Quadriceps Tendon Autograft in Pediatric ACL Reconstruction: Graft Dimensions and Prediction of Size on Preoperative MRI

Background: There is increased interest in quadriceps autograft anterior cruciate ligament (ACL) reconstruction in the pediatric population. Purpose: To evaluate children and adolescents who underwent ACL reconstruction using a quadriceps autograft to determine the properties of the harvested graft and to assess the value of demographic, anthropometric, and magnetic resonance imaging (MRI) measurements in predicting the graft size preoperatively. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective database search was performed from January 2018 through October 2020 for patients undergoing ACL reconstruction. Patients <18 years old at the time of surgery in whom a quadriceps tendon autograft was used were selected. Demographic data and anthropometric measurements were recorded, and graft measurements were abstracted from the operative notes. Knee MRI scans were reviewed to measure the quadriceps tendon thickness on sagittal cuts. Graft length and diameter were then correlated with anthropometric and radiographic data. Results: A total of 169 patients (98 male) were included in the final analysis, with a median age of 15 years (range, 9-17 years). A tendon length ≥65 mm was harvested in 159 (94%) patients. The final graft diameter was 8.4 ± 0.7 mm (mean ± SD; range, 7-11 mm). All patients had a graft diameter ≥7 mm, and 139 (82%) had a diameter ≥8 mm. Preconditioning decreased the graft diameter by a mean 0.67 ± 0.23 mm. Age ( P = .04) and quadriceps thickness on MRI ( P = .003) were significant predictors of the final graft diameter. An MRI sagittal thickness >6.7 mm was 97.4% sensitive for obtaining a graft ≥8 mm in diameter. Conclusion: Our findings suggest that tendon-only quadriceps autograft is a reliable graft source in pediatric ACL reconstruction, yielding a graft diameter ≥8 mm in 82% of pediatric patients. Furthermore, preoperative MRI measurements can be reliably used to predict a graft of adequate diameter in children and adolescents undergoing ACL reconstruction, with a sagittal thickness >6.7 mm being highly predictive of a final graft size ≥8 mm.

COMPARATIVE STUDY OF SINGLE BUNDLE ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION USING THE PERONEUS LONGUS TENDON AUTOGRAFT VERSUS HAMSTRING TENDON AUTOGRAFT

Introduction: Arthroscopic anterior cruciate ligament (ACL) reconstruction can be performed using autograft from various sources namely bone patellar tendon bone graft, hamstring graft, or peroneus longus tendon. Purpose of this study was to compare the clinical outcome and donor site morbidity of ACL reconstruction with peroneus longus tendon versus hamstring tendon autograft in patients with an isolated ACL injury. Methods: Patients who undervent isolated single bundle ACL reconstruction were allocated in peroneus and hamstring groups and observed prospectively. Functional score (IKDC, & Modified Cincinnati score) was recorded preoperatively and 1 year post-operatively. Graft diameter was measured intra-operatively. Donor site morbidity were assessed with thigh circumference measurments and ankle scoring by MRC grading and FADI Score. Results: 56 patients (28-Hamstring and 28-peroneus group) met the inclusion criteria. The average Peroneus longus graft diameter (8.8±0.8) was significantly larger than the Hamstring graft diameter (8.1±0.9). In terms of 1-year postoperative outcomes statistically there is very little comparable difference between both these grafts when used for arthroscopic ACL reconstruction. Conclusion: Our study brings forth the superior efficacy and quality of double stranded peroneus longus tendon autograft in term of good functional score (IKDC, & Modified Cincinnati score), larger graft diameter, less thigh hypotrophy, and excellent ankle function based on FADI Score. Prospective cohort study, level II. Abbreviations: ACL- Anterior cruciate ligament BPTB- Bone-patellar tendon-bone IKDC – International knee documentation committee FADI- Foot and ankle disability index.

Reduction in Diameter of Hamstring Autograft With Additional Circumferential Preconditioning During ACL Reconstruction in a Pediatric Population

Background: Over 130,000 anterior cruciate ligament (ACL) reconstructions (ACLRs) are performed annually in the United States. Previous studies have shown that circumferential preconditioning reduces the diameter of fresh-frozen allografts, but no studies have described the effect in ACL autografts used during ACLR. Purpose: To characterize the changes in the hamstring autograft diameter as a result of preparatory circumferential preconditioning. Study Design: Case series; Level of evidence, 4. Methods: A total of 135 patients with ACLR, with a median age of 15 years (interquartile range, 14-16 years; 50.4% boys), were identified in 2 pediatric hospitals. Three orthopaedic surgeons recorded hamstring autograft diameters at 2 time points during graft preparation. Hamstring tendons were prepared using a standardized procedure, tensioned to 15 to 20 lbs, and measured using cylindrical sizing guides. The graft was left with passive compression in the smallest initial rigid sizing guide for 10 minutes on both the tibial and femoral sides and then measured again immediately before implantation. Tunnels were drilled based on the second measurement of graft size. Comparisons were made between the graft diameter before and after circumferential preconditioning. A random-effects regression model and a linear regression model were performed to capture any unexplained variance on the linear predictor scale and determine correlations between demographics and graft characteristics. Results: The median initial diameter for both femoral and tibial sides was 9.5 mm. After longitudinal tension and circumferential preconditioning, the median autograft diameter of both sides decreased by 1 mm ( P < .001) to 8.5 mm. In the random-effects model, decreased patient height was a significant predictor of greater reduction in graft diameter. Increased height was a significant predictor for greater initial graft diameter (average beta coefficient = 3.08; P < .01). No intraoperative complications were noted with implantation of the preconditioned grafts in smaller diameter tunnels. Conclusion: The median diameter of hamstring ACL autografts decreases by 1 mm after circumferential preconditioning within standard cylindrical sizing guides. This allowed for drilling of tunnels that were an average of 1 mm smaller without any noted intraoperative complications with graft insertion.

Rebubbling rate in preloaded versus surgeon prepared DSAEK

Purpose: To compare the clinical outcomes of eye bank preloaded Descemet stripping automated endothelial keratoplasty (DSAEK) grafts and surgeon prepared. Methods: In this retrospective study, the data were obtained from two groups (a) surgeon cut DSAEK where tissue was prepared by the surgeon immediately before surgery, and (b) preloaded DSAEK tissue shipped to the surgeon after preparation by the eye bank. Standard DSAEK preparations using Moria microkeratome with single pass method were performed. For the tissues prepared by the eye banks, they were preloaded in an iGlide device and shipped in transport media. Standard DSAEK surgery using bimanual pull-through technique was performed for all the grafts. Air was used as a tamponade. Main outcome measures included best corrected visual acuity (BCVA) and rebubbling rate. Result: Out of 107 eyes of 101 patients that underwent DSAEK surgery, 33 tissues were prepared by the surgeon (sc-DSAEK), while 74 were prepared by the eye bank (pl-DSAEK). sc-DSAEK showed a rebubbling rate of 9.1%, compared to the 16.2% for the preloaded DSAEK ( p = 0.11). There was no statistical difference in postoperative BCVA between the two groups. Logistic regression analysis showed no association between detachment rate and cataract surgery, graft preparation method, graft diameter and reason for graft. Conclusion: Preloaded grafts have similar rebubbling rate and visual acuity achieved compared with surgeon prepared grafts.

384 Use of A Dry Swab During ACL Hamstring Tendon Graft Preparation May Lead to Decreased Graft Diameter at Implantation with Subsequent Rebound in Graft Diameter When Exposed to Haemarthrosis – A Porcine Tendon Study

Introduction ACL reconstruction surgery commonly utilises a hamstring tendon graft. Grafts are normally covered with a wet swab prior to implantation. The aim of this study was to determine the variance in graft diameter when comparing the traditional wet swab to a dry swab. Method Flexor tendons from a selection of fresh pig trotters were isolated and prepared with a standard ACL graft preparation technique. Half of the grafts were covered with a wet swab; the other half were covered with a dry swab. Graft diameters were measured at 10-minute intervals. After 30 minutes the grafts were submerged in Hartmann’s solution to simulate the post-operative haemarthrosis, diameters were checked again after 1 hour in the solution. Results Use of a dry swab resulted in a 0.5mm greater reduction in diameter than the wet swab group. The dry swab group also showed an increase in diameter by 0.5mm when soaked in Hartmann’s solution, this was not seen in the wet swab group. Conclusions Using a dry swab produces a smaller graft diameter, this would allow smaller bone tunnels, retaining bone stock. The subsequent rebound in diameter when in solution may increase the press fit mechanism and facilitate improved integration into the bone tunnel.

Evaluation of results of anterior cruciate ligament reconstruction using peroneus longus graft

<p class="abstract"><strong>Background: </strong>The objective of the study was to assess clinical outcome and donor site morbidity of ACL reconstruction with peroneus longus tendon autografts in patients with ACL injury.</p><p class="abstract"><strong>Methods:</strong> 60 Patients who underwent ACL reconstruction using peroneus longus autograft after fulfilling inclusion criteria and obtaining informed consent were assessed preoperatively and postoperatively and followed up for 1 year. Graft diameter was measured intraoperatively. Functional score of knee (Tegner and Lysholm Knee score) and American Orthopedic Foot and Ankle Score (AOFAS) for donor site morbidity were recorded preoperatively and 1 year after surgery.</p><p class="abstract"><strong>Results: </strong>93.3% Patients (56 out of 60) had good to excellent Lysholm knee score 1 year postoperatively and the mean AOFAS score was 96.7. The average peroneus longus graft diameter 8 .7mm.</p><p class="abstract"><strong>Conclusions: </strong>Anterior cruciate ligament reconstruction with peroneus longus autografts produces a good functional outcome at 1 year follow-up, with the advantages of large graft diameter and excellent ankle function based on AOFAS score.res.</p>

Preoperative Determination of the Size of the Semitendinosus and Gracilis Tendon by Multidetector Row CT Scanner for Anterior Cruciate Ligament Reconstruction

Accurately measuring the length and diameter of the hamstring tendon autograft preoperatively is important for planning anterior cruciate ligament (ACL) reconstructive surgery. The purpose of this study was to assess the reliability of three-dimensional computed tomography (3D CT) scanning technique to produce the actual measurement of the gracilis and semitendinosus (GT and ST, respectively) tendon grafts' length and diameter for surgery. Ninety patients were scheduled for ACL reconstruction with hamstring autograft. Before the surgery, patients were examined under the multidetector row CT scanner and the ST and GT tendons were qualitatively measured by a volume-rendering technique. The length of ST and GT was measured with 3D CT compared with the length of the harvested ST and GT. The cross-sectional area (CSA) of ST and GT measured with 3D CT compared with the ST and GT graft diameter. Tendon size measured preoperatively and during surgery were statistically compared and correlated. The GT tendons length and cross-sectional area measured during surgery was both shorter and smaller compared with the ST tendon. GT and ST tendon length were correlated to patients' body index such as the height and weight (p < 0.05). However, the correlation levels were low to medium (r = 0.23–0.49). There was strong correlation between the lengths of GT (r = 0.76; p < 0.001) and ST (r = 0.87; p < 0.001) measured with the 3D CT and tendon length at surgery. There was a moderate correlation between graft diameter measured at surgery and 3D CT cross-sectional area (r = 0.31; p < 0.05). A multidetector row CT scanner can determine the ST and GT tendons' length and diameter. These measurements can be used for preoperative planning to help determine the surgical method and counsel patients on appropriate graft choices prior to surgery.

Large-Diameter Penetrating Keratoplasties are Mostly Due to Very Severe Infectious Keratitis and Cannot Always Prevent Secondary Enucleation

Purpose To report the indications and outcomes of penetrating keratoplasties with a graft diameter > 8.5 mm in severe corneal diseases at the Department of Ophthalmology at Saarland University Medical Centre. Study Design Retrospective (6 years), descriptive, and observational. Methods Thirty-five large-diameter penetrating keratoplasties (LDPKPs) in 27 patients (mean age, 62 ± 22 years) were performed from March 2010 to December 2016. The indication for surgery, number of previous corneal transplantations, best-corrected visual acuity (BCVA) before surgery, intraocular pressure, graft status, and BCVA at last follow-up were recorded. Results Infectious keratitis represented 83% of the indications (of those, 45% fungal). The mean corneal graft diameter was 10.8 ± 1.7 (min 8.75, max 15.0) mm. Twenty-three eyes (65% absolute) had at least one previous penetrating keratoplasty (mean graft size, 9.2 ± 1.6 mm). The mean pre-surgery BCVA was 1.96 ± 0.23 logMAR. With a mean follow-up period of 20.2 ± 13.4 months, the mean BCVA was 1.57 ± 0.57 logMAR at last follow-up. Overall, 12 grafts (35%) remained clear until the last follow-up, and in 23 grafts (65%), the primary disease recurred, or corneal decompensation developed. Up to the last follow-up, 6 eyes (17%) had to be enucleated. Conclusions In complex cases of infectious keratitis requiring a LDPKP to remove the complete pathology and preserve eye integrity, the visual outcomes are generally expected to be poor, not only because of the well-known risks of LDPKP but also because of the consequences of the infectious disease itself. This knowledge is important for adequate counselling of the patient preoperatively.