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We describe a case of a failed anterior cruciate ligament (ACL) reconstruction that underwent revision surgery. Lachman, anterior drawer and valgus stress tests were all grade 3, indicating ACL and medial collateral ligament (MCL) insufficiency. Posterior tibial slope (PTS) was 18° and coronal alignment was 5° valgus. The PTS and valgus alignment were possible contributing factors to the failure of the ACL reconstruction (ACLR). A novel approach was taken wherein an anterior closing wedge osteotomy (ACWO) and varising osteotomy were done after performing a tibial tuberosity (TT) osteotomy followed by revision ACLR and MCL reconstruction (MCLR). At 2-year follow-up, the coronal alignment changed to 1° varus and the tibial slope to 5°. The Knee Society Score improved from 34 pre-operatively to 90, with the patient returning to weightlifting and pre-injury activity levels.

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Ultrasound is a useful adjunctive intra-operative imaging modality for soft tissue pathologies. It is readily available in the operating theater and has the distinct advantage of being more portable than an MRI, with no harmful radiation. It is especially useful for determining if any extra articular cysts have been decompressed through arthroscopic surgery, if a parameniscal cyst has been removed completely or if extrusion has been reduced adequately in a meniscus root repair. In our series, intra-operative ultrasound was used for two cases of medial meniscus horizontal tear with meniscus cyst excision, one case of lateral parameniscal cyst without a communicating tear, and five cases of meniscus root repairs. Ultrasound has the potential to be an important intra-operative diagnostic modality not only in diagnosing pathologies but also accurately localizing the soft tissue pathology, which is critical in arthroscopic surgery where the incisions are small. It also has the added advantage of guiding portal placements, especially in areas where there are neurovascular structures, to avoid injuring them. However, training in its effective use by the surgeon is important.

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The popliteus tendon is a useful anchor point to repair the posterior horn of the lateral meniscus. We describe a new, economical technique that does not violate the neurovascular structures, using an antegrade suture passer and a 2-0 fiberwire to repair the posterior segment including posterior horn of the lateral meniscus taking bites through the capsule and meniscus or the popliteus tendon and meniscus with no anchors in the capsule or popliteus. 9 patients were operated upon using this technique and the mean IKDC score improved from 24.2 to 84, p < 0.01, mean pre op Tegner improved from 1.88 to 6.63 p < 0.01, median hop test from 0 to 4, p = 0 at a mean 15.2 months post surgery. 8 patients had a negative Lachman and 1 grade 2 Lachman at 12 months follow up but was asymptomatic. The Barret's criteria was negative for all 9 patients at latest follow up.

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BACKGROUND: Drilling the femoral and tibial tunnels at their anatomical locations are critical for good outcomes and involve seeing the footprints well. We intended to compare two techniques of drilling the tunnels and the patient-reported outcomes and knee stability of patients undergoing single bundle ACL reconstruction using 3D CT to evaluate if the tunnels were anatomical or not. MATERIALS AND METHODS: Sixty single bundle ACL reconstructions were analyzed, 30 each with Technique A and B. Pre-operative and after a minimum 27 month follow-up Lysholm, IKDC, Tegner score, hop test, and Lachman test were noted. 3D CT was done to classify femoral tunnels positions as being well placed, slightly or grossly misplaced and tibial tunnels as optimal or suboptimal and compared. RESULTS: Sixty ACL reconstructions had full follow-up with a mean follow-up of 34 months. There was no significant difference between tunnel positions between the two techniques. Well-placed femoral tunnel had better Lysholm score (62.2 ± 16.2 v/s 48.5 ± 17.2, p 0.002) and IKDC score (62.5 ± 14.3 v/s 52.7 ± 15.1, p 0.012).). Those who had their surgeries within 3 months of their injury had better hop test (4.4 ± 0.9 v/s 3.9 ± 1, p 0.034) and IKDC scores (62.5 ± 15.8 v/s 33.2 ± 13.8, p 0.026) as compared to those that had surgery done after 3 months. CONCLUSION: Tibial tunnel positions were optimal in most cases and did not differ between the two techniques. Well-placed femoral tunnels and surgeries done within 3 months of the injury produced best results.

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BACKGROUND: Anatomical placement of an ACL graft is critical to the clinical outcome of an ACL reconstruction. The purpose of the study was to compare the conventional technique of drilling a femoral tunnel from a medial portal while viewing it from a lateral portal versus viewing it from a high anteromedial portal and drilling it from a low medial portal. We hypothesized that the high anteromedial portal possibly provides an end-on view of the tunnel and would lead to a more favourable tunnel position. MATERIALS AND METHODS: Sixty patients underwent arthroscopic single-bundle ACL reconstruction with a soft tissue graft. All patients had the same surgeon and same surgical technique (except viewing portal). Each patient underwent a 3D-CT 1-week post-op. We classified the patients into two groups (technique A and B) of 30 each. Postoperative tunnel position in each patient was visualized on CT scan with 3D reconstruction by the quadrant method described by Bernard et al. The distance of the centre of the femoral tunnel from the superior and posterior border of the Bernard frame was obtained in each patient of the two groups and mean value in each group was obtained and compared by Student 't' test at 5% level of significance. The position of the femoral tunnels was also studied in reference to the lateral intercondylar ridge and classified into type I (well placed), type II (moderately malpositioned) and type III (grossly malpositioned). RESULTS: The mean distances in technique A from the posterior and superior border of the lateral femoral condyle was 35.8 ± 8.2 and 35.2 ± 6.7, and in technique B was 38.1 ± 8.6 and 35.8 ± 9.4. The two groups did not differ significantly (P > 0.05) in femoral tunnel position as visualized on 3D-CT scan postoperatively. 53.3% patients had well-placed tunnels (type I) overall with 56.67% of technique A and 50% of technique B in this group. None of the tunnels were grossly malpositioned. CONCLUSIONS: The absence of any statistically significant difference between the groups suggests that a high anterolateral portal close to the patellar tendon gives an almost complete view of the lateral aspect of the notch, if not end on. Both techniques produced a majority of well placed (type I) tunnels.

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BACKGROUND: Previous studies have associated anthropometric data and pre-operative hamstring tendon measurements to intraoperative graft diameter for hamstring autograft ACL reconstruction, although an integrated model has yet to be described. The aim of this study was to present such a predictive model for quadrupled semitendinosus (4-ST) and doubled semitendinosus-gracilis (4-STG) graft constructs combining anthropometry (height and weight) and preoperative measurements of tendon as predictors. METHODS: ACL reconstructions using 4-STG and 4-ST were retrospectively reviewed. The outlines of the semitendinosus and gracilis tendons were identified manually in the axial slice of a preoperative T2 weighted MRI using a region-of-interest tool. Regression analysis using intraoperative graft diameter as the dependent variable was performed with tendon cross-sectional area (XSA), gender and height as predictors. RESULTS: 108 ACL reconstructions in 107 patients were examined, 75 of which were performed using the 4-STG construct, and 33 which employed the 4-ST construct. The mean graft diameter in the 4-ST group (8.6 ± 0.8 mm) was significantly (p < 0.001) greater than the 4-STG group (7.9 ± 0.7 mm). Female gender and 4-STG graft construct were associated with increased risk of graft diameter <8 mm. Predictive models of graft diameter were accurate to ±1 mm for both construct types. CONCLUSIONS: An integrated method for assessing patient risk of producing a diminutive graft diameter and planning augmentation in select cases has been presented. The present findings describe a validated predictive model that builds on previous univariable analyses. Further investigation of larger samples, including factors associated with graft preparation, is required to improve model accuracy for routine clinical application. LEVEL OF EVIDENCE: IV, Retrospective Cohort Study.

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BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) is one of the most well studied and performed procedures in the world. Thus, it would be useful to develop a tool to predict patient outcomes post-operatively to allow clinicians to optimise management. PURPOSE: To identify and summarise factors predictive of graft failure and patient-reported outcome (PROM) measures at minimum two years after ACLR with single-bundle quadruple hamstring autograft via the anteromedial portal technique. METHODS: Studies reporting IKDC, KOOS, Lysholm and graft failure in ACLR were systematically reviewed. A methodological score was applied to these studies, with those above the mean analysed further. Only those reporting primary predictors of patient outcomes following ACLR were included. RESULTS: Twenty-six studies satisfied our inclusion criteria. Fourteen scored above the mean 20 Downs and Black score (18.4) and were considered higher level evidence. The higher quality papers reported that younger age, female sex, higher BMI, smoking history and activity levels predicted poorer outcomes. High-grade tears of the menisci or full-thickness cartilage defects were identified as predictors of poorer PROMs. None of the factors investigated by more than a single paper were unanimously significant in predicting the outcome of ACLR. CONCLUSIONS: The evidence surrounding predictors of outcome was inconsistent in design, methodology and reporting of results, hindering our ability to draw conclusions regarding the validity of the reported relationships. However, this systematic review identified several patient demographics, concomitant injuries, and surgical factors that could be investigated further in future prospective studies to create a definitive predictive model.

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