On surgical techniques to reduce morbidity after anterior cruciate ligament reconstruction. The significance of harvesting technique, preconditioning, graft choice and the course of bone mineral in the calcaneus.

The aim of the study was to reduce undesired postoperative effects, such as anterior knee pain, loss of sensitivity in the knee region and problems with knee-walking after anterior cruciate ligament (ACL) reconstructive surgery. Furthermore, prospectively to evaluate the bone mineral in the calcanei before and after ACL reconstruction.In a study of 124 consecutive patients we compared the traditional one-incision technique and the subcutaneous two-incision technique to harvest the central third bone-patellar tendon bone (BTB) autograft. The subcutaneous two-incision technique rendered less disturbance in anterior knee sensitivity and a tendency towards less discomfort during knee-walking.In a prospective randomised study of 53 patients we evaluated the effect of preconditioning the BTB autograft with 39 N for ten minutes before implantation. The preconditioning rendered no advantages in terms of less laxity or better clinical outcome at the 2-year follow-up.Thirty-four consecutive patients with a unilateral ACL injury underwent arthroscopic reconstruction using BTB autografts. The bone mineral areal mass (BMA) was assessed bilaterally in the calcaneus using a g-camera according to the Dual-energy Photon Absorptiometry technique. The BMA was measured before the operation, after six and 26 months. The BMA in the calcaneus on both the injured and non-injured side decreased by 16% and 17% respectively from the preoperative measurement to the 26-month control. The Tegner activity level, though, increased from 3 preoperatively to 7 at 26 months.In a retrospective study we compared the outcome after ACL reconstruction in 49 recreational athletes with 226 competitive athletes with a minimum follow-up of two years. The functional and objective results were similar.In a prospective randomised study of seventy-one patients we compared the results after ACL reconstruction using either the central third BTB autograft or triple/quadruple semitendinosus autografts. At the two-year follow-up, the use of semitendinosus autografts rendered less discomfort during knee-walking, otherwise the subjective and objective results were similar.In conclusion, when the BTB autograft is used for ACL reconstruction, the donor-site morbidity in terms of loss of sensitivity and impaired knee walking ability can be reduced with a two incision subcutaneous harvesting technique. Preconditioning of BTB autografts does not decrease laxity or improve function in the perspective of two years. Arthroscopic ACL reconstruction using BTB autografts renders similar results irrespective of the preoperative activity level. ACL injury followed by reconstructive surgery causes a substantial loss of bone mineral in the calcaneus in the perspective of two years, in spite of a signifcantly increased activity level. This was found on both the injured and non-injured side and could be a risk factor for osteoporosis later in life. The use of triple/quadruple semitendinosus autografts renders a better knee walking ability than the use of BTB autografts. Both grafts render equal results in terms of stability and function. We therefore recommend the semitendinosus autograft as a first choice of graft when ACL reconstructive surgery is required

No significant histological or ultrastructural tendinosis changes in the hamstring tendon in patients with mild to moderate osteoarthritis of the knee?

Purpose - To investigate the periarticular degenerative changes of the knee joint in association with osteoarthritis (OA). More tendinosis was expected to be found in the semitendinosus tendon in patients with knee OA than in patients without knee OA. Methods - Samples from 41 patients were included between January 2016 and October 2017. Twenty-one patients median age 53 (33–63) years with mild to moderate OA underwent high tibial osteotomy (HTO) and 20 patients median age 38 (31–57) years without OA underwent anterior cruciate ligament reconstruction (ACLR). Biopsies from the semitendinosus tendon were obtained at the time of surgery and examined histologically, morphologically and ultrastructurally using light and electron microscope. Results - The histological evaluation of the semitendinosus tendon revealed the presence of more hemosiderin in the ACLR group. No significant morphological or ultrastructural differences were shown between patients in the HTO and ACLR group. Conclusion - Patients with mild and moderate medial compartment knee OA displayed no more degenerative changes in their semitendinosus tendon than patients without OA, as seen in both the light and the electron microscope

More histologic and ultrastructural degenerative signs in the subscapularis tendon and the joint capsule in male patients with shoulder impingement

Purpose: The purpose of the present study was to analyze biopsy samples from the subscapularis tendon and from the joint capsule from male patients with shoulder impingement syndrome (SAIS) and compare them with samples from male patients with post-traumatic recurrent shoulder instability. The hypothesis of the study was that patients with SAIS would have more histologic and ultrastructural degenerative changes in their subscapularis tendon and joint capsule than patients with post-traumatic recurrent shoulder instability. Methods: Male patients scheduled for surgery, with either subacromial decompression or Bankart reconstruction, were included. Four biopsies from each patient were obtained from the capsule and four from the subscapularis tendon during arthroscopic surgery. The histologic characteristics and the presence of glycosaminoglycans were assessed using the light microscope, and the ultrastructure was assessed using a transmission electron microscope. Results: Eight patients, median age 53 (45–74) years (p  Conclusion: Male patients with subacromial impingement have more histologic and ultrastructural degenerative changes in their shoulder compared with patients with post-traumatic recurrent shoulder instability. Clinical relevance: It appears that in patients with subacromial impingement, the whole shoulder joint is affected and not only the subacromial space. It is the opinion of the authors that intra-articular therapeutic injections could be tried more often in these patients. Level of evidence: III

Patellar Tendon Versus Hamstring Tendon Autografts for Reconstructing the Anterior Cruciate Ligament A Meta-Analysis Based on Individual Patient Data

Background: The best means of ensuring knee stability after anterior cruciate ligament (ACL) reconstruction remains a core debate in sports medicine. Hypothesis: There is no difference between ACL reconstruction with patellar tendon or hamstring tendon autografts with regard to postoperative knee laxity and instability. Study Design: Meta-analysis of individual patient data. Methods: Pooled analysis of individual patient data from 6 published randomized clinical trials included 423 patients with symptomatic unilateral anterior cruciate ligament injury randomly assigned to reconstruction with patellar tendon or hamstring tendon autograft. Knee instability, defined as a positive pivot-shift test result, was the primary outcome, and knee laxity, defined as a positive Lachman test result, was the secondary outcome. Odds ratios were computed before and after adjustment for potential confounders and trial effect. Regression analyses were performed to look for effects of covariates on outcomes, and mixedeffects models were used to account for a trial effect. Sensitivity analyses were conducted to explore the effects of missing data and excluding each trial. Results: Anterior cruciate ligament reconstruction with patellar tendon autograft was significantly associated with a decreased risk of a positive pivot-shift test result (adjusted odds ratio, 0.46; 95% confidence interval, 0.24-0.86; P = .016). The risk of having a positive Lachman test result was not significantly different between the 2 groups. The estimated treatment effect was not substantially changed by differences in handling missing data or exclusion of any of the trials. A positive pivot-shift test result was more common in female (P = .003) and younger patients (P = .017). Conclusion: Postoperative knee instability was less common after ACL reconstruction with patellar tendon autograft than with hamstring tendon autograft