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Background: The quadriceps tendon is crucial in allowing knee extension, attaching distally to the patella. While ruptures of the tendon are rare, retear can lead to muscle atrophy and complex tendon deficits with retraction which may make revision repairs difficult to perform. To avoid re-rupture, the repair is commonly augmented with an allograft or autograft, theoretically strengthening the repair. Indications: Patients are indicated for surgery when presenting with a chronic, symptomatic quadriceps rupture verified on provocative testing and advanced imaging. Technique Description: Adhesions and fibrotic tissues around the vastus muscles and tendon are released. Sutures and anchor materials from the previous reconstruction are removed. Fibrotic tissues at the distal end of the retracted quad tendon are removed. The tendon is then loosened from the proximal aspect with the applied traction through the suspension suture placed distal to the tendon. The gap is measured and a V-Y quadricepsplasty was performed at twice the length of the measured gap. In the proximal aspect of the tendon, the limbs of the V-plasty are left incomplete. Next, traction is applied to allow for a tightening exertion to the patella. The proximal Y limb is sutured together in a side-to-side fashion to allow for tendon distalization while retaining the distal traction of the patellar tendon. The medial and lateral limbs were then closed with a suture, completing the tendon advancement. Fibrotic tissues around the superior pole of the patella are removed to prepare for tendon reattachment. Two anchors on the medial and lateral sides are placed, and the suture threads from both anchors are tied in a Krackow configuration. The medial and lateral-sided suture knots are then tied together over the tendon and covered again with the Achilles allograft, completing the repair. Results: Outcomes of revision quadriceps repair have been promising, with good to excellent functional outcomes, successful return to activities, and objective outcomes. Discussion/Conclusion: Although initial studies report favorable outcomes following current repair techniques, there is a lack of quality literature on outcomes following primary or revision quadriceps repair. Future studies are necessary to determine the reliability, efficacy, and clinical outcomes following this procedure. 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.

Background: The incidence of anterior cruciate ligament (ACL) injuries has rapidly increased. Patients with ACL injuries frequently present with concomitant meniscal pathologies. Posterior medial meniscal root tears (PMMR) are less commonly seen with acute ACL injuries as compared with lateral tears and are often degenerative in nature or more rarely in an acute setting. Clinical studies have demonstrated medial meniscal deficiency to be a significant risk factor for graft failure and poor postoperative clinical outcomes. As such, given its demonstrated efficacy, there has been growing interest in transtibial meniscal repair mechanisms in combination with an ACL reconstruction as a potential solution to this challenging pathology. Indication: Patients are indicated for surgery when presenting with symptomatic ACL deficiency verified on provocative testing and advanced imaging and objective insufficiency of the medial meniscal root. Contraindications for this procedure include advanced osteoarthritis (Kellgren–Lawrence grade ≥3) on weight-bearing x-rays, age 30 as well as poor-quality meniscal tissue and unrepairable chondral defects. Technique Description: The ACL stump is debrided and a burr hole is created. A femoral aiming guide is used to drill the femoral tunnel. Following medial collateral ligament (MCL) release, a healing bony bed is prepared with a curette and shaver at the anatomic tibial footprint. An aiming device is then used through the anterior medial portal to create 2 transosseous tibial tunnels. A vertical mattress suture and simple suture are placed through the meniscal root, shuttled through the posterior and anterior transosseous tunnels, respectively. The tibial ACL tunnel is placed using a standard guide to avoid tunnel convergence with the root tunnels and prevent graft tunnel mismatch. After graft passage, interference screws are inserted while maintaining graft tension. The sutures are then tied over a cortical button over the tibia. Results: Within 2 years postoperatively, patients are expected to have improved overall knee-specific quality of life, reduced pain, and a successful return to activities with low rates of graft failure. Discussion/Conclusion: Recent advancements in our understanding of the relationship between the medial meniscus and the ACL should prompt surgeons to continue considering such combined treatments in indicated patients. 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.

Background: The incidence of anterior cruciate ligament (ACL) injuries, reconstructions, and re-ruptures has rapidly increased. Patients with failed ACL reconstructions have been reported to suffer from far worse outcomes as compared with those with primary reconstructions, prompting the advancement of surgical and biologic techniques. Effective treatment of re-tears has been shown to be achieved either utilizing a 1-stage or 2-staged approach, with the latter preferred if the patient presents with significant bone loss, previously malpositioned tunnels, or unacceptable tunnel expansion. Recent literature has shown the efficacy of bone marrow aspirate concentrate (BMAC) in improving clinical outcomes and graft integration as well as accelerated ligamentization. Indication: Patients are indicated for surgery when presenting with chronic ACL graft failure and objective insufficiency as well as concerns regarding tunnel overlap, enlargement, or interference. Contraindications for revision involve influences of concurrent injuries that may be secondary causes of the ACL injury. Technique Description: After bone marrow aspiration is performed, the tibial and femoral tunnel apertures are debrided of fibrous tissue with a combination of a shaver and curettes. A threaded guide wire is passed and the interference screws are removed, revealing the residual ruptured graft. A shaver and radiofrequency ablation device are utilized to clean off remaining graft remnants. Sequential debridement and reaming are performed to remove any residual fibrous tissue or sclerotic bone from the tunnel. The demineralized bone matrix is then combined with the prepared BMAC in a syringe with a cannula extension and subsequently injected into the tunnels. A freer elevate is used to tamp and smooth the graft to match the surrounding contour. A 12-mm cannulated allograft bone dowel is then passed up into the tibial tunnel and gently tamped into place. Results: Within 2 years postoperatively, patients are expected to have improved overall knee-specific quality of life, reduced pain, and a successful return to activities. No differences in outcomes have been noted in the literature between 1-staged and 2-staged ACL reconstructions. Discussion/Conclusion: Recent advancements in our understanding of the effects of BMAC in the setting of an ACL reconstruction should prompt surgeons to consider such treatments in indicated patients. 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.

Background: The meniscal roots are essential for preserving the structural and biomechanical properties of the tibiofemoral joint. Posterior meniscal root avulsions can cause meniscal extrusion, joint space narrowing, and progressive knee arthritis. Iatrogenic avulsions after malpositioning of the transtibial tunnels during anterior cruciate ligament (ACL) reconstruction have previously been reported in the literature to account for poor long-term outcomes seen in some patients following ACL reconstruction. Therefore, correct transtibial tunnel placement during ACL reconstruction is essential to avoid iatrogenic meniscal damage. Indication: Patients are indicated for surgery when presenting with a verified, symptomatic, complete meniscal root tear seen on advanced imaging or diagnostic arthroscopy. Contraindications for a root repair include the development of advanced osteoarthritis in the ipsilateral compartment, older age, and malalignment in the affected compartment. Technique Description: The ACL graft was appreciated and noted to be vertical and posterior relative to its native anatomical position, violating the lateral posterior horn root attachment. A full lateral posterior meniscal root avulsion was then confirmed directly adjacent to the graft tunnel. A curette was used to prepare the footprint of the lateral meniscal root on the posterolateral tibia for the 2-tunnel transtibial pull-out tunnels, and a grasper was used to position the torn meniscal root back into its anatomical site. Two ultrabraided sutures were passed through the posterior horn of the lateral meniscus using a suture passer. These were then passed through the tunnels into the body of the meniscal root and reduced to its native anatomical position. The suture repair was then secured over an Endobutton Fixation Device at 90° of knee flexion through each tunnel into its native anatomical position while confirming its adequate tension by viewing arthroscopically. Results: Within 2 years postoperatively, patients are expected to have improved overall knee-specific quality of life, reduced pain, and a successful return to activities. Discussion/Conclusion: This injury underscores the importance of an accurate tibial tunnel placement during ACL reconstruction to avoid posterior meniscal root injuries and other associated complications. Physicians should consider such pathology in the differential diagnosis of patients presenting with persistent pain and instability following a primary 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.