factors are Lachman test, pivot shift test, return to sports and graft rupture rate.Results: Lachman test became negative in 98% at 12 weeks and in all the patients at 24 months post-operatively. 74 patients (92.5%) among 80 patients develop full range of knee movement after ACL surgery. Post-operative scores are 95, 93, and 92 respectively.Conclusions: Remnant preserving ACL reconstruction having excellent clinical outcome with good knee stability, early return to sports activities and no incidence of graft rupture in our series.

We describe a surgical technique for arthroscopic posterior cruciate ligament (PCL) reconstruction with remnant preservation of the original PCL fibers using a posterior trans-septal portal approach. Using the transtibial technique and the posterior trans-septal portal approach allows good visualization of the tibial tunnel preparation, easy access to the tibial tunnel without neurovascular injury, and preservation of remnant PCL fibers. In the preparation of the tibial tunnel, we expose the PCL tibial attachment site completely, detach the posterior capsule from the PCL, and preserve the distal stump of the PCL without neurovascular injury. PCL reconstruction is performed in a way that preserves the remnant PCL fibers. We report on our surgical technique for arthroscopic PCL reconstruction preserving the original PCL fibers.

Background: The optimal graft choice of anterior cruciate ligament (ACL) reconstruction remains controversial. Purpose: To compare the outcomes, especially the long-term cumulative failure rate, of ACL reconstruction using either synthetics with remnant preservation or hamstring autografts (4-strand semitendinosus and gracilis tendons). Study Design: Cohort study; Level of evidence, 2. Methods: A total of 133 patients who underwent ACL reconstruction (synthetics: n = 43; hamstring autografts: n = 90) between July 2004 and December 2007 were included. Questionnaires (Tegner activity scale, Lysholm knee scale, and International Knee Documentation Committee [IKDC] subjective form) were completed preoperatively and at 6 months, 1 year, 5 years, and 10 years postoperatively. The Knee injury and Osteoarthritis Outcome Score (KOOS) was additionally applied at 10 years’ follow-up. The physical examination was based on the 2000 IKDC form. The manual maximum side-to-side difference (KT-1000 arthrometer), single-hop test, thigh muscle atrophy, and joint degeneration (Kellgren and Lawrence classification) were evaluated. The Kaplan-Meier curve and log-rank test (Mantel-Cox, 95% CI) were used to compare graft survivorship. Results: Ten years postoperatively, 111 patients were available, with 38 (88.4%) patients (mean age, 27.6 ± 9.3 years; 28 men) with synthetics and 73 (81.1%) patients (mean age, 28.6 ± 8.8 years; 64 men) with hamstring autografts. Among them, 104 patients (synthetics: n = 35 [81.4%]; hamstring autografts: n = 69 [76.7%]) completed subjective evaluations, and 89 patients (synthetics: n = 30 [69.8%]; hamstring autografts: n = 59 [65.6%]) completed objective evaluations. For hamstring autografts and synthetics, the cumulative failure rates were 8.2% and 7.9%, respectively, and the log-rank test demonstrated no significant difference between the 2 Kaplan-Meier survival curves ( P = .910). At 6 months postoperatively, for hamstring autografts and synthetics, the mean Lysholm score was 83.0 ± 7.8 and 88.1 ± 7.5, respectively ( P < .001); the mean IKDC score was 83.8 ± 7.8 and 86.9 ± 4.5, respectively ( P = .036); and the mean Tegner score was 3.7 ± 1.1 and 5.0 ± 1.5, respectively ( P < .001). At 1 year postoperatively, the mean Tegner score was 5.5 ± 1.9 and 6.5 ± 2.0, respectively ( P = .011). No statistically significant difference was observed on other subjective evaluation findings, physical examination findings (overall IKDC grade A: 45.8% of hamstring autografts, 50.0% of synthetics), side-to-side difference (1.5 ± 1.5 mm for synthetics, 2.4 ± 2.1 mm for hamstring autografts), single-hop test findings (grade A: 84.7% of hamstring autografts, 93.3% of synthetics), grade A/B thigh muscle atrophy (88.1% of hamstring autografts, 93.3% of synthetics), ipsilateral radiographic osteoarthritis (55.9% of hamstring autografts, 50.0% of synthetics), and graft survivorship. Conclusion: In this prospective cohort study, primary ACL reconstruction using either synthetics with remnant preservation or hamstring autografts showed satisfactory outcomes, especially the long-term cumulative failure rate, at 10 years postoperatively. Patient-reported outcomes suggested that symptom relief and restoration of function might occur earlier in those with synthetics.

The aim of the present study was to investigate the correlation between postoperative tunnel enlargement after ACLR and remnant tissue preservation using the hamstring tendon. One hundred and ninety-two subjects (male, n = 101; female, n = 91; mean age 27.1) who had undergone double-bundle ACL reconstruction were included in the present study. The patients were divided into two groups: the remnant tissue preservation group (Group R) and the non-remnant tissue preservation group (Group N). Computed tomographic scans of the operated knee were obtained at 2 weeks and 6 months after surgery. The area of the tunnel aperture for the anteromedial femoral tunnel (FAMT), posterolateral femoral tunnel (FPLT), anteromedial tibial tunnel (TAMT), and posterolateral tibial tunnel (TPLT) was measured. The area at 2 weeks after ACLR was subtracted from the area at 6 months after ACLR and then divided by the area at 2 weeks after ACLR. The differences in the outcomes and characteristics of the two groups were evaluated. Seventy-seven knees were classified into Group R, and 115 knees were classified into Group N. The age, gender, and body mass index did not differ to a statistically significant extent. The percentages of FAMT and TAMT enlargement in Group R were significantly smaller in comparison with Group N (P = 0.003 and P = 0.03, respectively). The percentage of FPLT and TPLT enlargement in the two groups did not differ to a statistically significant extent. The remnant-preserving technique reduces the amount of bone tunnel enlargement. The present findings indicate the advantages of the remnant-preserving ACLR technique, and therefore the remnant-preserving technique should be recommended. II.

Preservation of the anterior cruciate ligament (ACL) remnant tissue has attracted notice in ACL reconstruction. Remnant preservation has been expected to have several potential advantages to improve postoperative knee stability such as enhanced graft coverage, accelerated cell repopulation, and revascularization. Recently, we have developed a new remnant-preserving technique for anatomical double-bundle ACL reconstruction using the semitendinosus tendon. The anterior laxity values and the results of the pivot-shift test were significantly better in the remnant tissue–preserving procedure than in the remnant tissue–resecting procedure. The arthroscopic evaluation showed that the remnant-preserving procedure was significantly better than the remnant-resecting procedure concerning postoperative laceration or tear of the grafts as well as synovial and fibrous tissue coverage of the grafts. However, to establish the clinical use of remnant tissue preservation, further randomized clinical studies are needed to objectively examine the effects on rotatory stability and the long-term survival of graft function.

We describe the all-anterior approach for arthroscopic posterior cruciate ligament (PCL) reconstruction with remnant preservation. In this technique, PCL is reconstructed through 3 anterior portals: anterolateral portal, anteromedial portal, and inferior anterolateral portal, whereas the PCL remnant is preserved with great possibility. With the PCL elevator and wire catcher (Smith & Nephew), a self-made wire loop is introduced into the joint through the tibial tunnel, and is used to pass the graft in an all-inside-out fashion. In the transtibial PCL reconstruction technique, posterior portals are routinely adopted and the PCL remnant is often removed for good vision and adequate operative space, which can prolong surgery time and increase the potential risk of iatrogenic injury. In comparison, this technique not only simplifies the surgical procedure and reduces surgical trauma, but also preserves the remnant for our patients.

Purpose.This is a systematic review and meta-analysis of current evidence that aims at comparing the clinical outcomes of remnant-preserving anterior cruciate ligament reconstruction (ACLR) and standard ACLR.Methods.A systematic review of randomized controlled studies and cohort studies comparing remnant-preserving ACLR with standard ACLR with a minimum level of evidence of II was performed. Studies were included by strict inclusion and exclusion criteria. Extracted data were summarized as preoperative conditions, postoperative clinical outcomes, and postoperative complications. When feasible, meta-analysis was performed with RevMan5.3 software. Study methodological quality was evaluated with the modified Coleman methodology score (CMS).Results.Eleven studies (n = 466 remnant-preserving andn = 536 standard) met the inclusion criteria. The mean modified CMS for all included studies was 85.8 (range: 77–92 on a 100-point scale). In total, 466 patients underwent remnant-preserving ACLR by 3 different procedures: standard ACLR plus tibial remnant tensioning (n = 283), selective-bundle augmentation (n = 49), and standard ACLR plus tibial remnant sparing (n = 134). Remnant-preserving ACLR provided a superior outcome of postoperative knee anterior stability (WMD = −0.42, 95% CI, −0.66, −0.17;P<0.01) and Lysholm score (WMD = 2.01, 95% CI, 0.53 to 3.50;P<0.01). There was no significant difference between the two groups with respect to second-look arthroscopy (OR = 1.38, 95% CI, 0.53, 3.62;P=0.51), complications (OR = 1.24 95% CI, 0.76, 2.02;P=0.39), International Knee Documentation Committee (IKDC) subject scores, IKDC grades, Lachman test, and pivot-shift test.Summary/conclusion.Remnant-preserving ACLR promotes similar graft synovial coverage and revascularization to standard ACLR. Equivalent or superior postoperative knee stability and clinical scores were observed for remnant-preserving ACLR compared with standard ACLR. No significant difference in the total complication rate between the groups was evident.