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: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: The optimal treatment for chronic patella instability remains controversial. Medial patellofemoral ligament reconstruction (MPFLR) has emerged as the “gold standard” for soft tissue stabilization. However, isolated lateral release (ILR) is still commonly performed to treat chronic patella instability despite growing evidence against this approach. Hypothesis/Purpose: Our purpose is to evaluate long-term revision rates and short-term post-operative complications in pediatric patients undergoing either MPFLR or ILR for recurrent patellar instability. The hypothesis is that MPFLR is a superior treatment option with reduced long term revision rates and comparable short-term complications. Methods: The MarketScan database was queried from 2007-2015 to identify patients who underwent MPFLR or ILR as their primary surgical treatment of their chronic patellar instability. Patients were excluded if they had incomplete records up to 5 years or if they underwent concomitant osteotomy or cartilage restoration during their index stabilization procedure. Baseline demographic data and patient co-morbidities were documented. Two and five year revision surgical stabilization rate and post-operative complications were reported. Results were analyzed statistically. Results: This study identified 471 patients (mean age 15.6 years, female 56.9%) who underwent MPFLR and 528 patients (mean age 15.5 years, female 70.5%) who underwent ILR for chronic patellar instability. Patients were stratified into two mutually exclusive groups: 1) MPFLR only or 2) ILR only. Patients who underwent MPFLR experienced higher rates of overall complications within 90 days of surgery (8.7% vs 4.9%, p = 0.0171). MPFLR had a higher rate of early wound complications (0.8% vs. 0%, p <.033) There was no difference in revision stabilization rate between MPFLR and ILR at 2 year follow-up. However, at 5 years of follow-up, 8.9% of patients who underwent ILR underwent revision surgery compared to 3.0% of patients who underwent MPFLR as their index surgery (p < 0.0001). Conclusions: Isolated lateral release is an inferior treatment option for surgical stabilization of chronic patella instability as compared to medial patellofemoral ligament reconstruction in pediatric patients. Despite slightly higher rate of short term complications in the MPFLR group and similar revision rates at 2 years, MPFLR has significantly decreased risk of revision stabilization at 5 year follow-up. Table 1. Postoperative Complications - within 90 days Table 2. Quality Outcomes

To present a synthesis of recent literature regarding the treatment of patellofemoral arthritis Risk factors of PFJ OA include patella malalignment or maltracking, injury to supportive structures including the MPFL, dysfunction of hamstring and quadriceps coordination, lower limb alignment, trochlear dysplasia, patellar trauma, or ACL surgery. Special physical exam maneuvers include patellar grind test, apprehension test, and lateral patellar tilt angle. Radiographs that should be obtained first-line include weight bearing bilateral AP, lateral, and Merchant views. CT and MRI are used to assess trochlear dysplasia, excessive patellar height, and TT-TG distance. Non-operative management options discussed include non-pharmacologic treatment (patient education, self-management, physical therapy, weight loss), ESWT, cold therapy, taping, bracing, and orthotics. Pharmacologic management options discussed include NSAIDs, acetaminophen, oral narcotics, and duloxetine. Injection therapies include glucocorticoids, hyaluronic acid, PRP, and other regenerative therapies (BMAC, adipose, or mesenchymal stem cells). Other treatment options include radiofrequency ablation and botulinum toxin. The algorithm for the surgical treatment of PFJ OA can begin with arthroscopic assessment of the PF articular cartilage to address mechanical symptoms and to evaluate/treat lateral soft tissue with or without overhanging lateral osteophytes. If patients fail to have symptomatic improvement, a TTO can be considered in those patients less than 50 years of age or active patients >50 years old. In patients with severe PFJ OA, refractory to the above treatments, PFA should be considered. While early PFA design and technique were less than encouraging, more recent implant design and surgical technique have demonstrated robust results in the literature. Patellofemoral osteoarthritis is a challenging orthopedic problem to treat, in that it can often affect younger patients, with otherwise well-functioning knees. It is a unique entity compared to TF OA with distinct epidemiology, biomechanics and risk factors and treatment options.

Background: Commercially available products used in knee cartilage reconstructive and restorative surgical practices fall under unique US Food and Drug Administration (FDA) regulatory pathways that determine the level of evidence required to market each product. Purpose: To evaluate the levels of evidence in the literature supporting commercially available cartilage repair procedures stratified by FDA regulatory pathway (section 351 vs section 361 of “Human Cells, Tissues, and Cellular and Tissue-Based Products” [HCT/P] in the Code of Federal Regulation) with the hypothesis that products requiring approval under a stringent regulatory pathway (351 HCT/P) have higher levels of evidence in the literature supporting use and that products with a less stringent regulatory pathway (361 HCT/P) have a higher number of products available for use in the United States. Study Design: Systematic review; Level of evidence, 4. Methods: A search of the PubMed database was performed to identify all peer-reviewed articles pertaining to either allograft or autologous cartilage repair technologies. Predefined inclusion and exclusion criteria were used to find clinical, preclinical, and laboratory studies while excluding duplicates, systematic reviews, and products not available in the United States. Articles were categorized by regulatory pathway (351 and 361 HCT/P), and variables including publication year, type of publication, level of evidence, and number of publications were analyzed. Results: After application of predefined criteria, 470 of 1924 articles were included in this study. The 351 HCT/P group was composed entirely of autologous chondrocyte implantation (ACI) technology; 94% of the 361 HCT/P group was composed of osteochondral allografts (OCA). The articles regarding 351 HCT/P were more likely to be clinical in nature than the articles on 361 HCT/P (80% vs 48%, respectively; P = .0001) and entailed significantly more level 1 studies (25 vs 0, respectively; P < .0001). Twice as many articles in the 351 HCT/P group were published in the American Journal of Sports Medicine compared with the 361 HCT/P group (71 vs 38, respectively; P = .18). Conclusion: Both ACI and OCA have robust evidence supporting their use, whereas the remaining regulated products have little or no supporting evidence. Technologies regulated by 351 HCT/P were more likely to be level 1 clinical studies and published in the highest impact journal. The 361 HCT/P pathway regulated many more products, with fewer articles supporting their use.

Postoperative infection remains a potentially devastating complication facing the sports medicine surgeon. Infection prevention begins with a thorough history and physical examination to identify patient specific risk factors and aid in risk stratification. Perioperative steroid injections should be used cautiously, with increased time prior to or following surgery being associated with lower infection risk. Sterile preparation with an alcohol containing solution is typically preferred, though there is limited evidence to identify which product is superior. Diagnosis can be challenging with a high index of suspicion needed to identify and appropriately manage patients. Treatment involves prompt irrigation and debridement with deep cultures. Antibiotic coverage should begin with empiric broad treatment and be tailored based on culture results. Early consultation with an infectious disease specialist is recommended to ensure appropriate antibiotic coverage and duration of treatment.

Objectives The primary objective of this survey was to gauge the current global trends in anterior cruciate ligament reconstruction (ACLR) as reported by the members of the Anterior Cruciate Ligament (ACL) Study Group (SG). Methods A survey was created and distributed among the members of the ACL SG consisting of 87 questions and 16 categories related to ACLR, including member demographics, preoperative management, primary ACLR techniques and graft choice, use of concomitant procedures and biological augmentation, postoperative rehabilitation, and more. Results The survey was completed by the 140 members of the ACL SG. Fifty per cent of members are from Europe, 29% from the USA, 15% from the Asia-Pacific and the remaining 6% are from Latin America, the Middle East, New Zealand and Africa. Most (92%) do not believe there is a role for non-operative management of ACL tears in higher level athletes; conversely, most agree there is a role for non-operative management in lower impact athletes (92%). A single-bundle (90%) technique with hamstring autograft (53%) were most common for primary ACLR. Tunnel position varied among respondents. Sixty-one per cent do not use allograft for primary ACLR. Fifty per cent of respondents use cortical suspensory fixation on the femur, with variable responses on the tibia. Most (79%) do not use biologics in primary ACLR, while 83% think there is a selective role for extra-articular augmentation in primary ACLR. Fifty per cent prefer bone-tendon-bone autograft for revision ACLR and extra-articular augmentation is more commonly used (13% always, 26% often) than in primary ACLR (0% always, 15% often). A majority (53%) use a brace after primary ACLR. The most common responses for minimal time to return to play after primary ACLR were 6–8 months (44%) and 8–12 months (41%). Conclusion We presented the thoughts and preferences of the ACL SG on the management of ACL injuries. This survey will help to facilitate an ongoing discussion with regard to ACLR by providing global insights into the current surgical trends in ACLR. Level of evidence Level V, Expert Opinion.

Anterior knee pain is a multifactorial, often chronic condition, which can lead to long-term pain and disability. The purpose of this review is to examine the latest research on patient education for anterior knee pain. We will focus on how we might use patient education to increase the adoption of other efficacious treatment modalities and offer some suggestions for content and form of effective patient education. New research suggests that patient education, alone, or in combination with targeted exercise therapy, can be effective in reducing pain and improving function in patients with patellofemoral pain. Addressing non-physical or psychological factors may also be an important component of patient education in many patients with chronic pain. Incorporation of new technologies into patient education, such as those available online, or through phone- or tablet-based apps, is likely to be helpful in the future, as we move more towards connecting with patients virtually. Patient education has been shown to be effective in decreasing pain and improving activity in patients with patellofemoral pain. Patient education should be individualized to the patient, focus on the latest effective treatments, and emphasize those treatments that can be self-managed by the patient. Emphasis should also be placed on patient understanding of risk factors and patterns of movement that may lead to, or exacerbate, anterior knee pain. Future research should continue to further characterize the elements of patient education that offer the most efficient treatment benefit.

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

Meniscal injury potentiates a sequence of events that leads to degenerative changes and early osteoarthritis. It is therefore imperative to preserve the meniscus whenever possible. Given the expanding indications for meniscus repair, it is important to continually analyze and advance the understanding of rehabilitation and return to play following meniscal surgery. This article presents evidence-based rehabilitation and return-to-play guidelines as well as a brief review of return-to-play outcomes following isolated meniscus repair.

Objectives: Knee arthroscopy using isotonic irrigation fluids is performed safely in millions of patients each year. However, arthroscopic procedures can disrupt the native biology of the joint when hyperosmolar synovial fluid (400 mOsm/L) is replaced by isotonic irrigation fluid (270-300 mOsm/L). Potential ramifications include cell apoptosis and necrosis, alterations in gene expression, protein synthesis and calcium signaling, and extracellular matrix compositional changes with resultant material property perturbations. Recent in vitro studies suggest higher osmolarity irrigation fluids potentiate a chondroprotective environment and a clinical study using hyperosmolar saline for shoulder arthroscopy reported potential clinical advantages. To date, there are no studies examining the use of a hyperosmolar irrigation solution in patients undergoing knee arthroscopy to the authors’ knowledge. Therefore, this prospective randomized double-blind controlled clinical trial was designed to assess safety and efficacy of a hyperosmolar irrigation solution in patients undergoing arthroscopic knee surgery. Methods: With institutional review board approval and informed consent, adult patients scheduled to undergo arthroscopic knee surgery (i.e., chondroplasty, diagnostic, meniscectomy, meniscus repair) were randomized to surgery with either isotonic Lactated Ringer’s (273mOsm/L) or hyperosmolar saline (593 mOsm/L) irrigation solution. The hyperosmolar solution was created by adding 120cc of 23.4% NS solution to a 3L bag of 0.9% NS (Figure). Primary outcomes included perioperative blood pressure, knee girth, pain, and narcotic pain medication consumption. Blood pressure and knee girth measurements were performed before and after surgery. Visual Analogue Scale (VAS) pain scores and narcotic pain medication consumption were logged on post-operative days (POD) 1-3. Data from each cohort were pooled and analyzed for statistical significance (P<0.05) using an unpaired t-Test. Results: (Table): Forty-four patients underwent arthroscopic knee surgery with isotonic (N=23) or hyperosmolar (N=21) irrigation fluid. There were 11 males and 12 females (mean age 44.0 years) in the isotonic cohort and 7 males and 14 females (mean age 40.4 years) in the hyperosmolar cohort. There were no significant differences with respect to surgical duration (pump time), however, significantly (p=0.04) more irrigation fluid was used to complete the procedures in the isotonic cohort compared to the hyperosmolar cohort. There were no significant differences with respect to change in knee girth or blood pressure. There were no significant differences in VAS pain scores or narcotic medication consumption. Conclusion: The results of this randomized clinical trial suggest that the hyperosmolar irrigation solution used is safe for patients undergoing arthroscopic knee surgery. Less irrigation fluid was required when using the hyperosmolar solution with no apparent detrimental effects on execution of the surgical procedure, postoperative pain, or narcotic use. Taken together with previous studies showing chondroprotective and potential clinical benefits in arthroscopic shoulder surgery, the use of hyperosmolar saline irrigation fluid can be considered for clinical use in patients undergoing knee arthroscopy. Figure 1. Table 1. Demographic and Outcome Results Parameter Isotonic (n=23) Hyperosmolar (n=21) P Age (years) 44.0+13.8 40.4+11.5 0.34 Sex 11M/12F 7M/14F 0.37 Pre-Op Blood Pressure 139/88 123/78 Post-Op Blood Pressure 136/83 123/76 Change in Knee Girth (cm) 1.20+1.1 1.6+1.2 0.23 Surgical Time (min) 51.2+34.3 40.3+15.0 0.18 Irrigation Fluid Used (mL) 7374+4822 4823+2719 0.04 Amount of IVF (mL) 889+491 846+370 0.75 VAS Pain (POD 1) 4.8+2.0 4.9+2.0 0.90 VAS Pain (POD 2) 4.8+2.5 3.9+1.7 0.17 VAS Pain (POD 3) 3.8+1.7 3.8+1.9 0.90 Narcotic Pills Consumed (POD 1) 2.9_2.1 2.7+2.3 0.84 Narcotic Pills Consumed (POD 2) 2.5+2.5 2.6+3.2 0.84 Narcotic Pills Consumed (POD 3) 2.3+2.6 1.1+2.0 0.15

Objectives: Graft choice for anterior cruciate ligament (ACL) reconstruction remains controversial. Quadriceps autograft has emerged as an alternative graft choice. However, there remains a paucity of comparative outcomes. Our purpose is to compare subjective outcomes and complications of ACL reconstruction using either BTB or quadriceps autograft. Our hypothesis is that there will be no difference in subjective outcome or complications between groups. Methods: Following IRB approval, retrospective review of prospectively collected data identified consecutive cohorts of patients undergoing ACL reconstruction with either BTB or quadriceps autograft. Surgery was performed by a single sports fellowship trained surgeon between 2011-2019. Patients undergoing concomitant osteotomies, cartilage restoration, and other ligament reconstruction procedures were excluded. Pre- and post-surgical patient reported outcomes (PROs) including IKDC, KOOS, PROMIS, SANE, Tegner, and Marx were compared between groups. Complications requiring re-operation (infection, stiffness, reconstruction failure) were recorded. Results were analyzed statistically. Results: 141 patients met inclusion criteria. There were 72 BTB and 69 quadriceps autografts. Mean age was 20.5 years in the BTB group and 20.7 years in the quadriceps group (p=0.9). 28 of 69 (40.6%) BTB and 34 of 72 (47.2%) quadriceps were female. Pre-operative KOOS Pain (64.5, 78.0, p=0.0007), KOOS QOL (29.6, 37.7, p=0.05), IKDC (44.5, 52.6, p=0.05), and PROMIS Physical Function (39.0, 42.7 p=0.04) scores were significantly higher in the BTB cohort. There were no differences in other baseline PROs. At minimum 6-month follow-up (range 6 - 57 months), patients in both quadriceps and BTB autograft cohorts reported statistically significant improvements in all KOOS domains, Tegner (76.4%, p=0.0002; 94.0%, p=0.000000003), IKDC (67.3%, p=0.0000009; 54.0%, p=0.000000009), SANE (69.4%, p=0.0000001; 70.7%, p=0.000000002), PROMIS Mobility T-Score (30.6%, p=0.0000003; 24.6%, p=0.000002), PROMIS Global Physical Health (15.3%, p=0.00002; 14.3%, p=0.00004), PROMIS Physical Function (33.2%, p=0.0000000008; 29.6%, p=0.00000002), PROMIS Pain Interference (-17.9%, p=0.00000002; -20.8%, p=0.00000000007). Post-operative Tegner (4.7, 6.0, p=0.04) and Global Mental Health (55.7, 60.1, p=0.008) scores were significantly higher in the BTB cohort. Complications were low and not significant between groups. Both quadriceps and BTB autograft cohorts required post-operative re-operations (4.4% and 6.9%, p=0.5). Quadriceps had 2 ligament reconstructions (2.9%) and 1 surgery for stiffness (1.4%). BTB group had 3 ligament reconstructions (4.2%) and 2 surgeries for stiffness (2.8%). Conclusion: Patients undergoing either BTB and quadriceps autograft ACL reconstruction demonstrated significant subjective improvements and low rates of complications requiring re-operation. At mid-term follow-up, the BTB cohort had higher activity and mental health scores.

Large, focal articular cartilage defects of the knee (> 4 cm2) can be a source of significant morbidity and often require surgical intervention. Patient- and lesion-specific factors must be identified when evaluating a patient with an articular cartilage defect. In the management of large cartilage defects, the two classically utilized cartilage restoration procedures are osteochondral allograft (OCA) transplantation and cell therapy, or autologous chondrocyte implantation (ACI). Alternative techniques that are available or currently in clinical trials include a hyaluronan-based scaffold plus bone marrow aspirate concentrate, a third-generation autologous chondrocyte implant, and an aragonite-based scaffold. In this review, we will focus on OCA and ACI as the mainstay in management of large chondral and osteochondral defects of the knee. We will discuss the techniques and associated clinical outcomes for each, while including a brief mention of alternative treatments. Overall, cartilage restoration techniques have yielded favorable clinical outcomes and can be successfully employed to treat these challenging large focal lesions.

Isolated rupture of the distal biceps femoris insertion is rare. Current literature offers limited case reports and outcome measures after surgical management. We describe a knotless suture anchor fixation technique for this tear pattern. At surgery, the retracted biceps tendon and insertion site is debrided to healthy tissue, FiberTape suture (Arthrex) is passed in a Kracków fashion through the tendon, and the 2 ends of the suture are brought down to a SwiveLock anchor (Arthrex) at the anatomic insertion. FiberWire sutures (Arthrex) from the anchor are brought over the remnant stump, completing the repair.

Objectives: The medial patellofemoral ligament (MPFL) is the primary soft-tissue restraint against lateral patellar displacement. Surgery to address MPFL incompetence is the current gold standard for recurrent patellofemoral instability. The role of tibial tubercle osteotomy (TTO) as an adjunct to MPFL reconstruction remains controversial. Our purpose was to evaluate a cohort of patella instability patients undergoing surgical soft tissue stabilization with or without concomitant TTO. Our hypothesis was that there would be no difference between cohorts in baseline values, subjective outcome scores at final follow-up, or complication profile. Methods: Following IRB approval, retrospective review of prospectively collected data identified a consecutive cohort of patients undergoing soft tissue stabilization for recurrent patella instability, with or without concomitant TTO. Indications for TTO were at the surgeon’s discretion, including elevated TT-TG, Caton-Deschamps ratio, and/or unloading chondral lesion(s). Surgery was performed by a single sports fellowship trained surgeon. Pre-surgical and post-surgical patient reported outcomes were collected including KOOS domains, PROMIS (global health, mental health, physical function, pain interference), IKDC, SANE, and Marx scores. Complications requiring re-operation (infection, stiffness, recurrent instability) were recorded. Results were analyzed statistically. Results: The cohort was comprised of 87 patients (95 knees), with 25 males (28.7%) and 62 females (71.3%). The MPFL-TTO cohort had 32 patients (38 knees) and the MPFL-Iso had 55 patients (57 knees). The average age of the MPFL-TTO cohort was 28.3 (range 19.5-44.6) and the average age of the MPFL-Iso group was 29.8 (18.7-55.3). There was no significant difference in pre-operation outcome scores between groups (p>.05). Significant improvements were seen for all KOOS domains in both patient cohorts with no significant differences detected between groups. SANE, IKDC, and PROMIS scores improved significantly with no differences detected between groups. Marx activity score at 6 months post-operatively was significantly different between the groups favoring the isolate MPFL reconstruction cohort. (MPFL-TTO 0.79 +/- 2.15 vs. 4.61 +/- 5.44 in the MPFL-Iso group (p=0.01)). In terms of complications, 4 knees in the MPFL-TTO group required further surgery (2 for stiffness, 1 for infection, and 1 for fracture) and 6 knees in the MPFL-Iso cohort required surgery (4 for stiffness, 1 for infection, and 1 for recurrent instability). Neither the overall complication rate of 4 vs. 6 (p=1) nor the recurrent instability rate of 0 vs. 1 (p=0.41) was significant. Conclusion: In a cohort of patients undergoing MPFL reconstruction, the addition of an appropriately indicated TTO appears to be both safe and effective. Both MPFL-TTO and MPFL-Iso groups demonstrated significant improvement in the majority of subjective outcome scores without major difference between groups. Marx activity scores were higher for the isolated MPFL reconstruction cohort at relatively short term follow-up. The surgical complication profile was similar between groups. Further work is needed to clearly define the role of TTO as an adjunct procedure to MPFL reconstruction.

Imaging of the patellofemoral joint (PFJ) is useful to evaluate for injury and to better understand the relationship between osseous and soft tissue structures. Interpretation of PFJ imaging findings should be used in the context of patient's history and physical examination. X-rays and advanced imaging technology can provide information to confirm diagnosis and to help customize individual treatment plans. This chapter reviews relevant imaging studies utilized in the work-up and treatment of patients with patellofemoral disorders. (C) 2019 Published by Elsevier Inc.