A set S of vertices in an isolate-free graph G is a paired-dominating set if every vertex of G is adjacent to some other vertex in S and the subgraph G[S] induced by the set S contains a perfect matching. The paired-domination number gamma(pr)(G) of G is the minimum cardinality of a paired-dominating set in G. A binary tree is a tree in which every vertex has degree 1 or degree 3. We determine a tight upper bound on the paired-domination number of a binary tree and show that if T is a binary tree of order n > 4, then gamma(pr)(T) <= 2/3 (n-1). Thereafter we continue the study of a version of the paired-domination game recently introduced by the authors (Gray and Henning, 2023) that embraces both the domination and matching flavor of the game. We give an explicit formula for the game paired-domination number of an infinite family of binary trees and show that if T is a binary caterpillar of order n, then gamma(gpr)(T) = 3/4n-Phi(n), where Phi(n) takes on one of the values in the set {1, 3/2, 2, 5/2}. We show that if T is a complete binary tree of order n, then gamma gpr(T) < (2/3 + 1/192)n. We conclude with a conjecture that sup gamma gpr(T)/n = 3/4 where the supremum is over all binary trees T of order n > 4. (c) 2025 Elsevier B.V. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

PurposeCartilage restoration as an adjunct to patellofemoral soft tissue and/or bony stabilization in patients with symptomatic patellofemoral instability remains controversial. Our purpose was to evaluate patients undergoing surgical stabilization for patellofemoral instability with or without concomitant cartilage restoration.MethodsRetrospective review of prospectively collected data identified patients undergoing surgical stabilization for recurrent patella instability, with or without concomitant cartilage restoration. Pre- and post-surgical patient reported outcomes were collected. Complications requiring re-operation were recorded. Statistically significant difference was set at p< 0.05.Results130 patients (144 knees) were included. 113 knees in the isolated stabilization (STAB) and 31 knees in the Stabilization-Cartilage Restoration (STAB-CART) group. The average age was 20.64 and 25.03 in the STAB and STAB-CART groups (p=0.034), respectively. STAB-CART group had significantly lower pre-operative KOOS (57.24 +/- 17.45 vs. 46.11 +/- 14.74, p=0.019) and SANE scores (43.15 +/- 19.05 vs. 26.85 +/- 13.74, p=0.002). Both groups statistically improved in all KOOS, IKDC, and SANE domains with no statistically significant differences at final follow-up between groups. 13 knees (11.5%) in the STAB and 6 knees (19.4%) in the STAB-CART group had complications requiring re-operation, including 6 and 3 revision stabilizations, respectively. There were no statistically significant differences in total major complications (p=0.246) or MPFL revision (p=0.405).ConclusionsThe addition of cartilage restoration in patients undergoing soft tissue and/or bony patellofemoral stabilization appears to be safe and effective. Despite lower baseline scores, patients undergoing patellofemoral stabilization with cartilage restoration had similar final subjective outcome scores compared to the group without.

Purpose:To compare outcomes, activity scores, and complication rates of obese and non-obese patients undergoing medial patellofemoral ligament (MPFL) reconstruction. Methods:A retrospective review identified patients undergoing MPFL reconstruction for recurrent patellofemoral instability. Patients were included if they had undergone MPFL reconstruction and had follow-up for a minimum of 6 months. Patients were excluded if they underwent surgery less than 6 months earlier, had no outcome data recorded, or underwent concomitant bony procedures. Patients were divided into 2 groups based on body mass index (BMI): BMI of 30 or greater and BMI less than 30. Presurgical and postsurgical patient-reported outcomes including Knee Injury and Osteoarthritis Outcome Score (KOOS) domains and the Tegner score were collected. Complications requiring reoperation were recorded. P < .05 was defined as a statistically significant difference. Results:A total of 55 patients (57 knees) were included. There were 26 knees with a BMI of 30 or greater and 31 knees with a BMI less than 30. There were no differences in patient demographic characteristics between the 2 groups. Preoperatively, no significant differences were found in KOOS subscores or Tegner scores (P = .21) between groups. At minimum 6-month follow-up (range, 6.1-70.5 months), patients with a BMI of 30 or greater showed statistically significant improvements in the KOOS Pain, Activities of Daily Living, Symptoms, and Sport/Recreation subscores. Patients with a BMI less than 30 showed a statistically significant improvement in the KOOS Quality of Life subscore. The group with a BMI of 30 or greater had significantly lower KOOS Quality of Life (33.34 ± 19.10 vs 54.47 ± 28.00, P = .03) and Tegner (2.56 ± 1.59 vs 4.78 ± 2.68, P = .05) scores. Complication rates were low, with 2 knees (7.69%) requiring reoperation in the cohort with a BMI of 30 or greater and 4 knees (12.90%) requiring reoperation in the cohort with a BMI less than 30, including 1 reoperation for recurrent patellofemoral instability (P = .68). Conclusions:In this study, MPFL reconstruction in obese patients was safe and effective, with low complication rates and improvements in most patient-reported outcomes. Compared with patients with a BMI less than 30, obese patients had lower quality-of-life and activity scores at final follow-up. Level of Evidence:Level III, retrospective cohort study.

PURPOSE:The diagnosis of amyloidosis is important for early intervention, disease monitoring, and prevention of complications and progression. Carpal tunnel syndrome (CTS) and trigger digit (TD) are two common conditions associated with early disease. The purpose of this study was to define disease prevalence among patients with bilateral CTS and multiple TDs and assess for an increased rate of diagnosis in the presence of both. METHODS:Men older than 50 years and women older than 60 years of age diagnosed with bilateral CTS, multiple TDs, or a combination of the 2 were prospectively enrolled in our study. Tenosynovial biopsy samples taken at the time of surgery were tested for the presence of amyloid using Congo red staining. Demographic and medical covariates were also collected and analyzed for differences between amyloid-positive and -negative patients. RESULTS:Fifty-six patients were enrolled in the study, and nine patients tested positive for amyloid deposition. The demographics and medical comorbidities were similar between amyloid-positive and -negative patients. Thirty patients with bilateral CTS were enrolled, and four tested positive for amyloid. For patients with multiple TDs, a total of 17 patients were enrolled, and 4 tested positive for amyloid. Among patients with multiple TDs, only men tested positive for amyloid and were, on average, younger than those who tested negative (61 and 73 years, respectively). Patients presenting with a combination of CTS and TD did not exhibit increased amyloid discovery. CONCLUSIONS:Hand surgeons should consider tenosynovial biopsy in men older than 50 years and women older than 60 years presenting with either bilateral CTS or multiple TDs. TYPE OF STUDY/LEVEL OF EVIDENCE:Prognostic IV.

In this paper, we continue the study of a version of the paired-domination game recently introduced by the authors that embraces both the domination and the matching flavor of the game. The game is played on a graph G by two players, named Dominator and Staller. The players take turns choosing a pair of adjacent vertices of G such that neither vertex in the pair has yet been chosen and the vertices in the pair must dominate at least one vertex not dominated by the previously chosen vertices. This process eventually produces a paired-dominating set of vertices of G; that is, a dominating set in G that induces a subgraph that contains a perfect matching. The game paired-domination number γ _gpr(G) of G is the number of vertices chosen when Dominator starts the game and both players play optimally, and the Staller-start game paired-domination number γ _gpr'(G) of G is the number of vertices chosen when Staller starts the game and both players play optimally. In this paper, we determine the game paired-domination numbers γ _gpr(G) and γ _gpr'(G) when the graph G is a path P_n on n vertices. We show that γ _gpr(P_n) = 2 ⌈n/3⌉ for all n ≥ 2 , unless n = 4 , in which case γ _gpr(P_n) = 2 , and we show that γ _gpr'(P_n) = 2 ⌈n+1/3⌉ for all n ≥ 2 , unless n ∈{3,9} , in which case γ _gpr'(P_n) = 2/3n . Moreover we describe optimal strategies for both Dominator and Staller for the paired-domination game played on a path.

BACKGROUND:Tarsal navicular bone stress injuries (BSIs) are considered "high risk" because of prolonged healing times and higher rates of nonunion in adult populations but, to our knowledge, have not been comprehensively examined in adolescent athletes.PURPOSE:To describe the characteristics of tarsal navicular BSIs in adolescents.STUDY DESIGN:Case series; Level of evidence, 4.METHODS:A retrospective analysis of patients aged 10 to 19 years with a radiographically diagnosed tarsal navicular BSI was performed at 8 academic centers over a 9-year study period. Age, sex, body mass index (BMI), primary sport, physical examination findings, imaging, treatment, surgical technique, return-to-sport time, and complications were analyzed.RESULTS:Among 110 patients (mean age, 14.7 ± 2.7 years; 65% female), common primary sports were cross-country/track and field (29/92 [32%]) and gymnastics/dance (25/92 [27%]). Grade 4 BSIs were identified in 44% (48/110) of patients, with fracture lines present on radiography or magnetic resonance imaging. Nonoperative treatment (mean age, 14.4 ± 2.6 years), consisting of protected weightbearing and either a protective boot (69/88 [78%]) or a cast (19/88 [22%]), was trialed in all patients and was successful in 94 patients (85%). Operative treatment (mean age, 17.1 ± 1.4 years) was ultimately pursued for 16 patients (15%). Patients who required surgery had a higher BMI and a higher percentage of fracture lines present on imaging (nonoperative: 36/94 [38%]; operative: 14/16 [88%]). The median time to return to weightbearing, running, and full sport was significantly longer in duration for the operative group than the nonoperative group (P <.05). Complications associated with surgery included 1 case each of delayed union, nonunion, and painful implants, the latter of which required secondary surgery.CONCLUSION:Adolescent tarsal navicular BSIs were identified most commonly in female patients in leanness sports. Adolescents who required surgery were more likely to be older, have higher BMIs, and have grade 4 BSIs, and they returned to sport within a median of 5 months after single- or double-screw fixation with a low risk of postoperative complications. A better understanding of the presenting signs and symptoms and appropriate diagnostic imaging of navicular BSIs may lead to an earlier diagnosis and improved outcomes.

Purpose:To compare subjective outcomes and complications of anterior cruciate ligament reconstruction (ACLR) using either bone-patellar tendon-bone (BPTB) or quadriceps tendon (QT) autograft.Methods:A retrospective analysis of prospectively collected data identified consecutive cohorts of patients undergoing ACLR with either BPTB or QT autograft. Patients with less than 12-month follow-up and those undergoing concomitant osteotomies, cartilage restoration, and/or other ligament reconstruction procedures were excluded. Pre- and postsurgical patient-reported outcomes including International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score, Patient-Reported Outcomes Measurement Information System (PROMIS), Single Assessment Numeric Evaluation, Tegner, and Marx were compared between groups. Complications requiring reoperation were recorded.Results:One hundred nineteen patients met inclusion criteria, including 39 QT autografts and 80 BPTB autografts. Demographic information was comparable between groups. Mean follow-up was comparable between groups (QT 22.4 ± 10.6 months vs BPTB 28.5 ± 18.5 months, P = .06). At minimum 12-month follow-up (range 12.0-100.8 months), patients in both groups demonstrated statistically significant improvements in International Knee Documentation Committee (QT 60.0%, P < .0001; BPTB 57.7%, P < .0001), all Knee Injury and Osteoarthritis Outcome Score domains, PROMIS Mobility T-Score (QT 27.2%, P = .0001; BPTB 23.2%, P < .0001), PROMIS Global Physical Health (QT 14.4%, P = .002; BPTB 13.4%, P = .001), PROMIS Physical Function (QT 29.6%, P < .0001; BPTB 37.1%, P < .0001), PROMIS Pain Interference (QT -16.5%, P < .0001; BPTB -20.8%, P < .0001), Single Assessment Numeric Evaluation, (QT 76.9%, P < .0001; BPTB 73.3%, P < .0001), Tegner (QT 92.9%, P = .0002; BPTB 101.4%, P < .0001), and Marx (QT -26.6%, P = .02; BPTB -32.0%, P = .0002) with no statistically significant differences between the 2 groups. Overall postoperative reoperation rate did not differ between groups (QT 12.8% vs BPTB 23.8%, P = .2). Revision ACL reconstruction rate did not differ between groups (QT 5.1% vs BPTB 7.5%, P = .6).Conclusions:Patients undergoing autograft ACLR with either BPTB or QT demonstrated significant subjective improvements in patient-reported outcomes from preoperative values and no statistically significant differences in outcomes between the groups. Complication and revision ACLR rates were similar between the 2 groups.Level of Evidence:III, retrospective cohort study.

BACKGROUND:In treating occupational hand injuries under workers' compensation, the 2 most important goals are to maximize patient function, ideally to preinjury levels, and permit a timely return to work (RTW). The purpose of this study was to determine factors affecting total case length, that is, the total time from injury until primary closure of a patient's claim, and disposition among patients with hand injuries treated under workers' compensation.METHODS:All cases treated under workers' compensation by a single fellowship-trained hand surgeon within a single year were retrospectively reviewed. A case is defined as the entire management and treatment of a single patient related to a single occupational injury incident. Independent variables included age, sex, body mass index, comorbidity, occupation, injury pattern, and treatment modality. Dependent variables included treatment duration from injury to case closure and final case disposition (RTW, functional capacity evaluation [FCE], or loss to follow-up [LTFU]). Comparison between groups was accomplished with analysis of variance. Multivariate linear and logistic regression analysis was performed to predict case length and disposition.RESULTS:In all, 447 cases involving a workers' compensation claim were reviewed. Among these, 75 (16.8%) were LTFU, 24 (5.4%) required an FCE, and 346 (77.4%) an RTW. The RTW cases averaged 138.5 days, whereas those requiring FCE averaged 331.5 days. Compared with average case length, crush injuries (76.8 days. P < .001) and fractures (111.8 days, P = .0224) had significantly shorter time to closure. In a multivariate linear model, cases of soft tissue and nerve injury were associated with longer case lengths, remaining open for an additional 56.8 and 347.1 days, respectively (P < .001). Each treatment modality studied, therapy, injections, and surgery, was associated with an increase in case length.CONCLUSIONS:Cases requiring FCE were open significantly longer than those resulting in RTW. In addition, injury pattern and treatment modality were associated with significant variations in total case length. These results imply that a specific subset of patients, namely those with soft tissue and nerve injuries, may experience delayed resolution among patients treated under a workers' compensation claim.

Objectives: To describe demographic and presenting clinical characteristics, diagnostic features, treatment approaches, and clinical outcomes of adolescent tarsal navicular BSI’s. Methods: A retrospective chart review of patients with tarsal navicular BSIs was performed at eight academic centers. Diagnosis was confirmed by radiologic imaging in all cases. The following variables were collected utilizing a REDCap database and analyzed with basic descriptive and comparative statistics: age, sex, primary sport, physical exam (PE) findings, diagnostic imaging modality, treatment modalities, surgical technique (when applicable), time of protected weight-bearing, time to running, and time to return to sport. Results: 110 patients (mean age: 14.7 years +/-2.7 years; 65% female) met inclusion criteria, 103 (94%) of whom reported a primary sport, most commonly cross country/track and field (33%) and gymnastics/dance (27%). Common PE findings included navicular tenderness (96%), pain with walking (89%), and pain with resisted inversion (55%). Both x-ray and MRI were obtained in the majority of patients (91%), while CT was obtained for 30%. A radiologically detectable fracture line was present in 44%, most commonly on the dorsal navicular cortex. Non-operative treatment was successful in 85% of patients, consisting of protective boot (79%) or cast (21%). Operative treatment was pursued for 15% of patients, with 73% treated with open reduction internal fixation and 27% undergoing percutaneous screw fixation. All operative patients underwent fixation with either 1 (50%) or 2 screws (50%). Bone grafting was performed in 5 patients (31%). Significant differences between non-operative and operative cohorts included presence of fracture line (38% vs. 88%, P<0.001), age (14.3 years vs. 17.1, P<0.001), time of protected weightbearing (7 weeks vs 10 weeks, P=0.012), time to running (12 weeks vs 18 weeks, P=0.001), and time to return to sport (14 weeks vs 20 weeks, P=0.001). Conclusions: Adolescent tarsal navicular BSIs occur most commonly in sports involving repetitive loading, such as cross country, track and field, gymnastics, and dance. The most common PE findings are navicular tenderness to palpation, pain with walking, and pain with resisted inversion. Patients that ultimately require surgical treatment were more likely to have a radiologic fracture line, prolonged return to weightbearing, running and sport than those successfully treated non-operatively. Table 1: Total Cohort Demographics of patients with bone stress injury to the tarsal navicular bone from eight institutions across the United States from 2013 to 2021 Table 2: Demographic and clinical characteristics of non-operative vs. operative patients with tarsal navicular bone stress injuries from eight institutions across the United States from 2013 to 2021

To analyze the velocity and movement of the 4-seam fastball, curve, and slider thrown before and after ulnar collateral ligament reconstruction (UCLR) in Major League Baseball pitchers using PITCHf/x data.Velocity and movement data of the 4-seam fastball, curve, and slider were collected for 3 time frames (12-24 months before the date of UCLR as an uninjured baseline, 12-24 months after the date of UCLR, and 24-36 months after the date of UCLR). Pitchers were separated into 3 age groups (<26, 26 to 31, and >31 years). A paired t-test for means was used to assess mean differences between 2 time periods and a generalized linear model, with time-dependent covariance structure and age group as a covariate, was used to determine differences across time. All analyses were performed using SAS, version 9.4.Vertical movement of the 4-seam fastball decreased in the 24 to 36 months' postoperative time frame, compared with 12 to 24 months' preoperatively (9.46 to 9.14 inches, P = .032). Movement decreases in the 4-seam fastball were not age-related. Velocity did not significantly change for any pitch and movement did not change for the slider or curve pitches.Following UCLR, Major League Baseball pitchers experienced no changes in horizontal or vertical movement or velocity of the curve or slider in either time frame. Decreased upward vertical movement of the fastball occurred after UCLR at final follow-up, but no change was observed in velocity. Similar trends in pitch movement and velocity effects were observed regardless of age.IV, case series.

Peg solitaire is a game in which pegs are placed in every hole but one and the player jumps over pegs along rows or columns to remove them. Usually, the goal is to remove all but one peg. In a 2011 paper, this game is generalized to graphs. In this paper, we examine graphs in which any single edge addition changes solvability. In order to do this, we introduce a family of graphs and provide necessary and sufficient conditions for the solvability for this family. We show that infinite subsets of this family are edge critical. We also determine the maximum number of pegs that can be left on this family with the condition that a jump is made whenever possible. Finally, we give a list of graphs on eight vertices that are edge critical.

The purpose of the study was to evaluate the effect of skeletal age and lesion size, location, and grade on the success of nonoperative treatment for juvenile osteochondritis dissecans (OCD). It is hypothesized that skeletal maturity, including a combination of maturation phenotypes, correlates with nonoperative lesion healing. The clinical and radiographic data on 52 patients aged 7–20 years treated for OCD of the distal femur between 2010 and 2019 were retrospectively reviewed. Knee radiographs were assessed for number of lesions present and lesion location, size, and stage. Assessments of skeletal maturation were performed on all antero-posterior knee radiographs using the Roche, Wainer, and Thissen (RWT) method. Patients were categorized as healed if they demonstrated no pain on clinical examination. The relationship between skeletal maturity and nonoperative lesion healing was determined using Spearman rank correlations on available variables. Neither chronological nor skeletal age was associated with surgical status (Rho = 0.03, n.s., and Rho = 0.13, n.s., respectively) or the healing status of nonoperatively treated OCD lesions (Rho = 0.44, n.s., and Rho = 0.03, n.s., respectively). Epiphyseal fusion status of the distal femoral physis was moderately correlated with nonoperative healing, but was not statistically significant (lateral femoral physis: Rho = 0.43, p = 0.05; medial femoral physis: Rho = 0.43, n.s.). Lesion length correlated with surgical status (Rho = − 0.38, p = 0.009). The extent of fusion of the distal femoral physis (multi-stage grading) may be more strongly correlated with nonoperative healing than other markers of skeletal maturity or chronological age. Clinicians can use this as an additional radiographic sign when considering nonoperative treatment for juvenile OCD lesions in the distal femur. OCD lesion length and physeal fusion status appear to be more important for healing than patient age.

ABSTRACTBackgroundAs college students in the United States return to university campuses, it is important to understand their beliefs and practices on coronavirus disease 2019 (COVID-19) prevention.PurposeTo assess beliefs and practices regarding COVID-19 prevention among college students in the United StatesMethodsAn online, self-administered survey was developed that collected information on COVID-19 preventative practice and beliefs. Survey responses were collected between July 13, 2020 and July 31, 2020.ResultsA total of 4,834 college students participated in the survey with a response rate of 22.9%. Compared to males, more female college students practiced COVID-19 preventative measures, includingalwayswearing masks or face coverings in public (52% vs. 44%, p<0.001) andalwaysoroftenobserving social distancing (70% vs. 63%, p<0.001). In contrast to students from larger population areas, fewer college students from rural areas reported practicing prevention measures, such asalwayswearing a mask (24% rural v. 45% towns vs. 55% cities, p<0.001) andalwayssocial distancing (20% rural vs. 21% towns vs. 29% cities, p<0.001). Additionally, more students from rural areas have becomemuch lessworried about personally contracting COVID-19 over the last 3 months when compared to students from towns and cities (21% vs. 16% vs. 11%, p<0.001). Fewer white college students compared to other racial groups thought it wasvery importantto wear masks (55% white vs. 76% Black vs. 82% Asian vs. 63% American Indian or Alaskan native (AIAN) & Native Hawaiian or Other Pacific Islander (NHOPI), p<0.001) andvery importantto practice social distancing (29% white vs. 50% Black vs. 53% Asian vs. 36% AIAN/NHOPI, p <0.001). Compared to Non-Hispanic students, more Hispanic students thought it wasvery importantto practice preventative measures, including wearing a mask (71% vs. 58%, p<0.001), social distancing (37% vs. 32%, p=0.017), and good hand hygiene (77% vs. 67%, p=0.013).ConclusionCOVID-19 prevention beliefs and practices differ between sexes, the size of town one lives, race, and ethnicity. In general, female students followed Center for Disease Control and Prevention (CDC) COVID-19 prevention guidelines more closely than male students. Students who reside in areas of larger populations have more strict COVID-19 prevention beliefs and practices than students from areas with smaller populations. Asian and Black/African American students adhered closer to CDC COVID-19 prevention guidelines and had stronger beliefs for infection prevention measures than white or AIAN/NHOPI students. Hispanic/Latino students were more stringent in COVID-19 prevention beliefs and practices than non-Hispanic/Latino students.

Peg solitaire is a game in which pegs are placed in every hole but one and the player jumps over pegs along rows or columns to remove them. Usually, the goal is to have a single peg remaining. In a 2011 paper, this game is generalized to graphs. In this paper, we consider a variation in which each peg must be jumped twice in order to be removed. For this variation, we consider the solvability of several graph families. For our major results, we characterize solvable joins of graphs and show that the Cartesian product of solvable graphs is likewise solvable.

In alignment with efforts to mitigate the negative health consequences of Parkinson's Disease (PD), the purpose of this investigation was to examine if participation in a community-based boxing program (CBP) was associated with improvements in balance and fall risk reduction among individuals with PD. In this retrospective cross-sectional study, de-identified data from 12 individuals with PD participating in a CBP was examined. Participants included those with a Hoehn and Yahr stage between 1 and 3, averaging 2.8 ± 0.8 CBP sessions per week for 6.1 ± 0.8 months between testing. Baseline and re-evaluation testing included the Fullerton Advanced Balance (FAB) Scale and Timed Up and Go (TUG) to quantify balance and fall risk. Sessions were 90-minutes in length involving a warm-up, boxing drills, strength and endurance exercises, and cool down. Sessions included multiple bouts of 30-60 second high-intensity exercise intervals (RPE between 15/20 to 17/20). Paired t-tests were used to determine if differences existed between the FAB and TUG from baseline to re-evaluation, with statistical significance accepted at p < 0.05 and > 0.8 interpreted as a large effect using Cohen's d. Results indicated a statistically significant increase and large effect in FAB performance, with a mean increase in score above previously reported minimal detectable change (MDC). While participation in CBP was associated with a statistically significant improvement and medium effect in the TUG, this did not demonstrate a population specific MDC. This study found that participation in a CBP was associated with improved balance among clients with PD.

I read with great interest the article entitled “No Difference in Complication Rates or Patient-Reported Outcomes Between Bone–Patella Tendon–Bone and Quadriceps Tendon Autograft for Anterior Cruciate Ligament Reconstruction” by Hogan et al.,1Hogan D.W. Burch M.B. Rund J.M. et al.No difference in complication rates or patient-reported outcomes between bone-patella tendon-bone and quadriceps tendon autograft for anterior cruciate ligament reconstruction.Arthrosc Sports Med Rehabil. 2022; 4: e417-e424Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar The authors should be commended on publishing among the first studies to directly compare clinical outcomes following anterior cruciate ligament reconstruction (ACLR) using all-soft tissue quadriceps tendon (ASTQT) and bone–patellar tendon–bone (BPTB) autograft, long considered the gold standard and benchmark to which other grafts are compared.2Carmichael J.R. Cross M.J. Why bone–patella tendon–bone grafts should still be considered the gold standard for anterior cruciate ligament reconstruction.Br J Sports Med. 2009; 43: 323-325Crossref PubMed Scopus (32) Google Scholar, 3Kaeding C.C. Aros B. Pedroza A. et al.Allograft versus autograft anterior cruciate ligament reconstruction: Predictors of failure from a MOON prospective longitudinal cohort.Sports Health. 2011; 3: 73-81Crossref PubMed Scopus (320) Google Scholar, 4Magnussen R.A. Carey J.L. Spindler K.P. Does autograft choice determine intermediate-term outcome of ACL reconstruction?.Knee Surg Sports Traumatol Arthrosc. 2011; 19: 462-472Crossref PubMed Scopus (90) Google Scholar, 5Spindler K.P. Kuhn J.E. Freedman K.B. Matthews C.E. Dittus R.S. Harrell Jr., F.E. Anterior cruciate ligament reconstruction autograft choice: Bone-tendon-bone versus hamstring: does it really matter? A systematic review.Am J Sports Med. 2004; 32: 1986-1995Crossref PubMed Scopus (294) Google Scholar Despite an increase in the popularity and use of quadriceps tendon (QT) autograft over the past decade,6Arnold M.P. Calcei J.G. Vogel N. et al.ACL Study Group survey reveals the evolution of anterior cruciate ligament reconstruction graft choice over the past three decades.Knee Surg Sports Traumatol Arthrosc. 2021; 29: 3871-3876Crossref PubMed Scopus (14) Google Scholar the QT autograft is the least studied among autograft choices for ACLR. The ACL Study Group recently published the findings of their biannual survey of Study Group members, finding an increased use in QT autograft since 2014 and a peak in 2018.6Arnold M.P. Calcei J.G. Vogel N. et al.ACL Study Group survey reveals the evolution of anterior cruciate ligament reconstruction graft choice over the past three decades.Knee Surg Sports Traumatol Arthrosc. 2021; 29: 3871-3876Crossref PubMed Scopus (14) Google Scholar By comparison, survey data from the 2010 American Academy of Orthopaedic Surgeons Annual Meeting found that only 1% of surgeons were using QT autograft at that time.7van Eck C.F. Illingworth K.D. Fu F.H. Quadriceps tendon: The forgotten graft.Arthroscopy. 2010; 26 (author reply 442-443): 441-442Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar The QT autograft, specifically the ASTQT, has had a renaissance in part due to newer technology, including improved instrumentation for graft harvest8Slone H.S. Xerogeanes J.W. Anterior cruciate ligament reconstruction with quadriceps tendon autograft: A minimally invasive harvest technique.JBJS Essent Surg Tech. 2014; 4: e16Crossref PubMed Google Scholar, 9Sprowls G.R. Robin B.N. The quad link technique for an all-soft-tissue quadriceps graft in minimally invasive, all-inside anterior cruciate ligament reconstruction.Arthrosc Tech. 2018; 7: e845-e852Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 10Ollivier M. Cognault J. Pailhe R. Bayle-Iniguez X. Cavaignac E. Murgier J. Minimally invasive harvesting of the quadriceps tendon: Technical note.Orthop Traumatol Surg Res. 2021; 107: 102819Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar and suspensory fixation devices.11Slone H.S. Romine S.E. Premkumar A. Xerogeanes J.W. Quadriceps tendon autograft for anterior cruciate ligament reconstruction: A comprehensive review of current literature and systematic review of clinical results.Arthroscopy. 2015; 31: 541-554Abstract Full Text Full Text PDF PubMed Scopus (146) Google Scholar,12Sheean A.J. Musahl V. Slone H.S. et al.Quadriceps tendon autograft for arthroscopic knee ligament reconstruction: Use it now, use it often.Br J Sports Med. 2018; 52: 698-701Crossref PubMed Scopus (51) Google Scholar These technological advancements have allowed for improved efficiency of ACLR including graft harvest, preparation, and fixation.8Slone H.S. Xerogeanes J.W. Anterior cruciate ligament reconstruction with quadriceps tendon autograft: A minimally invasive harvest technique.JBJS Essent Surg Tech. 2014; 4: e16Crossref PubMed Google Scholar, 9Sprowls G.R. Robin B.N. The quad link technique for an all-soft-tissue quadriceps graft in minimally invasive, all-inside anterior cruciate ligament reconstruction.Arthrosc Tech. 2018; 7: e845-e852Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 10Ollivier M. Cognault J. Pailhe R. Bayle-Iniguez X. Cavaignac E. Murgier J. Minimally invasive harvesting of the quadriceps tendon: Technical note.Orthop Traumatol Surg Res. 2021; 107: 102819Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar In addition, the authors cited several advantages to the ASTQT compared with BPTB autograft, including a lower incidence of kneeling pain, patella fracture, and numbness related to injury of the infrapatellar branch of the saphenous nerve that often occurs during BPTB harvest. While concerns about prolonged postoperative quadriceps weakness exist following QT autograft, a recent meta-analysis specifically examining this topic demonstrated no difference in quadriceps strength or time to recovery of quadriceps strength when comparing QT and BPTB autograft.13Johnston P.T. McClelland J.A. Feller J.A. Webster K.E. Knee muscle strength after quadriceps tendon autograft anterior cruciate ligament reconstruction: Systematic review and meta-analysis.Knee Surg Sports Traumatol Arthrosc. 2021; 29: 2918-2933Crossref PubMed Scopus (12) Google Scholar Another study directly comparing QT and BPTB autografts found that the patients who received QT autograft required less pain medication postoperatively,14Joseph M. Fulkerson J. Nissen C. Sheehan T.J. Short-term recovery after anterior cruciate ligament reconstruction: A prospective comparison of three autografts.Orthopedics. 2006; 29: 243-248Crossref PubMed Scopus (27) Google Scholar a finding that is not unexpected, given the lack of bone harvest with an ASTQT autograft and consistent with my clinical experience using both of these autograft types. From a biomechanical standpoint, the QT has 20% more collagen fibrils per cross-sectional area than the patellar tendon, an ultimate load to failure that is 70% greater than a similar width patellar tendon graft, and a modulus of elasticity more similar to the native ACL than either BPTB or hamstring graft.15Xerogeanes J.W. Quadriceps tendon graft for anterior cruciate ligament reconstruction: The graft of the future.Arthroscopy. 2019; 35: 696-697Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Nonetheless, QT remains less commonly used than either hamstring or BTPB autograft.6Arnold M.P. Calcei J.G. Vogel N. et al.ACL Study Group survey reveals the evolution of anterior cruciate ligament reconstruction graft choice over the past three decades.Knee Surg Sports Traumatol Arthrosc. 2021; 29: 3871-3876Crossref PubMed Scopus (14) Google Scholar Interestingly, despite all these positive attributes of the ASTQT, the most recent ACL Study Group survey found a decline in the use of QT between its peak in 2018 in its most recent survey in 2020. The reasons for this observed decrease were not discussed but may have been due, in part, to a Danish registry study that demonstrated a higher revision rate following QT autograft compared with hamstring and BPTB autografts.16Lind M. Strauss M.J. Nielsen T. Engebretsen L. Quadriceps tendon autograft for anterior cruciate ligament reconstruction is associated with high revision rates: Results from the Danish Knee Ligament Registry.Knee Surg Sports Traumatol Arthrosc. 2020; 28: 2163-2169Crossref PubMed Scopus (27) Google Scholar However, a subsequent study from the same registry found higher revision rates for QT autograft only at sites performing a low volume of ACLR with this graft (<100 from 2012 to 2019), suggesting that learning curve played a role in the inferior outcomes observed in the first study.17Lind M. Strauss M.J. Nielsen T. Engebretsen L. Low surgical routine increases revision rates after quadriceps tendon autograft for anterior cruciate ligament reconstruction: Results from the Danish Knee Ligament Reconstruction Registry.Knee Surg Sports Traumatol Arthrosc. 2021; 29: 1880-1886Crossref PubMed Scopus (14) Google Scholar As ASTQT appears to have less donor-site morbidity compared with BPTB, favorable biomechanical characteristics, decreased opioid consumption postoperatively, and from the currently available evidence, similar clinical outcomes including objective functional measures,18Kim S.J. Kumar P. Oh K.S. Anterior cruciate ligament reconstruction: Autogenous quadriceps tendon-bone compared with bone-patellar tendon-bone grafts at 2-year follow-up.Arthroscopy. 2009; 25: 137-144Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar, 19Renstrom P.A. Eight clinical conundrums relating to anterior cruciate ligament (ACL) injury in sport: Recent evidence and a personal reflection.Br J Sports Med. 2013; 47: 367-372Crossref PubMed Scopus (63) Google Scholar, 20Lund B. Nielsen T. Fauno P. Christiansen S.E. Lind M. Is quadriceps tendon a better graft choice than patellar tendon? A prospective randomized study.Arthroscopy. 2014; 30: 593-598Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar, 21Cavaignac E. Coulin B. Tscholl P. Nik Mohd Fatmy N. Duthon V. Menetrey J. Is quadriceps tendon autograft a better choice than hamstring autograft for anterior cruciate ligament reconstruction? A comparative study with a mean follow-up of 3.6 years.Am J Sports Med. 2017; 45: 1326-1332Crossref PubMed Scopus (92) Google Scholar, 22Hurley E.T. Calvo-Gurry M. Withers D. Farrington S.K. Moran R. Moran C.J. Quadriceps tendon autograft in anterior cruciate ligament reconstruction: A systematic review.Arthroscopy. 2018; 34: 1690-1698Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar patient-reported outcomes,18Kim S.J. Kumar P. Oh K.S. Anterior cruciate ligament reconstruction: Autogenous quadriceps tendon-bone compared with bone-patellar tendon-bone grafts at 2-year follow-up.Arthroscopy. 2009; 25: 137-144Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar,20Lund B. Nielsen T. Fauno P. Christiansen S.E. Lind M. Is quadriceps tendon a better graft choice than patellar tendon? A prospective randomized study.Arthroscopy. 2014; 30: 593-598Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar,21Cavaignac E. Coulin B. Tscholl P. Nik Mohd Fatmy N. Duthon V. Menetrey J. Is quadriceps tendon autograft a better choice than hamstring autograft for anterior cruciate ligament reconstruction? A comparative study with a mean follow-up of 3.6 years.Am J Sports Med. 2017; 45: 1326-1332Crossref PubMed Scopus (92) Google Scholar,23Geib T.M. Shelton W.R. Phelps R.A. Clark L. Anterior cruciate ligament reconstruction using quadriceps tendon autograft: Intermediate-term outcome.Arthroscopy. 2009; 25: 1408-1414Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar and graft failure rates,21Cavaignac E. Coulin B. Tscholl P. Nik Mohd Fatmy N. Duthon V. Menetrey J. Is quadriceps tendon autograft a better choice than hamstring autograft for anterior cruciate ligament reconstruction? A comparative study with a mean follow-up of 3.6 years.Am J Sports Med. 2017; 45: 1326-1332Crossref PubMed Scopus (92) Google Scholar,22Hurley E.T. Calvo-Gurry M. Withers D. Farrington S.K. Moran R. Moran C.J. Quadriceps tendon autograft in anterior cruciate ligament reconstruction: A systematic review.Arthroscopy. 2018; 34: 1690-1698Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar,24Crum R.J. Kay J. Lesniak B.P. Getgood A. Musahl V. de Sa D. Bone versus all soft tissue quadriceps tendon autografts for anterior cruciate ligament reconstruction: A systematic review.Arthroscopy. 2021; 37: 1040-1052Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar it remains unclear why this graft has not gained more widespread adoption. Current technologies for graft harvest and fixation are user-friendly and allow for a relatively short learning curve.8Slone H.S. Xerogeanes J.W. Anterior cruciate ligament reconstruction with quadriceps tendon autograft: A minimally invasive harvest technique.JBJS Essent Surg Tech. 2014; 4: e16Crossref PubMed Google Scholar, 9Sprowls G.R. Robin B.N. The quad link technique for an all-soft-tissue quadriceps graft in minimally invasive, all-inside anterior cruciate ligament reconstruction.Arthrosc Tech. 2018; 7: e845-e852Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 10Ollivier M. Cognault J. Pailhe R. Bayle-Iniguez X. Cavaignac E. Murgier J. Minimally invasive harvesting of the quadriceps tendon: Technical note.Orthop Traumatol Surg Res. 2021; 107: 102819Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar So why have we all not made the switch to the ASTQT autograft? Is now the time to make the switch? In this single-surgeon study over a 9-year period, Hogan et al. reported a minimum of 1-year follow up on 39 patients who underwent primary ACLR with ASTQT autograft and 80 who underwent primary ACLR with BPTB autograft. There was selection bias, as “contact athletes” preferably received BPTB autograft, whereas “young patients with high-athletic demand” preferably underwent ASTQT autograft. These 2 categories are unclear, seem to overlap with one another, and should be clarified. Furthermore, 38 patients who underwent BPTB autograft had not yet met the 12-month minimum follow-up requirement at the time of data analysis and were excluded, whereas all patients in the ASTQT group met the 12-month minimum follow-up requirement. This suggests that the surgeon may have stopped performing ASTQT for a period of time, which warrants explanation, given the findings and conclusions of the study. While nonsignificant (P = .06), the BPTB group had a mean follow-up that was 6.1 months longer than the ASTQT autograft in a study that the authors acknowledged was not adequately powered, indicating that the BPTB group may have had more exposure risk for reinjury. As the authors stated, graft failure is one of the most important outcome measures to consider when comparing ACL graft choices. Few conclusions can be drawn regarding graft failure in this study due to a low number of failures (and a relatively low number of patients overall), although notably, there were early failures that underwent revision in both groups (4.3 months in ASTQT autograft and 2.3 months in BPTB autograft). Throughout the discussion, the authors state that ASTQT autograft can produce reliable and similar results as compared with BPTB autograft reconstruction, performing comparably with BPTB in patient-reported outcome measures at “mid-term follow-up.” With a minimum follow-up of 1 year in both groups and a mean follow-up of less than 2 years in the ASTQT group, this should be considered a short-term follow-up study rather than “mid-term.” The authors correctly acknowledge that additional longer-term studies are necessary to identify whether these outcomes diminish over time. I would add that larger, adequately powered studies in the greatest-risk populations, such as young athletes returning to level 1 sports (multidirectional field sports that involve landing, pivoting, or change of direction),25King E. Richter C. Daniels K.A.J. et al.Biomechanical but not strength or performance measures differentiate male athletes who experience ACL reinjury on return to level 1 Sports.Am J Sports Med. 2021; 49: 918-927Crossref PubMed Scopus (19) Google Scholar will be critical to sufficiently support the notion that the ASTQT can produce similar outcomes and is a safe, reliable, and effective graft as compared with BPTB autograft. Within their discussion, the authors thoroughly review the existing literature comparing QT with other autografts, with nearly all studies demonstrating no significant difference when comparing QT with BPTB in any clinical outcome measure.18Kim S.J. Kumar P. Oh K.S. Anterior cruciate ligament reconstruction: Autogenous quadriceps tendon-bone compared with bone-patellar tendon-bone grafts at 2-year follow-up.Arthroscopy. 2009; 25: 137-144Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar,20Lund B. Nielsen T. Fauno P. Christiansen S.E. Lind M. Is quadriceps tendon a better graft choice than patellar tendon? A prospective randomized study.Arthroscopy. 2014; 30: 593-598Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar, 21Cavaignac E. Coulin B. Tscholl P. Nik Mohd Fatmy N. Duthon V. Menetrey J. Is quadriceps tendon autograft a better choice than hamstring autograft for anterior cruciate ligament reconstruction? A comparative study with a mean follow-up of 3.6 years.Am J Sports Med. 2017; 45: 1326-1332Crossref PubMed Scopus (92) Google Scholar, 22Hurley E.T. Calvo-Gurry M. Withers D. Farrington S.K. Moran R. Moran C.J. Quadriceps tendon autograft in anterior cruciate ligament reconstruction: A systematic review.Arthroscopy. 2018; 34: 1690-1698Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 23Geib T.M. Shelton W.R. Phelps R.A. Clark L. Anterior cruciate ligament reconstruction using quadriceps tendon autograft: Intermediate-term outcome.Arthroscopy. 2009; 25: 1408-1414Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar,26Gorschewsky O. Klakow A. Putz A. Mahn H. Neumann W. Clinical comparison of the autologous quadriceps tendon (BQT) and the autologous patella tendon (BPTB) for the reconstruction of the anterior cruciate ligament.Knee Surg Sports Traumatol Arthrosc. 2007; 15: 1284-1292Crossref PubMed Scopus (79) Google Scholar, 27Han H.S. Seong S.C. Lee S. Lee M.C. Anterior cruciate ligament reconstruction: Quadriceps versus patellar autograft.Clin Orthop Relat Res. 2008; 466: 198-204Crossref PubMed Scopus (112) Google Scholar, 28Lee S. Seong S.C. Jo H. Park Y.K. Lee M.C. Outcome of anterior cruciate ligament reconstruction using quadriceps tendon autograft.Arthroscopy. 2004; 20: 795-802Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 29Runer A. Csapo R. Hepperger C. Herbort M. Hoser C. Fink C. Anterior cruciate ligament reconstructions with quadriceps tendon autograft result in lower graft rupture rates but similar patient-reported outcomes as compared with hamstring tendon autograft: A comparison of 875 patients.Am J Sports Med. 2020; 48: 2195-2204Crossref PubMed Scopus (17) Google Scholar, 30Sofu H. Sahin V. Gursu S. Yildirim T. Issin A. Ordueri M. Use of quadriceps tendon versus hamstring tendon autograft for arthroscopic anterior cruciate ligament reconstruction: A comparative analysis of clinical results.Eklem Hastalik Cerrahisi. 2013; 24: 139-143Crossref PubMed Scopus (29) Google Scholar, 31Fischer F. Fink C. Herbst E. et al.Higher hamstring-to-quadriceps isokinetic strength ratio during the first post-operative months in patients with quadriceps tendon compared to hamstring tendon graft following ACL reconstruction.Knee Surg Sports Traumatol Arthrosc. 2018; 26: 418-425Crossref PubMed Scopus (56) Google Scholar However, in many of these previous studies, there was heterogeneity in graft fixation methods and whether a bone plug was harvested along with the QT autograft. As such, this is among the first study to directly compare ASTQT with BPTB autograft, and the authors should be commended for this. Despite all this optimism, we should be cautious in adopting the ASTQT as a one-size-fits-all approach to ACL graft choice. When assessing outcomes following ACLR and comparing graft choices, data should be stratified according to the risk profile of the patients following their return to preinjury activity level. When ACLR is performed in older patients and in nonathletes, the risk of graft failure following appropriate rehabilitation and return to activities is substantially lower than that in high-risk groups including young patients (<18-25 years old) and in those returning to level 1 sports.3Kaeding C.C. Aros B. Pedroza A. et al.Allograft versus autograft anterior cruciate ligament reconstruction: Predictors of failure from a MOON prospective longitudinal cohort.Sports Health. 2011; 3: 73-81Crossref PubMed Scopus (320) Google Scholar,25King E. Richter C. Daniels K.A.J. et al.Biomechanical but not strength or performance measures differentiate male athletes who experience ACL reinjury on return to level 1 Sports.Am J Sports Med. 2021; 49: 918-927Crossref PubMed Scopus (19) Google Scholar,32Webster K.E. Feller J.A. Exploring the high reinjury rate in younger patients undergoing anterior cruciate ligament reconstruction.Am J Sports Med. 2016; 44: 2827-2832Crossref PubMed Scopus (263) Google Scholar,33Wiggins A.J. Grandhi R.K. Schneider D.K. Stanfield D. Webster K.E. Myer G.D. Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: A systematic review and meta-analysis.Am J Sports Med. 2016; 44: 1861-1876Crossref PubMed Scopus (501) Google Scholar These factors are considered within the MOON Knee Group’s ACL Autograft Retear Risk Calculator, a validated tool that I use to counsel each of my ACL-injured patients.34Tan S.H.S. Lau B.P.H. Krishna L. Outcomes of anterior cruciate ligament reconstruction in females using patellar-tendon-bone versus hamstring autografts: A systematic review and meta-analysis.J Knee Surg. 2019; 32: 770-787Crossref PubMed Scopus (14) Google Scholar Multiple previous studies, including one from the MOON group, has made it clear that allograft is not an appropriate graft choice for young patients and for athletes who participate in level 1 sports due to a 3-fold risk of failure compared with autograft.3Kaeding C.C. Aros B. Pedroza A. et al.Allograft versus autograft anterior cruciate ligament reconstruction: Predictors of failure from a MOON prospective longitudinal cohort.Sports Health. 2011; 3: 73-81Crossref PubMed Scopus (320) Google Scholar,35Spindler K.P. Parker R.D. Andrish J.T. et al.Prognosis and predictors of ACL reconstructions using the MOON cohort: A model for comparative effectiveness studies.J Orthop Res. 2013; 31: 2-9Crossref PubMed Scopus (57) Google Scholar Autograft literature also continues to evolve. Despite several large meta-analyses that have reported equivalent or near-equivalent clinical outcomes including graft failure rates when comparing hamstring and BPTB autograft,34Tan S.H.S. Lau B.P.H. Krishna L. Outcomes of anterior cruciate ligament reconstruction in females using patellar-tendon-bone versus hamstring autografts: A systematic review and meta-analysis.J Knee Surg. 2019; 32: 770-787Crossref PubMed Scopus (14) Google Scholar,36Chen H. Liu H. Chen L. Patellar tendon versus 4-strand semitendinosus and gracilis autografts for anterior cruciate ligament reconstruction: A meta-analysis of randomized controlled trials with mid- to long-term follow-up.Arthroscopy. 2020; 36: 2279-2291 e2278Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 37He X. Yang X.G. Feng J.T. et al.Clinical outcomes of the central third patellar tendon versus four-strand hamstring tendon autograft used for anterior cruciate ligament reconstruction: A systematic review and subgroup meta-analysis of randomized controlled trials.Injury. 2020; 51: 1714-1725Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 38Zhao L. Lu M. Deng M. Xing J. He L. Wang C. Outcome of bone-patellar tendon-bone vs hamstring tendon autograft for anterior cruciate ligament reconstruction: A meta-analysis of randomized controlled trials with a 5-year minimum follow-up.Medicine (Baltimore). 2020; 99e23476Crossref Scopus (7) Google Scholar, 39Samuelsen B.T. Webster K.E. Johnson N.R. Hewett T.E. Krych A.J. Hamstring autograft versus patellar tendon autograft for ACL reconstruction: Is there a difference in graft failure rate? A meta-analysis of 47,613 patients.Clin Orthop Relat Res. 2017; 475: 2459-2468Crossref PubMed Scopus (154) Google Scholar recent data suggest that BPTB is preferable to hamstring autograft in young athletes. The devil is in the details: Most previous studies comparing hamstring and BPTB autograft that have suggested equivalent outcomes have included all-comers regardless of risk profile and have failed to sufficiently stratify data according to age and activity level.40Spindler K.P. Huston L.J. et al.MOON Knee GroupAnterior cruciate ligament reconstruction in high school and college-aged athletes: Does Autograft choice influence anterior cruciate ligament revision rates?.Am J Sports Med. 2020; 48: 298-309Crossref PubMed Scopus (36) Google Scholar In a mid-term follow-up study that only included patients aged 14-22 years injured in sports, the MOON Knee Group reported a 2.1 times greater odds of ACL graft revision after ACLR with hamstring autograft compared to BPTB at minimum 6-year follow-up.40Spindler K.P. Huston L.J. et al.MOON Knee GroupAnterior cruciate ligament reconstruction in high school and college-aged athletes: Does Autograft choice influence anterior cruciate ligament revision rates?.Am J Sports Med. 2020; 48: 298-309Crossref PubMed Scopus (36) Google Scholar This cohort comprises the greatest-risk group undergoing ACLR and may also represent the group in which graft choice has the largest impact on failure rates following ACLR. While the findings of that study should not be extrapolated to other soft-tissue autografts, a head-to-head comparison of the ASTQT autograft and BPTB autograft in a similar high-risk population has yet to be published. Currently, BPTB autograft remains the most commonly used graft among high-level collegiate and professional athletes as well as among young recreational athletes in the United States.40Spindler K.P. Huston L.J. et al.MOON Knee GroupAnterior cruciate ligament reconstruction in high school and college-aged athletes: Does Autograft choice influence anterior cruciate ligament revision rates?.Am J Sports Med. 2020; 48: 298-309Crossref PubMed Scopus (36) Google Scholar, 41Erickson B.J. Harris J.D. Fillingham Y.A. et al.Anterior cruciate ligament reconstruction practice patterns by NFL and NCAA football team physicians.Arthroscopy. 2014; 30: 731-738Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar, 42Farber J. Harris J.D. Kolstad K. McCulloch P.C. Treatment of anterior cruciate ligament injuries by major league soccer team physicians.Orthop J Sports Med. 2014; 2 (2325967114559892)Crossref PubMed Scopus (25) Google Scholar It is possible that future studies will show that the ASTQT has equivalent clinical outcomes, including graft failure rates, successful return to sport at the preinjury level, and equivalent patient-reported outcomes as BPTB in these high-risk populations, but these important comparative data are not yet available. The ASTQT autograft appears to have an increasing role in ACLR, but the specific populations in which it should be the preferred graft remain to be defined. Our choice of graft for each patient should not depend on surgeon preference or comfort level based on exposure during training. Instead, we must continue to evolve based on the best available evidence and provide the most suitable graft for each patient based their risk profile and post-rehabilitation goals. Future comparative clinical outcomes studies will continue to guide us in selecting the appropriate graft for each patient, and we must remain open and critical in interpreting these studies and applying them to our practices. Download .pdf (.08 MB) Help with pdf files ICMJE author disclosure forms Author Reply to ”Regarding ‘No Difference in Complication Rates or Patient-Reported Outcomes Between Bone-Patellar Tendon-Bone and Quadriceps Tendon Autograft for Anterior Cruciate Ligament Reconstruction”’ArthroscopyVol. 38Issue 6PreviewWe would like to thank Dr. Joseph Lamplot for his interest, appreciation, and critical review of our article. We agree with his expanded discussion, commentary, and cautious optimism that surrounds the use of all-soft tissue quadriceps autograft (ASTQT) for ACL reconstruction. We feel there are potential benefits of ASTQT in certain patient subsets but agree that we must resist the temptation for a one-size-fits-all approach. Additionally, we fully acknowledge the limitations of our study, namely selection bias for graft choice and relatively short follow-up duration. Full-Text PDF

Cartilage restoration as an adjunct to patella stabilization is controversial. Our purpose was to evaluate patients undergoing surgical stabilization with or without concomitant cartilage restoration. Our hypothesis was that there would be lower baselines scores and higher complications in the cartilage restoration cohort with no differences in final outcome.

OBJECTIVE:To evaluate the effects of silicone ankle sleeves (SASs) and lace-up ankle braces (LABs) on neuromuscular control, net joint torques, and cutting agility in healthy, active individuals. DESIGN:Markerless motion-capture technology tracked subjects fitted with SASs, LABs, or no brace while they performed the movements: Y-excursion, left cutting, right cutting, single-leg drop vertical jump (SLDVJ), 45-degree bound, and single-leg squat (SLS). SETTING:University Laboratory. PARTICIPANTS:Ten healthy, active individuals (5 males and 5 females, mean ± SD 23.60 ± 1.43 years of age). MAIN OUTCOME MEASURES:Degrees of joint range of motion (ROM), Newton-meters of joint torque, time to perform a cutting maneuver. RESULTS:SASs and LABs resulted in significantly different knee and ankle ROM and hip internal rotation in the SLDVJ, SLS, Y-excursion, cutting maneuver, and 45-degree bound when compared to control (p < .05). Both ankle and knee torque were significantly reduced in the 45-degree bound and cutting movements with both types of PABs (p < .05). There were minimal differences between the SASs and LABs for all conditions. There were no statistically significant differences in cutting times for any of the 3 conditions. CONCLUSION:Both SAS and LAB positively impacted neuromuscular control, reduced net joint torque, and neither impaired cutting agility when compared to control.

Avulsion fractures of the anterior inferior iliac spine (AIIS) are rare injuries in adolescent athletes. We present a case of a 15-year-old male who sustained an avulsion injury to his right AIIS when kicking a soccer ball. The patient had chronic pain and extra-articular subspinal impingement leading to decreased hip flexion and rotation. The injury occurred 1.5 years prior to symptom onset, and we were the first health care providers to manage the injury. We attempted six months of nonoperative management including activity modifications and nonsteroidal anti-inflammatory (NSAID) therapy without improvement. Although this injury can often be managed nonoperatively, his symptoms required excision of the AIIS and associated heterotopic ossification. He had an excellent outcome with return to soccer and no pain at his final follow-up visit two years after surgery. Due to the limited literature guiding the surgeon's management of AIIS avulsion injuries with associated heterotopic ossification, we provide a review of the literature detailing pre- and postoperative ranges of motion, surgical approach, fixation or excision of the avulsion fragment, and return to sport in this patient population.