The posterior cruciate ligament (PCL) is vital for regulating posterior tibial translation in relation to the femur, which is critical for knee stability. PCL tears are infrequently isolated in knee injuries; however, the absence of the PCL results in abnormal knee kinematics, which may cause injuries to other ligaments. The ideal tendon source for PCL reconstruction is still a subject of debate.

To evaluate the results of employing the peroneus longus tendon (PLT) in PCL reconstruction.

A comprehensive search was conducted to identify relevant randomized controlled trials and retrospective observational studies discussing the outcomes of using the PLT for PCL reconstruction. Studies published up to August 2024 were searched across multiple databases, including PubMed, EMBASE, Scopus, Web of Science, Cochrane Library, and Google Scholar. Full texts of the selected articles were retrieved, reviewed, and independently assessed by the investigators. Discrepancies were resolved by consensus, with any remaining disagreements being arbitrated by a third author.

This meta-analysis included five studies on PLT use for PCL reconstruction: (1) Four prospective studies with 104 patients; and (2) One retrospective study with 18 patients. Most studies followed up participants for 24 months, while one had a shorter follow-up of 18 months. Lysholm and modified cincinnati scores improved by pooled means of 32.2 (95%CI: 29.3-35.1, I 2 = 0%) and 31.1 (95%CI: 27.98-34.22, I 2 = 0%), respectively. Postoperative American Orthopaedic Foot and Ankle Society and Foot and Ankle Disability Index scores were 94.5 (I 2 = 61.5%) and 94.5 (I 2 = 80.09%), respectively. Single-hop and triple-hop test scores averaged 95.5 (95%CI: 94.5-96.5) and 92.4 (95%CI: 91.9-92.9) respectively. No significant differences were observed in thigh circumference at 10 cm and 20 cm between the injured and healthy sides.

Evidence supports PLT autografts for PCL reconstruction, improving knee function and patient outcomes. Larger randomized trials are needed to confirm efficacy and compare graft options.

Anterior cruciate ligament (ACL) injuries are common in sports and often require surgical intervention, e.g., ACL reconstruction (ACLR), aimed at restoring knee stability and enabling a return to pre-injury activity levels. The choice of graft is crucial, impacting biomechanical properties, clinical outcomes, and complication rates, and is especially important in revision surgeries after graft failure. Over the past 30 years, trends in graft selection have evolved towards more individualized approaches, considering factors such as patient activity level, prior injuries, and tissue availability. In Europe, autografts like hamstring tendon (HT), bone-patellar tendon-bone (BTB), and quadriceps tendon (QT) are preferred, with the increasing use of QT grafts. This review synthesizes the current literature on graft selection and its influence on ACLR outcomes.

To investigate the healing of the quadriceps tendon donor site after partial thickness graft harvesting through ultrasound imaging at a short-term follow-up of 6-month following anterior cruciate ligament reconstruction (ACLR) and to investigate the clinical outcomes.

Between March 2019 and August 2020, 61 knees were retrospectively included in this study. Intraoperatively, the length, width and thickness of the harvested QT graft were measured. At a 6-month follow-up, patients were assessed by one of five radiologists, following the same protocol to calculate the defect volume, and patients performed a self-evaluation of pain on the Visual Analogue Scale, International Knee Documentation Committee (IKDC) and the Knee injury and Osteoarthritis Outcome Scores (KOOS).

Intraoperatively, the QT grafts had a volume of 4635.4 ± 912.5 mm3. Postoperatively, ultrasound was performed at 6.5 ± 0.7 months, and the defect volume was 323.3 ± 389.2 mm3, representing a healing rate of 93% ± 9% of the donor site. At a minimum 6-month follow-up, IKDC was 61.6 ± 16 and KOOS was 70.2 ± 16.6. Age was significantly associated with the healing rate (β: -0.005; p = 0.032).

At 6 months follow-up, the defect size of the QT donor site had healed by 93 ± 9% leaving a mean defect volume of 323.3 mm3 according to ultrasound measurements. This suggests that the QT has a high capacity for healing after graft harvesting, with 10 patients reaching full defect closure 6 months after surgery. The clinical relevance of these findings is that the quadriceps tendon donor site has high rates of healing, but surgeons should be aware of lower healing rates in older patients.

Level IV, retrospective case series.

Anterior cruciate ligament (ACL) injuries are a common occurrence among athletes and active individuals, often necessitating surgical intervention for optimal recovery. The choice of graft material for ACL reconstruction remains a topic of debate, with various options available, including quadriceps tendon (QT), patellar tendon bone allograft (PTBA), and cadaver graft (CG). This paper aims to provide an extensive review and comparison of the efficacy, outcomes, and complications associated with these graft types based on recent research. A systematic literature search following PRISMA guidelines was conducted to identify relevant studies published in the past six years. The findings suggest that while each graft type has its advantages and limitations, there is no definitive superior choice. Factors such as patient age, activity level, comorbidities, and surgeon preference should be considered when selecting the most appropriate graft for ACL repair surgery. QT grafts are associated with lower donor-site morbidity compared to patellar tendon grafts. However, QT grafts may have a higher risk of graft rupture and decreased knee flexion strength. PTBA grafts, compared to QT grafts, have a higher risk of donor-site morbidity but a lower risk of graft rupture and improved knee stability. CG grafts have lower donor-site morbidity compared to PTBA grafts but may have a higher risk of graft rupture and decreased knee flexion strength compared to PTBA grafts. In conclusion, the choice of graft material for ACL reconstruction is a complex decision that requires careful consideration of various factors, including patient age, activity level, comorbidities, and surgeon preference. While each graft type has its advantages and limitations, there is no definitive superior choice. Therefore, it is essential to carefully weigh the risks and benefits of each graft type to ensure optimal outcomes for patients undergoing ACL repair surgery.

This technical note aimed to present a straigthforward method for harvesting quadriceps tendon autografts with the use of a simple vaginal speculum and direct visualisation of a scope. Anterior cruciate ligament reconstruction with quadriceps tendon autografts has gained popularity in recent years, with many harvesting techniques that use different harvesting systems available on the market. These techniques vary from transverse to longitudinal skin incisions and from open to minimally invasive approaches and have a learning curve, as with the majority of surgical procedures. The technique proposed in this technical note is minimally invasive, can be easily reproduced by any surgeon irrespective of their experience, has a short learning curve, requires no additional cost or technical support during the procedure and creates a stable working space that allows for freedom of manipulation of surgical instruments and the arthroscope.

To compare postoperative knee stability, functional outcomes, and complications after anterior cruciate ligament (ACL) reconstruction using bone-patellar tendon-bone (BPTB) versus quadriceps tendon autograft.

In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, the PubMed, Embase, and Cochrane Library databases were searched for studies published in 2002 or later. Studies were included if they met the following criteria: randomized controlled trials that included patients who underwent ACL reconstruction with BPTB or quadriceps tendon autograft including all soft tissue and bone-quadriceps tendon and in which measures of postoperative stability and functional outcomes were reported. Studies that were not written in English and those that analyzed animals or cadavers, were not randomized controlled trials, or used other grafts (e.g., hamstring) were excluded.

The initial search identified 348 studies, 6 of which were included in this systematic review. Two of the six studies found no significant difference in performance outcomes or complications between quadriceps and BPTB autografts. One study found that patients receiving quadriceps autograft self-reported improved knee functional status compared with those receiving BPTB autograft. Another study found that quadriceps autograft resulted in a significantly reduced Quadriceps Index postoperatively compared with BPTB autograft (69.5 vs 82.8, P = .01) but found no difference in postoperative quadriceps strength. An additional study found that the outcomes of quadriceps tendon and BPTB autografts were equivalent per the International Knee Documentation Committee scale, but anterior knee pain was less severe in patients with quadriceps tendon autograft. Furthermore, one study revealed the overall International Knee Documentation Committee score was reported as normal significantly more often in patients who underwent ACL reconstruction with BPTB autograft (85% vs 50%, P < .001) and that donor-site morbidity was greater in patients with quadriceps autograft. No significant difference was found in complications requiring reoperation across studies.

Patients undergoing ACL reconstruction with either BPTB or quadriceps tendon autograft reported improved postoperative knee stability and functional outcomes. There is no significant difference in complications between quadriceps autograft use and BPTB autograft use.

Level III, systematic review of Level III retrospective studies.

We describe a surgical technique for reconstruction of the posterior cruciate ligament with quad tendon autograft using transseptal portal. We place the guide for the tibial socket through the posteromedial portal instead of transnotch, which is the most common practice. The use of the transseptal portal allows good visualization during the drilling of the tibial socket to protect the neurovascular bundle while avoiding the use of fluoroscopy. The advantage of using the posteromedial approach is the easy placement of the drill guide and to option to pull the graft once through the posteromedial portal and a second time through the notch, which helps passing the "killer turn." The quad tendon is harvested with a bone block that is placed in the tibial socket and fixed with screws in the tibial and femoral side.

Lateral posterior meniscal root tear (LPMRT) repair, at the time of anterior cruciate ligament (ACL) reconstruction are increasingly being performed. The aim of this study was to compare the clinical and functional outcomes, as well as the complication rates at a minimum of 2 years follow-up, between an isolated ACL reconstruction group with intact menisci and a combined ACL reconstruction and LPMRT repair group.

All patients who underwent combined ACL reconstruction and LPMRT repair between 2016 and 2020 were included in the study. They were matched with an isolated ACL reconstruction group with intact menisci based on age, gender and the pre-injury IKDC score. The KOOS, ACLRSI Tegner-Lysholm score and the TELOS-test were collected pre- and postoperatively; complications (re-rupture, recurrence or persistence of a high grade pivot shift, new meniscal injury) were recorded. All LPMRTs were repaired using transtibial pull-out technique.

After matching, 100 patients were included in this study (mean age 29.6 ± 1.0 years and mean follow-up 42.9 ± 7.3 months): 50 patients in the isolated ACL reconstruction group with intact menisci (group A) and 50 in the combined ACL reconstruction and LPMRT repair group (group B). Preoperatively, patients in group B had significant lower KOOS scores (Global 55.9 ± 2.9 vs. 64.6 ± 2.3, p = 0.02), but similar ACLRSI, TEGNER and TELOS scores. At the last follow-up, all functional scores had improved, and no significant difference between the two groups on any score was observed. There was also no difference in terms of complications rates.

At a minimum of 2 years follow-up (mean follow-up 42.9 months), LPMRT repair during ACL reconstruction has no significant difference in terms of post-operative functional outcomes compared to the isolated ACL reconstruction group.

Level III.

Posterior cruciate ligament (PCL) injury hampers the rotational stability and stability front to back of the knee joint, seriously affecting the quality of life of patients. Some studies have reported that the peroneus longus tendon (PLT) has sufficient length and strength.

We hypothesized that the PLT can be used as a novel appropriate material for PCL reconstruction therapy.

Herein, we systematically analysed the clinical effect of the double-stranded PLT and the four-stranded hamstring tendon in the reconstruction of the PCL and compared the effectiveness and safety of these two surgical approaches in the reconstruction of PCL injury. A total of 48 patients with complete rupture of the PCL were divided into Group A (reconstructed with the double-stranded PLT, 25 cases) and Group B (reconstructed with the four-stranded hamstring tendon, 23 cases).

The patients were followed up for more than 1 year. The intraoperative time for tendon extraction was significantly shorter in Group A than Group B. Twenty-four months after operation, patients in the two groups showed the alleviated tibial posterior displacement and the increased IKDC score, Lysholm score and Tegner score. Nevertheless, these scores showed no significant differences between the two groups. Additionally, compared with the therapy using the four-stranded hamstring tendon, therapy using the double-stranded PLT is simpler and safer.

Both surgical methods are effective in the treatment of PCL injury. The PLT could be a good choice for PCL injury reconstruction material, especially when the four-stranded hamstring tendon is accidentally damaged or ineffective. Our study may provide guidance for the clinical treatment of PCL injury.

III, retrospective study.

The purpose of this study was to evaluate whether there was a difference in clinical outcomes between patients who underwent primary ACL reconstruction (ACLR) with all-soft tissue quadriceps tendon (sQT) autograft versus QT with bone block (bQT).

A retrospective cohort study of 708 patients who underwent QT ACLR was conducted. Primary ACLR patients with at least 1 year of follow-up were identified and those who received sQT were compared to those who received bQT. Data collection entailed patient demographics, surgical variables, patient reported outcomes (PROs), knee stability testing, and complications. The primary outcome of interest was International Knee Documentation Committee (IKDC) score, reported as mean score, pre- and postoperative difference, and number who met minimum clinically important difference (MCID). Secondary outcomes included Lachman and pivot shift grade, other patient reported outcomes (PROs), complication rates, and return to sport (RTS).

A total of 195 patients (147 sQT, 48 bQT) who underwent primary QT ACLR met criteria for analysis, with mean follow-up of 17.0 ± 7.9 months. No difference was detected between cohorts with respect to postoperative IKDC score (sQT: n = 120, 81.0 ± 18.9, bQT: n = 10, 80.9 ± 20.4, n.s.), proportion of patients who met MCID (sQT: 68/78 [87%], bQT: 6/7 [86%], n.s.), or results of stability testing. In the sQT cohort, 86% (106/123) of athletes achieved full RTS, compared to 85% (34/40) in the bQT cohort (n.s.). Time to RTS was less than a year in both cohorts (sQT: 10.5 ± 3.8 months [n = 106], bQT: 11.1 ± 3.9 months [n = 31], n.s.). Graft rupture occurred in 7 (5%) sQT patients and 3 (6%) bQT patients (n.s.), and all clinical failures were due to graft rupture (n.s.). No differences were detected for rates of postoperative complications.

No differences in clinical outcomes were detected between patients who underwent primary ACLR with sQT autograft versus bQT autograft. Currently, the decision to employ sQT or bQT is largely determined by surgeon preference. This study demonstrates excellent outcomes with both preparations and supports the use of either graft type at the discretion of the treating surgeon.

III.

The most common mechanical complication following an anterior cruciate ligament (ACL) reconstruction is joint stiffness, due in part to cyclops syndrome. A narrow intercondylar notch is an anatomical risk factor. A reliable preoperative notch measurement would help anticipate proper graft size, or plan a notchplasty during the ligament reconstruction, if necessary. No study has yet assessed the accuracy of the methods used to measure notch size.

The novel measurement protocol proposed in this study would be more reproducible than the reference technique.

A total of 20 preoperative knee MRIs performed during the assessment of an ACL rupture were randomly selected. The notch size was measured using 2 methods: traditional (ratio of the notch and metaphyseal widths measured on a line drawn through the popliteal groove) and novel. The latter was measured using the same ratio but took into account the notch width in its proximal third, according to a coronal slice that passes through the ACL tibial attachment. Three orthopedic surgeons with different levels of experience (senior surgeon, junior surgeon and surgical resident) performed these measurement protocols twice on anonymized MRI scans, 10days apart. Spearman's rank correlation coefficient was used to assess the intraobserver correlations and a concordance index was used to assess the interobserver correlations. The influence of the second MRI reading was analyzed with a bootstrap test.

The mean intraobserver reliability was 0.73 for the reference method and 0.83 for the proposed method. The values of the bootstrap tests were higher for the proposed method (0.45 vs. 0.45 and 0.70; p<05 for interobserver; 0.49 vs. 0.69 and 0.62; p<05 for intraobserver).

The proposed measurement protocol showed a higher reproducibility in assessing notch size than the traditional method. This technique therefore provides a reliable assessment of the intercondylar notch width.

IV; retrospective study.

Bioactive factors combined with advanced anterior cruciate ligament (ACL) primary repair technology have been used to treat ACL repairs. The current review was conducted to identify whether biological enhancement could enable superior clinical outcome, including side-to-side difference, failure rate, reoperation rate and subjective scores.

The implementation of ACL primary repair with biological enhancement will provide better clinical outcomes in terms of side-to-side differences, failure rate, reoperation rate and subjective scores than ACL primary repair alone.

A systematic literature review was performed following PRISMA guidelines by searching all studies reporting outcomes of arthroscopic primary repair with or without biological augmentation published until April 19, 2020, in Medline, PubMed, Embase and the Cochrane Library. Primary metrics were side-to-side differences, failure rate and reoperation rate, as well as measurements of patient-reported outcomes at the last follow-up.

A total of 20 studies were finally included in this work, of which 3 were Grade I (15%), 3 studies were Grade III (15%), and 14 studies were Grade IV (70%) in terms of the level of evidence. There were 729 patients with a mean age of 30 (range: 8-68) years, and the mean follow-up period of which was 38 (range: 3-122) months. At the final follow-up, the postoperative side-to-side differences (the proportion of patients with a side-to-side difference less than 3mm) and patient-report outcomes were significantly better in the biological enhancement group. Nevertheless, there were no significant differences between the two groups in the rate of surgical failure, the rate of revision, or the positive Lachman test or pivot shift test.

Biologically enhanced arthroscopic ACL primary repair was superior to ACL primary repair alone in terms of postoperative side-to-side differences (proportion of patients with a side-to-side difference less than 3mm) and patient-reported outcomes. Thus, biologically enhanced arthroscopic ACL primary repair can be preferentially recommended over ACL arthroscopic primary repair alone.

IV, systematic review.

It has been recognized that psychological factors influence the return to sports after anterior cruciate ligament reconstruction (ACLR). The ACL-return to sports after injury (RSI) scale was developed based on subcategories of emotions, confidence in physical performance and risk appraisal. However, it has not been clarified describing which is the most influential psychological factor of the ACL-RSI scale.

Risk appraisal is the most influent for return to sports in the subcategories of the ACL-RSI scale.

A total of 85 competitive patients who had undergone ACLR were evaluated at 6, 12 and 24 months after surgery. They were classified the return to sports (RTS) group and non-return to sports (NRTS) group. Evaluations were several clinical and functional scores including Cincinnati knee rating system, Knee Osteoarthritis Outcome Score (KOOS), Lysholm score, limitation in activities of daily living (ADL) and sports which estimated by Visual Analog Scale (VAS) score, Isokinetic Muscle Strength (quadriceps and hamstrings), single hop test and anterior laxity. They were investigated their relationship with the ACL-RSI scale including each subcategory.

The total ACL-RSI scale significantly improved at each point. Of the subcategories, only risk appraisal was not significantly different at each point (p=0.21 and p=0.13). There was a significant difference at 24 months after ACLR between the RTS group and NRTS group. In terms of risk appraisal, compared with emotion and performance confidence, the difference in the mean value was the most divergent (RTS group: 55.9±22.7 and NRTS group: 23.8±19.3) and took time to improve through 24 months. Among various clinical and functional scores, there were significant differences in the VAS score for sports, KOOS-symptoms, sports and QOL, Cincinnati Knee Rating System-cut, and single hop test values between two groups. Of these, the KOOS-QOL and VAS score for sports showed particularly strong correlations with ACL-RSI risk appraisal (r=0.75 and -0.68, respectively).

Of the ACL-RSI scale, risk appraisal took the longest time to improve and strongly affected the return to sports. The KOOS-QOL and VAS score for sports were most strongly correlated with the ACL-RSI risk appraisal. It seems that it is important to reduce the psychological risk as soon as possible after ACL injury in ACLR patients.

II.

Quadriceps tendon (QT) autografts with and without a bone block are the least studied and least used options for anterior cruciate ligament reconstruction surgery. In particular, there is a lack of literature describing patellar anatomy. Until now, guidelines for patellar bone block harvesting have been based solely on personal experience. In this study, we intended to derive recommendations from physical regularities and objective criteria.

To determine the maximal, individual-related length and depth of the bone block that can be safely harvested and to provide guidelines to help surgeons make decisions on graft choice.

Descriptive laboratory study.

The study group consisted of 50 male participants and 50 female participants (mean age, 29.4 ± 7.9 years) who underwent 3.0-T magnetic resonance imaging of their knee. Patellar height was determined at the center of the middle third of the QT insertion on the patella and the medial and lateral endpoints; the depth was measured at the midpoints of the respective heights.

The mean width of the QT and the mean thickness were 49.0 ± 7.6 and 7.3 ± 1.0 mm, respectively. The mean patellar thickness in reference to the medial endpoint, the center, and the lateral endpoint was 18.3 ± 2.4, 17.9 ± 2.3, and 15.1 ± 2.3 mm, respectively, whereas the mean patellar height was 35.1 ± 4.1, 36.7 ± 4.2, and 35.1 ± 3.9 mm. In general, the tendon and patellar dimensions were significantly larger in male participants than in female participants (P = .016).

Bone block harvesting, with its depth not exceeding 50% of the patellar thickness and its length accounting for <50% of the patellar height, poses the least risk for a patellar fracture when located medial to midline. If the bone block is excised from the medial half of the central area (the latter is defined by the middle third of the QT insertion), with the outer edge of the saw positioned at the medial border of the central area, a graft of 15 mm length, 10 mm width, and 8 mm depth can be safely harvested in all White male participants and almost all female participants taller than 165 cm, according to our findings.

This is the first study presenting recommendations for patellar bone block harvesting at the quadriceps tendon insertionbased on physical regularities and objective criteria and not on personal experience.