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Background: Medial patellofemoral ligament (MPFL) reconstruction is a standard treatment option for selected patients with patellar instability. Although frequently performed, the optimal graft source for the procedure has not yet been established. This study aimed to determine whether a two-strand plantaris tendon construct possesses the biomechanical properties needed to act as an MPFL reconstruction graft. Methods: Thirty paired plantaris and gracilis tendons were harvested from 15 cadavers, mean age at death of 42.7 years. All specimens were frozen and maintained at -20 °C until biomechanical testing. Prior to mechanical testing, specimens were thawed at room temperature. The two-strand plantaris tendon and two-strand gracilis tendon constructs were created and secured in a uniaxial tensile testing machine in a triangular-shaped mode. Biomechanical properties for tensile testing to failure were determined using validated method. Results obtained were compared with the previously published data on native MPFL biomechanical properties. Results: The mean maximal force was 220.3 ± 108.1 N and 448.1 ± 117 N for the two- strand plantaris tendon construct and two-strand gracilis tendon construct, respectively. Significant differences were observed between all biomechanical properties of two-strand plantaris tendon and two-strand gracilis tendon constructs. The mean maximal force of a two-strand plantaris tendon construct and a two-strand gracilis tendon construct were greater than the mean maximal force of the native MPFL reported in all previous studies. Conclusions: This study suggests that, due to its biomechanical properties, the two- strand plantaris tendon graft is suitable as a graft for MPFL reconstruction.

Background The medial patellofemoral ligament (MPFL) is considered the primary soft tissue restrain to lateral translation of the patella during the first 15–30 degrees of knee flexion. The primary restraint thereafter is the slope of the lateral wall of the trochlea. A plenty of procedures are described in literature for MPFL reconstruction with different types of graft, angle of knee flexion for fixation and rehabilitation protocols. In this study we used MPFL reconstruction with doubled autologous gracilis tendon with the Schottle’s technique. The aim of our study is to evaluate outcomes at medium-long term follow up of MPFL reconstruction. Methods Patients who underwent arthroscopic MPFL reconstruction for recurrent patellar dislocation were followed up for a minimum of 2 to 10 years. Patient-reported outcomes including the Kujala, Visual Analogue Scale (VAS) score were collected preoperatively and postoperatively. Clinical complications such as loss of ROM, recurrent sub-luxation or dislocation were recorded. Results A total of 38 patients with recurrent patellar dislocation were treated with MPFL reconstruction and data were available for final follow up (mean 72.3 months, SD 33.6). Mean age at time of surgery was 23.4 (SD 7.8). Mean number of dislocations before surgery was 7.1 (SD 10.5). Recurrent dislocations were not observed in any of the patients treated at last follow-up. Significant clinical improvements were also noted with Kujala and VAS score. Patellar tilt angle decreased significantly from pre to post-operative. Conclusion Our study demonstrated that MPFL reconstruction with patellar suture anchors fixation using autologous gracilis tendon is an effective, safe and reliable method for treating recurrent patellar dislocation.

The acetabular labrum is essential for stability during physiologic motion of the hip. Labral repairs frequently are attempted in cases of primary tears, although labral reconstruction is an important alternative in the revision setting or in the primary setting when the tissue is unsalvageable. Labral reconstruction has been shown to restore the hip’s suction-seal and fluid pressurization to that of the premorbid state, and cohort studies have demonstrated significantly improved patient-reported outcomes at midterm follow-up. Notably, the cost is of consideration during any reconstruction, and techniques have been described using both allograft and autograft sources. Autograft sources include the iliotibial band, ligamentum teres, gracilis tendon, and hip capsule. A previously described technique using the capsule was noted to hinder routine capsular closure. We present an alternative method for labral reconstruction using hip capsular tissue that is easily performed and allows for routine capsular closure., Technique Video Video 1 The patient is positioned supine in a lower-extremity traction table to undergo a right hip arthroscopy. An assessment of the central compartment and labral tissue is performed where it is determined that a labral reconstruction is indicated. Given the laxity of the capsular tissue, a capsular autograft is harvested longitudinally from the interportal capsulotomy for labral reconstruction. A traction stitch is placed in the capsulotomy to perform a complete femoral osteochondroplasty. A dynamic examination using fluoroscopy confirms complete resection of cam-type impingement. Labral reconstruction using capsular autograft is then performed along the areas of labral deficiency.

Accurately measuring the length and diameter of the hamstring tendon autograft preoperatively is important for planning anterior cruciate ligament (ACL) reconstructive surgery. The purpose of this study was to assess the reliability of three-dimensional computed tomography (3D CT) scanning technique to produce the actual measurement of the gracilis and semitendinosus (GT and ST, respectively) tendon grafts' length and diameter for surgery. Ninety patients were scheduled for ACL reconstruction with hamstring autograft. Before the surgery, patients were examined under the multidetector row CT scanner and the ST and GT tendons were qualitatively measured by a volume-rendering technique. The length of ST and GT was measured with 3D CT compared with the length of the harvested ST and GT. The cross-sectional area (CSA) of ST and GT measured with 3D CT compared with the ST and GT graft diameter. Tendon size measured preoperatively and during surgery were statistically compared and correlated. The GT tendons length and cross-sectional area measured during surgery was both shorter and smaller compared with the ST tendon. GT and ST tendon length were correlated to patients' body index such as the height and weight (p

Anterior cruciate ligament (ACL) reconstruction using hamstring tendons may involve harvesting of the gracilis tendon in addition to the semitendinosus tendon (ST) depending on the size of the ST graft. However, the effect of gracilis harvesting in addition to ST harvesting on muscle strength, such as the hamstring-to-quadriceps (HQ) ratio, remains unclear. Hence, this study aimed to investigate the effect of gracilis harvesting on subsequent knee muscle strength. Eighty-two patients who underwent ACL reconstruction were included in this retrospective study. They were divided into the following two groups depending on the tendon graft used for ACL reconstruction: the ST group (41 patients) and the semitendinosus tendon/gracilis tendon (STG) group (41 patients). The isokinetic peak torque of the knee extensor and flexor was measured using a BIODEX dynamometer at a velocity of 60°/s and 180°/s, respectively, 3 and 6 months after ACL reconstruction. The groups were compared in terms of the limb symmetry index (LSI) and HQ ratio. The significant difference in the knee flexor of the LSI at 6 months after ACL reconstruction was as follows: ST group, 120.3 ± 28.3 vs STG group, 105.6 ± 19.0 (p

Background: Patellar tendon rupture is a relatively infrequent injury, resulting in severe morbidity if neglected or treated improperly. The treatment aims to preserve the extensor mechanism. Quite a few reconstruction techniques have been proposed. Still, most result in complications including contractures, adhesions & atrophy of the quadriceps tendon, fracture of the patella, damage to the patellar articular surface and patella Alta or Baja. We use a modified technique to reconstruct a ruptured patellar tendon using ipsilateral semitendinosus and gracilis autograft without making a trans-osseous patellar tunnel. Surgical technique: The patellar tendon is sutured using an end to end technique. The procedure involves harvesting and suturing semitendinosus, and gracilis tendons end to end. A horizontal tunnel of 4.5-mm diameter is drilled at a point one centimetre posterior to the tibial tuberosity. One free end of the graft is passed through this tunnel in a medial to the lateral direction and then placed in front of the patella in a figure-of-eight fashion. Each end is then introduced transversely through the distal end of the quadriceps tendon along the proximal margin of the patella. The two ends are pulled distally and placed in a figure-of-eight fashion again. Finally, the ends were sutured in between where they overlapped after adjusting the tension and the position of the patella. Conclusion: This modified technique reduces patella associated complications like fracture and patellofemoral cartilage damage. The figure of eight patterns allows the adjustment of graft tension as deemed required for keeping the patella in the ideal position. The load from the patella is directly transmitted to the tibial tubercle so that the repaired patellar tendon remains tension-free and can heal properly. Moreover, when the knee flexes, the patella is pulled downward and is prevented from anterior translation to stabilise the patella and maintain appropriate tracking. Most importantly, this technique avoids postoperative splinting and thereby facilitates early mobilisation and hence a better outcome.

Multiple studies found hamstring tendon (HT) autograft diameter to be a risk factor for anterior cruciate ligament (ACL) reconstruction failure. This study aimed to determine which preoperative measurements are associated with HT autograft diameter in ACL reconstruction by directly comparing patient characteristics and cross-sectional area (CSA) measurement of the semitendinosus and gracilis tendon on magnetic resonance imaging (MRI). Fifty-three patients with a primary ACL reconstruction with a four-stranded HT autograft were included in this study. Preoperatively we recorded length, weight, thigh circumference, gender, age, preinjury Tegner activity score, and CSA of the semitendinosus and gracilis tendon on MRI. Total CSA on MRI, weight, height, gender, and thigh circumference were all significantly correlated with HT autograft diameter (p

Purpose Open or fenestrated interference screw design that allow bone ingrowth is a concept for improved bone healing to softtissue graft and bone filling in bone tunnels after anterior cruciate ligament reconstruction (ACLR) The aim of the current study was to assess CT scanning evaluated bone ingrowth into an open architecture interference screws in the tibial tunnel of patients undergoing ACL with soft tissue grafts. It was hypothesized that open architecture interference screws would stimulate bone ingrowth into the screw cavities. Methods Twelve patients requiring ACLR were included. They underwent arthroscopic ACLR with semitendinosus−/gracilis tendon graft and an open architecture polyetheretherketone (PEEK) interference screw. The patients were scanned with a multi-slice CT scanner two weeks, six and twelve months postoperatively. On CT reconstruction slices bone ingrowth into the screw was measured. Subjective and objective clinical outcome international knee documentation committee score and instrumented knee laxity determination were collected. Results At six months no implants demonstrated more than 10% bone ingrowth. At twelve months 42% (5/12) implants had more than 10% bone ingrowth (p = 0.009). The average bone filling into the screws was 7.7%. There was no tunnel widening or cyst formation seen in relation to any of the implants. Subjective IKDC score improved significantly from 50.6 baseline to 80.1 at 24 month follow-up. Preoperative side-to-side knee laxity improved from 3.7 (2.1) to 1.4 (1.2) mm at twelve months. There were no serious adverse events in relation to the new open architecture thread PEEK interference screw during or after hamstring ACL reconstruction. Conclusion The present study demonstrated that open architecture thread PEEK interference screw can stimulate bone ingrowth into the screws after soft tissue ACL reconstruction with at 12 months with an average bone filling into screws was 7.7%. Knee stability, functional, subjective and objective outcomes were similar to large volume ACL outcome studies. Trial registration The study was registered at ClinicalTrials # NCT02382341. 12-09-2014. Level of evidence IV.

Introduction. The modern development of technologies of ACL-R allows us to take a fresh look at the methods for recovery of anterior and rotational knee instability of the knee joint, which were used in the middle of the XX century. The objective was to evaluate the non-free tendon grafts while maintaining their anatomical attachment point for the isolated and complex ACL-R. Methods and materials. From 2014 to 2018, 128 patients were operated on the isolated ACL injuries (102 patients – 79.7 %) and complex ACL injuries (26 patients – 20.3 %). 26 (20.3 %) patients were operated on the rupture of a previously installed ACL graft. There were 72 men (56.3 %) and 56 women (43.7 %). The average age was (34.7±2.5) years. The average body weight was (82.7±1.6) kg; 24 (18.8 %) patients weighed over 85 kg. In 87 (68.0 %) cases, an anatomic single bundle ACL-R was performed by non-free graft either from the tendon of semitendinosus or in combination with the gracilis tendon. In 41 (32.0 %) cases, ACL-R was supplemented by LEAT (non-free iliotibial tract or free gracilis tendon grafts). The results were evaluated clinically, radiologically, and using the 2000 IKDC, KOSS and Lysholm Knee Scoring Scale integrated scales. In all cases, high stability of the knee joint was noted. Lachman and the pivot shift test recorded only 0 and 1 degrees. By the KOSS scale: «pain» was (86.7±2.3) points, «pathological symptoms» – (88.5±1.6) points, «daily activity» – (93.1±2.8) points, «sports activity» – (73.9±2.1) points, «quality of life» – (84.6±1.9) points. The average values of knee function by the Lysholm Knee Scoring Scale was 95.1±2.1. According to the 2000 IKDC, 117 (91.4 %) patients were included in group A, and 11 (8.6 %) in group B. Patients with moderate or severe impaired knee function (C and D) were not observed. The average time of the ACL-R was (82.1±2.4) min., ACL-R and LEAT – (94.7±6.9) min. The mean hospital stay was (3.2±1.8) days and (3.8±1.3) days, respectively. Conclusion. Non-free grafts for ACL-R and LEAT have an anatomically reliable fixation point, which allows to achieve high functional results of the knee joint. The proposed techniques can be reproduced with standard instruments and implants, taking into account the average operating time and blood loss, and without significant infection complications, persistent synovitis, contractures and hypotrophy of the thigh muscles.

For anterior cruciate ligament (ACL)-deficient patients, using a single bone-patellar tendon-bone (BPTB) graft for the double-bundle concept is one of the suitable approaches for acquiring better stability and reducing bone tunnel enlargement compared with the use of hamstring grafts. At least 10-mm width of BPTB autograft is needed to achieve this concept; however, it is larger than one-third of the patellar tendon width for small or middle physique patients. This study aimed to assess the clinical and radiographic outcomes of BPTB and gracilis (G) composite autografts for primary double-bundle ACL reconstruction in Asian athletes. Thirty-two Asian patients undergoing double-bundle ACL reconstruction with 7.0 to 7.5 mm of BPTB and 5.0 to 5.5 mm of G composite grafts were compared with 43 double-bundle ACL reconstruction with hamstring graft cases. The BPTB graft was used for the anteromedial bundle (AMB), with the G graft for the posterolateral bundle (PLB). Percentage of femoral bone tunnel enlargement compared with the original size was determined by computed digital radiographs on the first postoperative day and at 12 months in the anteroposterior (AP) and lateral views. Standard clinical evaluations, including the limb symmetry index (LSI), were also performed. Less PLB tunnel enlargement was found in the BPTB + G group than in the hamstring group in the AP (101.9 ± 22.9 vs.113.7 ± 20.6%, p = 0.031) and lateral views (104.4 ± 18.1 vs. 120.6 ± 23.4%, p

To compare isometric hamstring strength deficits, knee laxity, functional outcomes, and patient-reported outcomes between patients who underwent anterior cruciate ligament (ACL) reconstruction with doubled semitendinosus and gracilis tendon autograft (ST/G) versus quadrupled semitendinosus autograft (ST), at a minimum follow-up of 1-year postoperatively.Patients who underwent ACL reconstruction with ST/G or ST hamstring autografts were retrospectively identified. Isometric hamstring strength was tested with a hand-held dynamometer at 30, 60, and 90° of knee flexion. Anterior knee laxity was assessed using a KT-1000 arthrometer. Functional outcomes were collected using the single-leg hop test and single-leg squat test. Side-to-side differences were determined and compared between the ST/G and ST groups. Patient-reported outcomes were collected on all patients.Eighty-four patients who underwent ST/G (n = 34) or ST (n = 50) autograft ACL reconstruction were recruited to participate in this study. There was no difference in knee laxity between the groups. Side-to-side hamstring strength deficits increased with increased flexion angles. At 90° of flexion, the ST/G group had a significantly greater flexion strength deficit compared with the ST group (37.8 ± 15.1% vs 24.7 ± 12.5%, P.001). Aside from a significant difference in the KOOS pain Score (P .045), no other significant differences in functional or patient reported outcomes between the groups were identified.Patients who underwent ACL reconstruction with ST/G compared with ST autograft have a significantly greater isometric flexion strength deficit at 90° of flexion. Future investigations are required to determine the clinical relevance of this difference and whether specialized therapy protocols can mitigate this deficit.Level III, retrospective comparative study.

To achieve in the reconstruction of the anterior cruciate ligament a graft with strength, tension and low comorbidity is fundamental. An emerging concept is that a graft diameter of less than 7 mm carries a greater risk of re-rupture and instability. Consequently, different methods are being sought to predict intra-surgical size. The objective is to predict the size of the hamstring graft by measuring the area of the semitendinous and gracilis tendon with magnetic resonance imaging (MRI). Methodology We carried out an observational retrospective study of 56 patients. They underwent anterior cruciate ligament reconstruction with 4-GST hamstring graft. The parameters evaluated were anthropometric data, hamstring graft diameter, area of gracilis and semitendinosus tendon in MRI. The measurements were made by three independent evaluators. Results The mean diameter of the intrasurgical graft was 8.46 mm, in the MRI the area of the gracilis was 8875 mm and the semitendinosus area was 13,068 mm. Their mean was 22.12 for the automatic measurement and 21.53 for the manual measurement. The interobserver correlation was regular for the automatic measurement (ICC = .595) and low for the manual measurement (ICC = .446). The result of the intraobserver correlation was excellent (ICC = .917). We did not obtain a statistical correlation between the measurement of areas and the increase of the graft diameter (R = .069, P = .63). Conclusion We determined with our results that the intrasurgical graft size is not predictable with the measurement of the area of the gracilis and semitendinosus tendon on the MRI.

Background The purpose of this study was to retrospectively analyze the clinical outcomes of patients with recurrent patellar dislocation who underwent arthroscopic medial patellofemoral ligament (MPFL) reconstruction using gracilis tendon autograft and a modified double-patellar tunnel method. We hypothesized that our modified method would provide good clinical outcomes. Methods Patients who underwent arthroscopic MPFL reconstruction with autograft gracilis tendon and modified double-patellar tunnels technique for recurrent patellar dislocation and were followed up for a minimum of 5 years were identified, and the clinical and follow-up data were retrospectively analyzed. Preoperatively, joint hypermobility was assessed with the Beighton score. The Insall–Salvati ratio, TT–TG distance, and Q angle were measured on radiographic images. Patient-reported outcomes including the Kujala, Lysholm, and Tegner scores were collected preoperatively and postoperatively. Patient satisfaction was assessed at the end of 5 years. Complications and recurrent dislocation occurring after surgery were recorded. Results A total of 79 patients (94 knees) were enrolled; of these, 13 (16.5%) were lost to follow-up. The data of 66 patients (80 knees) were available for final analysis. Mean age at surgery was 21.3 ± 7.8 years. Mean follow-up time was 66.1 ± 5.5 months (range, 60–78 months). Postoperative patient-reported outcome was not associated with Beighton score, Insall–Salvati ratio, or TT–TG distance. Q angle was negatively correlated to Kujala scores and Lysholm scores. Severity of trochlear dysplasia was not associated with postoperative patient-reported outcome. The mean Kujala score increased from 69.4 ± 7.9 to 96.1 ± 1.9, the mean Tegner score increased from 3.1 ± 1.3 to 5.9 ± 1.3, and the mean Lysholm score increased from 73.5 ± 14.6 to 95.3 ± 3.4. Two patients experienced recurrent patellar dislocation during follow-up. Conclusions MPFL reconstruction using autologous gracilis tendon under arthroscopy appears to be a reliable and safe method for treating recurrent patellar dislocation. Level of evidence Level IV.

The prevalence of ulnar collateral ligament injuries and reconstructions among overhead throwing athletes has significantly risen in recent years. Surgical reconstruction has become the main treatment modality for athletes who have failed conservative treatment and wish to return to their sport. There has been an increased interest in graft augmentation in ligament reconstruction surgeries as surgeons search for ways to decrease the chance of graft failure. Augmented graft techniques have been described for other procedures. We present a technique that incorporates a cross-linked suture tape into either a palmaris longus or gracilis tendon autograft or allograft for ulnar collateral ligament reconstruction. This may allow for a biomechanically stronger construct because it appears this is the case in other settings. The goal is that this would lead to decreased rates of failure or possibly allow athletes to return at an accelerated rate.

Background Subluxation of the extensor carpi ulnaris (ECU) tendon can be a challenging problem to the surgeon, with no options described for failure following autologous reconstruction. It is our intention to provide guidance on technique by describing our experience in a 20-year-old male with Ehlers–Danlos syndrome. Case Description The patient presented with pain and snapping of the ECU tendon, and failed both immobilization and ECU reconstruction with autologous extensor retinaculum. A gracilis tendon allograft was used to reconstruct the ECU sheath, in addition to ulnar groove deepening. At 1-year follow-up, the patient had no pain and the ECU was stable without recurrent subluxation. Literature Review To the authors' knowledge, the use of tendon allograft for stabilization of recurrent ECU subluxation following surgical repair or reconstruction has not been previously described in the medical literature. Clinical Relevance Utilization of tendon allograft is a viable technique to stabilize the ECU tendon while minimizing the risk in relying on compromised autologous tissue. This report represents the first account of successful reconstruction following failed autologous reconstruction.

Objectives: This study’s objective was to determine whether multimodal analgesia plus an injection of the hamstring sheath immediately following the harvest of the semitendinosus and gracilis tendons during hamstring autograft anterior cruciate ligament reconstruction (ACLR) reduces postoperative pain. We hypothesized that multimodal analgesia plus a hamstring sheath injection of the harvest site for autograft hamstring ACLR reduces postoperative pain. Methods: The Institutional Review Board approved this study registered with ClinicalTrials.gov and identified by NCT01868425. This study was a single-center, surgeon stratified double-blind, placebo-controlled, randomized study from April 2013 to December 2017. Patients were randomly assigned to one of two groups, in a 1:1 ratio per surgeon, to receive either standard of care analgesia plus intra-operative hamstring sheath saline injection (Placebo group) or standard of care analgesia plus multimodal analgesia plus intraoperative hamstring sheath anesthetic injection (MA group) for patients undergoing ACLR with hamstring autograft. Eligible participants were adults aged 18 years to 55 years old consented for ACLR using hamstring tendon autograft. Contraindication to a femoral nerve block, allergy to protocol medications, nervous system disease, renal or hepatic impairment, history of opioid dependence or current narcotic use, significant psychiatric disease, pregnancy or lactating, a seizure disorder, history of postoperative nausea and vomiting, latex allergy, and clinically significant cardiac or pulmonary disease excluded patients for participation in this study. The primary endpoint was total postoperative opioid administration. Secondary endpoints included the patient’s subjective pain score for the posterior, anterior, and lateral side of the knee, postoperative nausea, sedation, and pruritus scores. Based on our preliminary data, we estimated the mean opioid for standard care will be 6.6 morphine equivalents with a standard deviation of 6.2 morphine equivalents. Testing the ability of multimodal analgesia to reduce opioid usage by at least 50%, a minimal sample size of 45 subjects per group was needed to achieve 80% power based on a one-tailed t-test and a significance level < 0.05. Student’s t-test compared outcomes between groups. Additionally, a linear regression model for was also used for the primary outcome with total opioid administration as the dependent variable in order to control for body mass index (BMI) and sex, providing an adjusted estimate of the difference between groups. Results: A total of 112 patients (Figure 1) met inclusion criteria and were randomized into the placebo group (n = 57) and MA group (n = 55). Demographic data demonstrated no significant differences between groups (Table 1). The primary analysis was postoperative opioid administration and included all patients randomly assigned to either group for opioid administration in the postoperative anesthetic care unit (PACU), however opioid administration in 24 hours after discharge was not recorded for five patients in the MA group, leaving 50 patients remaining for the per-protocol analyses. Secondary outcome data was not recorded for one patient in the placebo group leaving 56 patients remaining for the per-protocol analyses. The mean postoperative opioid needs (Table 2) for patients in the MA group (18.7 ± 13.14) was less than those in the placebo group (22.6 ± 11.15), although this was not statistically significant (p-value = 0.140). Secondary outcomes (Figure 2A) demonstrated a significant reduction in posterior knee pain postoperatively in the MA group (2.84 ± 2.25) compared to Placebo (3.56 ± 1.97; p-value = 0.0362). There were no significant differences in postoperative pain in the front or sides of the knee. Similarly, there were no significant differences in pruritis (MA: 0.26 ± 0.99 vs. Placebo: 0.696 ± 1.73; p-value = 0.2163), sedation (MA: 5.02 ± 2.29 vs. Placebo: 4.61 ± 2.16; p-value = 0.656), and nausea (MA: 1.16 ± 2.28 vs Placebo: 0.714 ± 1.72; p-value = 0.243) scores (Figure 2B). Conclusions: Multimodal analgesia plus hamstring sheath injection reduces postoperative patient reported posterior knee pain compared to placebo for patients undergoing ACLR using hamstring tendon autograft. However, multimodal analgesia plus a hamstring sheath injection does not reduce postoperative opioid requirements.

Case A 14-year-old girl with a hypermobility syndrome presented with bilateral snapping semimembranosus (SM) and semitendinosus (ST) tendons. After failure of conservative treatment, she was treated with tenotomy of SM and later tendon transposition of her ST to her gracilis. Conclusions Surgical treatment of snapping hamstring tendons has historically consisted of the release of the tendon insertions (tenotomy) or tendon harvest. This new surgical technique describes an alternative technique for definitive management with tenotomy and tendon transposition where the snapping ST is transposed to the gracilis tendon to maintain hamstring muscle length, strength, and function.

The significance of graft diameter in anterior cruciate ligament reconstruction (ACLR) with soft tissue grafts is well established, with a minimum graft diameter of 8.0 mm associated with lower rates of revision surgery. Consistently achieving grafts that meet or exceed the ideal diameter of 8.0 mm is still a concern with traditional tibial screw fixation, even with quadrupled hamstring autografts. The authors hypothesized that following a simple intraoperative algorithm selectively incorporating the gracilis tendon in an 8-stranded construct for all-inside ACLR with suspensory fixation on both ends of the graft would consistently achieve graft diameters of 8.0 mm or larger by allowing more of the graft material to contribute to increased diameter instead of increased length for screw fixation, with no allograft tissue required. A total of 113 eligible cases were identified, including 70 male patients and 43 female patients (mean±SD age, 25.92±6.47 years; range, 14–49 years). All 113 grafts (100%) were at least 8.0 mm in diameter. There were 8 grafts that were 8.0 mm. Overall mean±SD graft diameter was 9.32±0.71 mm (median, 9.5 mm; range, 8.0–11.0 mm). There were no cases in which allograft tissue was needed to increase graft size. An analysis of 113 cases of all-inside hamstring autograft ACLR with dual suspensory fixation showed that a graft diameter of at least 8.0 mm was achieved in every case, without the use of allograft tissue. These results suggest that this technique for ACLR is reliable in producing grafts that meet or exceed the recommended minimum diameter of 8.0 mm. [ Orthopedics . 2021;44(4):e539–e545.]

Recurrent shoulder instability complicated by capsular insufficiency due to underlying soft-tissue disorders or multiple prior failed surgical procedures poses a challenging surgical problem. Traditional capsulolabral soft-tissue reconstruction techniques are less effective in this setting, and bony procedures sacrifice normal anatomic relations. The described arthroscopic technique aims to prevent instability while maintaining range of motion through creation of a soft-tissue allograft “sling” augmenting the posterior glenohumeral capsule.

The purpose of this study was to map saphenous nerve injuries after gracilis tendon harvest, with the aim of contributing knowledge that makes it possible to prevent these injuries. Twenty-two cadaver limbs were used. Three were dissected to examine fascial structures between the saphenous nerve and the gracilis tendon. In 19 limbs, the gracilis tendon was harvested according to standard operative routine. The saphenous nerve was subsequently exposed by dissection and injuries were recorded. A well-defined sub-sartorial fascial layer separated the saphenous nerve from the gracilis tendon. Incisional injuries involving either a medial cutaneous crural branch or the infrapatellar branch were found in 14 of the 19 cases. Non-incisional injuries affecting the sartorial branch of the saphenous nerve (to conform to most surgical literature, we use the term 'sartorial branch' to denote the continuation of the saphenous nerve after departure of the infrapatellar branch) were found in six cases located 5–8 cm proximal and posterior to the gracilis tendon insertion on tibia. The fascia separating the saphenous nerve from the gracilis tendon had been perforated in relation to all non-incisional injuries. Small subcutaneous branches of the saphenous nerve are at risk of injury from the incision, while the sartorial branch is at risk outside the incision area. Descriptions of the location of non-incisional injuries have not been published before and are of clinical relevance, as they can contribute to the prevention of saphenous nerve injuries during gracilis tendon harvest.

Background: Semitendinosus tendon is considered one of the best grafts for ACL reconstruction. Only if the semitendinosus graft is inadequate in length or diameter the need for gracilis tendon occurs. Harvesting the semitendinosus tendon along with a 1.5 to 2 cm periosteal strip from anteromedial tibia will increase the graft dimensions. The purpose of this study is to assess the functional outcome of ACL reconstruction with this modified form of semitendinosus graft. Materials and methods: Twenty patients with symptomatic ACL tear underwent arthroscopic ACL reconstruction using quadrupled semitendinosus tendon along with a strip of periosteum from the anteromedial tibia. No patient required gracilis tendon and all had a graft diameter of 8mm and above with a length greater than 7.5cm. Seventeen patients completed a period of one year follow up. Results: The average preoperative score was 61.24 (S.D.=5.8). After surgery, the average Tegner Lysholm score at one year was 87.76 (S.D.=4.1). This shows a significant improvement in the score (p value

Background: The debate continues regarding the best way to reconstruct posterior cruciate ligament (PCL). The objective of this study was to compare the knee stability and clinical outcomes after single and double bundle (SB and DB) PCL reconstruction. Materials and Methods: A total of 98 patients with PCL injury were enrolled for PCL reconstruction with four-strand semitendinosus and gracilis tendon autograft in the SB technique (n = 65) or two-strand Achilles allograft in the DB technique (n = 33). Each bundle fixation was achieved by the means of femoral Endo Button CL and tibial bioabsorbable interference screw. Demographic data, knee stability, and clinical outcomes were collected for analysis. Results: The SB and DB groups showed comparable demographic data. After a minimum followup interval of 24 months, the data of 59 patients in the SB group and 30 patients in the DB group were analyzed. There was no statistical difference between the SB and DB group in terms of both knee stability and clinical outcomes (P > 0.05). Conclusions: Compared with the SB technique, the DB technique did not exhibit any superiority in knee stability or clinical outcomes.

Background: Patella instability and medial patellofemoral ligament (MPFL) injury are frequently encountered in pediatric patients. MPFL reconstruction is often chosen to treat this condition with good results; however, no consensus has been reached about which graft or technique to use. The purpose of this study was to evaluate the differences in graft survivorship, clinical outcomes (assessed with Kujala scores), and cost between autograft and allograft usage in MPFL reconstruction in pediatric patients. Methods: In this retrospective review of patients who underwent MPFL reconstruction between 2012-2015, autograft gracilis tendon was used for Group 1, and allograft gracilis tendon was used for Group 2. Outcomes were graft survivorship, postoperative Kujala scores, operative time, costs, graft size, and tibial tubercle–trochlear groove distance. Results: Fifty-six patients were included in this study, 21 in Group 1 and 35 in Group 2. No differences in age, sex, or chronicity were seen between the groups. Patients in Group 1 had longer operative times (134.5 minutes vs 97.3 minutes, P=0.0002), higher rates of graft failure (28.6% vs 0%, P=0.0037), and lower Kujala scores (80.3 vs 92.1, P=0.0032) compared to Group 2. All graft failures occurred in patients with chronic patella dislocations and occurred an average of 13.8 months postoperatively. Overall, autograft was costlier than allograft because of the cost of reoperation. Conclusion: This study supports the use of allograft for chronic patellar instability because of improved graft survivorship and clinical outcome scores, as well as the lower cost and reoperation rate.