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Background: There is still debate regarding the association between arthrometric knee laxity measurements and subjective knee outcome and revision surgery after primary anterior cruciate ligament reconstruction (ACLR). Purpose: To assess whether arthrometric knee laxity (measured with the KT-1000 arthrometer) 6 months after primary ACLR was associated with the 1-, 2-, and 5-year subjective knee outcomes or revision ACLR at a 5-year follow-up. Study Design: Cohort study, Level of evidence 3. Methods: Patients who underwent primary ACLR with a hamstring tendon autograft at the authors' institution between January 1, 2005, and December 31, 2017, with no concomitant ligamentous injuries, were identified. Anterior knee laxity (KT-1000 arthrometer, 134 N) was assessed 6 months postoperatively. The Knee injury and Osteoarthritis Outcome Score (KOOS) was collected preoperatively and 1, 2, and 5 years postoperatively. Patients who underwent revision ACLR at any institution in the country within 5 years of primary surgery were identified through the Swedish National Knee Ligament Registry. Results: A total of 4697 patients (54.3% male) with available KT-1000 arthrometer measurements were included (normal: side-to-side [STS] ≤2 mm, 3015 [64.2%]; nearly normal: STS 3-5 mm, 1446 [30.8%]; abnormal: STS >5 mm, 236 [5.0%]). The only significant difference in subjective knee outcome between the groups was for the KOOS Symptoms subscale at the 1-year follow-up (STS ≤2 mm, 79.9 ± 16.2; STS 3-5 mm, 82.5 ± 14.8; STS >5 mm, 85.1 ± 14.2; P <.001). No other significant differences between the groups were found preoperatively or at 1, 2, or 5 years postoperatively for any of the KOOS subscales. The hazard for revision ACLR within 5 years of the primary surgery was significantly higher for the groups with an STS of 3 to 5 mm (6.6%; 95/1446) (hazard ratio [HR], 1.42; 95% CI, 1.07-1.87; P =.01) and an STS >5 mm (11.4%; 27/236) (HR, 2.61; 95% CI, 1.69-4.03; P <.001) compared with the group with an STS ≤2 mm (3.8%; 116/3015). Conclusion: A high grade of postoperative knee laxity (STS 3-5 mm and STS >5 mm) 6 months after primary ACLR was associated with an increased hazard of revision ACLR within 5 years, but it was not associated with an inferior subjective knee outcome. [ABSTRACT FROM AUTHOR]

To create a cut-off point for hyperextension that best discriminates retear and to verify whether this cut-off point can predict retear regardless of other characteristics after primary anterior cruciate ligament (ACL) reconstruction with hamstrings autograft. A cohort of patients submitted to primary isolated ACL reconstruction with hamstrings autografts was retrospectively evaluated. Patients were stratified according to the degree of passive knee hyperextension measured in the normal contralateral knee. The following data were collected: patient age and sex, time from injury to surgery, knee hyperextension, KT-1000 and pivot-shift, associated meniscus injury, intra-articular graft size, follow-up time, graft failure, and postoperative Lysholm and subjective International Knee Documentation Committee scores. Data from 457 patients were evaluated. Median age was 31 years. Thirty-two (7.0%) presented with retear. There was a significant difference in hyperextension between patients with and without retear (P <.001), with the cut-off point established by the receiver operating characteristic curve from 6.5°. Patients with greater hyperextension had a statistically greater frequency of women, longer injury time, greater intra-articular graft diameter, greater postoperative KT-1000, and greater frequency of retear, whereas the subjective International Knee Documentation Committee and Lysholm scores were statistically lower in patients with greater hyperextension. Only hyperextension showed a statistically significant association with re-rupture (P <.001). The odds of retear in patients with hyperextension greater than 6.5 was 14.65 times the odds of patients with hyperextension less than 6.5. Patients with more than 6.5° of hyperextension are 14.6 times more likely to have a graft rupture than patients with lower hyperextension when submitted to ACL reconstruction with hamstring tendons. Also, they present worse knee stability by the KT-1000 test and worse functional outcomes. Therefore, patients with this degree of hyperextension should not have isolated reconstruction with hamstrings as their first choice. Level III, retrospective comparative prognostic trial. [ABSTRACT FROM AUTHOR]

To compare patients undergoing anterior cruciate ligament (ACL) reconstruction with hamstring grafts 7 mm or less in diameter combined with anterolateral ligament (ALL) reconstruction versus isolated ACL reconstruction with grafts greater than 7 mm in diameter. We retrospectively evaluated the descriptive data and clinical outcomes of patients who underwent primary ACL reconstruction with hamstring grafts from June 2013 to January 2020 and had a minimum follow-up period of 2 years. Patients with quadrupled or quintupled semitendinosus and gracilis autograft 7 mm or less in diameter combined with single-strand ALL reconstruction (ACL-ALL group) were matched in a 1:2 propensity ratio to patients who underwent isolated single-bundle ACL reconstruction with hamstring grafts greater than 7 mm (ACL group). We identified 30 patients in our database who met the criteria for the ACL-ALL group. The patients in this group were matched to 60 patients comprising the ACL group. Both groups were similar regarding all preoperative matched and unmatched variables. The mean ACL graft diameter was 6.8 ± 0.4 mm in the ACL-ALL group and 8.6 ± 0.6 mm in the ACL group (P <.001). The ACL-ALL group presented 1 failure (3.3%), and the ACL group presented 3 failures (5%) (P =.717). Postoperative KT-1000 measurements were similar between the groups (2.1 ± 1.1 mm vs 1.9 ± 1.2 mm, P =.114), as were postoperative pivot-shift grades (P =.652). Subjective International Knee Documentation Committee scores and Lysholm scores did not present any differences between the groups (P =.058 and P =.280, respectively). Patients who undergo combined ACL-ALL reconstruction with an ACL graft diameter of 7 mm or less can achieve similar results to patients who undergo isolated ACL reconstruction with a graft diameter greater than 7 mm. An associated ALL reconstruction can be performed to increase knee stability in patients with small-diameter hamstring grafts. Level III, retrospective, comparative therapeutic trial. [ABSTRACT FROM AUTHOR]

The indications for combining anterior cruciate ligament reconstruction with anterolateral ligament reconstruction have increased considerably in recent years since several anatomical, clinical, and biomechanical studies have proven the importance of the anterolateral periphery in knee rotational stability. Much is still being discussed on how to combine these techniques in terms of which grafts and fixation options to use, as well as avoiding tunnel convergence. This study aims to describe anterior cruciate ligament reconstruction with a triple-bundle semitendinosus tendon graft all-inside technique combined with an anterolateral ligament reconstruction maintaining the gracilis tendon insertion on the tibia, using independent anatomical tunnels. With this, we were able to reconstruct both using only hamstring autografts, reducing morbidity in other possible donor areas, in addition to allowing stable fixation of both grafts without tunnel convergence. [Display omitted] [ABSTRACT FROM AUTHOR]

Anterior cruciate ligament injuries are common in high school and college with an estimated 120,000 cases per year in the United States. Most sports injuries occur without direct contact, and knee valgus with external rotation of the foot is the most common movement. This movement may be related to the injury of the anterior oblique ligament located in the anteromedial quadrant of the knee. This technical note presents anterior cruciate ligament reconstruction with extraarticular anteromedial reinforcement using hamstring and the anterior half of the peroneus longus grafts. [Display omitted] [ABSTRACT FROM AUTHOR]

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Background: Combining an anterior cruciate ligament (ACL) reconstruction with an anterolateral ligament (ALL) reconstruction results in significant advantages including reduced graft rupture rates, a lower risk of reoperation for secondary meniscectomy, improved knee stability, and higher rates of return to preinjury levels of sport. Indications: The previously reported indications for combined ACL and ALL reconstruction are as follows: ACL reconstruction revision; high-grade pivot shift test; long-term ACL rupture; young patients; pivoting activities; concomitant medial meniscus repair, and, specifically, regarding the ALL repair, it must be an acute surgery (within 15 days from injury). Technique Description: Several modern techniques have been described to repair and reconstruct the ALL. This technical note details a number of these techniques performed by the Scientific Anterior Cruciate Ligament Network International (SANTI) Study Group. Results: First, we describe a combined ACL reconstruction and double-bundle ALL reconstruction using hamstring autograft. Secondly, we describe a single-bundle ALL reconstruction using gracilis autograft. Thirdly, we describe an ALL reconstruction technique using a knotless soft anchor, which provides shallow fixation and prevents tunnel convergence. Finally, we describe a technique for ALL repair. Conclusion: Several techniques have been described to repair and reconstruct the ALL, all offering significant advantages over an isolated ACL reconstruction. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication. Graphical Abstract This is a visual representation of the abstract. [ABSTRACT FROM AUTHOR]

To compare the failure rate in patients who underwent revision anterior cruciate ligament (ACL) reconstruction alone or associated with an extra-articular procedure. Secondary objectives were to compare ACL laxity, patient-reported outcome measures, and complication rates in these patients and, subsequently, to compare the outcomes of patients who underwent revision ACL reconstruction associated with anatomical anterolateral ligament (ALL) reconstruction or lateral extra-articular tenodesis (LET). This was a retrospective comparative study. Patients were classified into 2 groups, according to whether (group 2) or not (group 1) an extra-articular reconstruction was performed. Patients who underwent an extra-articular procedure were further divided into ALL reconstruction (group 2A) and LET (group 2B). Baseline demographic variables, operative data and postoperative data were evaluated. The groups with (86 patients) and without (88 patients) an associated extra-articular reconstruction had similar preoperative data. Group 2 had a lower failure rate (4.6% vs 14.7%; P =.038), better KT-1000, better pivot–shift, and better Lysholm. There was no difference regarding complications, except more lateral pain in group 2. Regarding the groups who underwent ALL reconstruction (41 patients) and LET (46 patients), group 2A showed better Lysholm scores. Both groups had similar failure rates and complications. Patients who underwent revision ACL reconstruction with a laterally based augmentation procedure had a lower failure rate than patients who underwent isolated revision ACL reconstruction. KT-1000 and pivot–shift examination were also significantly better when a lateral augmentation was performed. Complications were similar except for an increase in lateral pain in the augmented group. No clinically important differences were found when comparing the LET group to the ALL group other than a statistical improvement in the Lysholm functional scale, likely not clinically meaningful, favoring the ALL group and an increased duration of post-operative lateral pain in the LET group. III, retrospective comparative therapeutic trial. [ABSTRACT FROM AUTHOR]

We present a technique for the combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction using the superficial layer quadriceps tendon graft. Anatomic reconstruction is achieved with outside-in femoral tunnel drilling. The femoral drill guide has an intra-articular placement at the femoral footprint of the ACL and an extra-articular placement at the femoral ALL attachment. This surgical technique does not need any special instruments and consists of 3 bone tunnels. The long length and customized superficial quadriceps tendon graft is harvested in a minimally invasive manner and allows an accessible and low-cost reconstruction of both ligaments. [Display omitted] [ABSTRACT FROM AUTHOR]

Ramp lesions are peripheral tears of the posterior horn of the medial meniscus that involve the meniscocapsular attachments. They are commonly associated with anterior cruciate ligament injury and frequently not diagnosed. There are several suture techniques for ramp lesions. However, most have a long learning curve to be performed adequately and to minimize the risks of neurovascular lesions, cartilage injury, as well as damage to the meniscotibial ligament and meniscus. Thus, as an alternative to minimize costs and provide adequate ramp lesion repair, we present a simple, easy-to-reproduce technique using a Scorpion Suture Passer and all-inside sutures, without the need to leave devices inside the knee, causing no additional lesions and making it less costly than conventional methods. Our technique, which consists of a biomechanically strong suture, with no internal devices, is cheaper, allows several sutures with the same thread and produces satisfactory clinical results. [Display omitted] [ABSTRACT FROM AUTHOR]

This article presents a surgical technique for combined reconstruction of the anterior cruciate ligament (ACL) and anterolateral ligament (ALL) of the knee using hamstring tendon graft. This approach involves creating a single femoral tunnel and using a triple-strand braided hamstring graft for the ACL and a strand of the gracilis tendon for the ALL. This technique aims to increase strength and improve knee stability, potentially reducing the risk of reinjury. The described method provides anatomic reconstruction of the ACL and ALL and allows for combined reconstruction with just 1 graft donor site. Another advantage is that the triple braided graft takes on a tape-like shape, mimicking the native form of the ACL and theoretically increasing biomechanical strength. Combined reconstruction of the ALL and ACL has shown excellent results in specific patient groups, reducing graft failure and improving outcomes in patients with a high risk of rupture. Thus, we describe a promising option for ligament reconstruction in cases of combined ACL and ALL injuries. This method may be a valuable alternative for orthopaedic surgeons, combining anatomic reconstruction with the use of a single donor site. [Display omitted] [ABSTRACT FROM AUTHOR]

Purpose: To report the arthroscopic treatment results of a degenerative medial meniscus tear with a displaced flap into the meniscotibial recess, tibial peripheral reactive bone edema, and focal knee medial pain. As a secondary objective, we propose to identify possible factors associated with a good or poor prognosis of the surgical treatment of this lesion.Methods: From 2012 to 2018, patients who had this specific meniscus pathology and underwent arthroscopic surgical treatment were retrospectively evaluated. Patients with Kellgren-Lawrence (KL) classification greater than 2 were excluded. KL classification, the presence of an Outerbridge grade III/V chondral lesion of the medial compartment, limb alignment, body mass index, and smoking were evaluated. The subjective outcomes included the International Knee Documentation Committee score, improvement in the pain reported by patients, and the Global Perceived Effect (GPE) scale score.Results: A total of 69 patients were evaluated. The mean age was 58.6 ± 7.1 years. The follow-up time was 48.7 ± 20.8 months. Fifty-five (79.7%) patients reported pain improvement. The postoperative International Knee Documentation Committee was 62.6 ± 15.4, and the mean GPE was 2.3 ± 2.6. Fourteen patients (20.3%) showed no improvement in pain, and 7 patients (10.2%) presented complications. Groups that improved (GPE > 0) and did not improve (GPE < 0) did not present differences regarding age, sex, follow-up time, chondral lesions, or body mass index. Patients without improvement had a greater incidence of smoking (P = .001), varus alignment (P = .008), and more advanced KL classification (P < .001). In the multivariate analysis based on the GPE score, KL classification (P = .038) and smoking (P = .003) were significant.Conclusions: Arthroscopic surgical treatment of degenerative medial meniscal tears with a meniscal flap displaced into the meniscotibial recess and adjacent focal bone edema in the tibia shows good results in approximately 80% of cases. Smoking and KL grade 2 were factors associated with poor prognosis of surgical treatment.Level Of Evidence: Level IV (case series). [ABSTRACT FROM AUTHOR]

Purpose Methods Results Conclusions Level of Evidence To evaluate and compare the subjective knee function in patients undergoing revision and bilateral anterior cruciate ligament (ACL) reconstruction (ACLR) with those undergoing primary ACLR in a large cohort.Patients without concomitant ligament injuries who underwent primary, revision or bilateral ACLR at the Capio Artro Clinic, Stockholm, Sweden, between 2005 and 2018 were identified. The Knee injury and Osteoarthritis Outcome Score (KOOS) was collected preoperatively and at 1, 2 and 5 years postoperatively from the Swedish National Knee Ligament Registry. Patients who underwent revision and bilateral ACLR were compared with those who underwent primary ACLR (control group) using Student's t test.A total of 6831 patients (6102 with primary ACLRs, 343 with revision ACLRs and 386 with bilateral ACLRs) were included. Preoperatively, there were significant but nonclinically relevant differences in favour of the revision ACLR group for KOOS Symptoms, Pain, Activities of Daily Living (ADL) and Sport/Rec subscale scores compared with the primary ACLR group. Postoperatively, except for the 1‐year Symptoms and ADL subscales, the revision ACLR group reported significantly lower scores on all KOOS subscales than the primary ACLR group, with clinically relevant differences (>8–10 points) for the 1‐, 2‐ and 5‐year Sport/Rec and Quality of Life (QOL) subscales. The bilateral ACLR group reported significantly, but not clinically relevant, inferior scores on the 1‐year Symptoms and QOL subscales and the 5‐year Sport/Rec and QOL subscales compared with the primary ACLR group.Revision ACLR, but not bilateral ACLR, was associated with clinically relevant inferior subjective knee function compared with primary ACLR. It is important to counsel patients regarding their future subjective knee function after repeated ACLR. Compared to primary ACLR, inferior subjective results should be expected after revision ACLR, but not after bilateral ACLR.Level III. [ABSTRACT FROM AUTHOR]

Purpose: To compare the functional outcomes, knee stability, failure rate and complication rates of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction with hamstrings grafts between acute and chronic cases.Methods: Consecutive patients who underwent combined ACL and ALL reconstruction with hamstrings grafts were evaluated. Patients operated on less than 8 weeks after injury were allocated to group 1, and the others were allocated to group 2. Demographic data, knee stability, and functional outcomes of the 2 groups were evaluated.Results: Thirty-four patients in the acute group and 96 in the chronic group were evaluated. The follow-up time was similar between the groups (28.7 ± 5.2 [24-43] months vs 29.4 ± 7.2 [24-58] months; P = 0.696). No differences were found between the groups in age, sex, trauma mechanism, presence of knee hyperextension, graft diameter, and meniscal injuries. There was no difference between the groups in the postoperative KT-1000 and in the pre- or postoperative pivot shift. The preoperative KT-1000 was higher in group 2 (7.9 ± 1.1 vs 7.4 ± 1.2; P = 0.031). There were no differences in the International Knee Documentation Committee or Lysholm. Three (2.3%) patients developed failure, 1 (2.9%) in group 1 and 2 (2.1%) in group 2. The total complication rate was 10% and did not differ between the groups.Conclusions: Combined ACL and ALL reconstruction has similar outcomes in patients undergoing surgery in the acute and chronic phases. Patients with chronic injury have similar knee stability, functional scores, and failure rates as acute-injury patients, and patients with acute injury have no more complications than chronic patients.Level Of Evidence: Level III, retrospective comparative therapeutic trial. [ABSTRACT FROM AUTHOR]

The reconstruction of the medial patellofemoral ligament (MPFL) is an essential procedure in the surgical treatment of patellar instability. The medial third of the patellar tendon is a good graft option for this reconstruction, maintaining the insertion of the graft in the patella, with no need for hardware for patellar fixation. The objective of this article is to describe the MPFL reconstruction technique with the patellar tendon graft. [Display omitted] [ABSTRACT FROM AUTHOR]

Improved understanding and treatment of posterior medial and lateral meniscus root tears have attracted increasing interest. These lesions significantly compromise meniscal function, which can result in an outcome resembling total meniscectomy, and are also a potential cause of knee instability. Despite facilitating repair procedures and reducing the operative time for these lesions, all-inside meniscal repair devices are not available in all circumstances or registered for use in all countries worldwide. Furthermore, all-inside arthroscopic devices can be expensive. Therefore, low-cost alternatives for the treatment of these lesions must be identified. We present 2 efficient and safe techniques: an outside-in technique for repairing medial meniscus root tears and a technique using a simple needle inserted through the transtibial tunnel for lateral meniscal root repairs, neither of which requires the use of specific instruments, thus enabling appropriate treatment of posterior medial and lateral meniscus root tears. [ABSTRACT FROM AUTHOR]