Economopoulos, Kostas J.

Objectives: Anterior cruciate ligament (ACL) reconstruction remains one of the most common procedures performed on the knee with over 250,000 being performed each year in the United States. Although common, results of ACL reconstructions remain less impressive than would be expected. Getgood et al showed a 40% failure of ACL reconstructions including recurrent ACL tears and continued rotational instability. 1 The group found that by adding a lateral extra-articular tenodesis (LET) decreased the failure rate to 25%. Sommerfeldt et al identified recurrent ACL instability as a risk factor for meniscal tears after ACL reconstruction. 2 In patients with a medial meniscal tear after ACL reconstruction, the decision to proceed with revision ACL reconstruction is straightforward when the graft is completely torn. However, the best approach for a medial meniscal tear after ACL reconstruction with recurrent rotational instability when the ACL graft is intact or partially torn has not been determined. The purpose of this study was to evaluate clinical outcomes of patients with intact or partially torn ACL grafts with continued rotational instability and a medial meniscal tears treated with revision ACL reconstruction, ACL reconstruction with lateral extra-articular tenodesis (LET) and isolated LET. We hypothesized that an isolated LET would have similar clinical outcomes compared to the ACL and ACL+LET groups at 2 years. Methods: A retrospective review was performed of all patients with medial meniscal tears after ACL reconstruction. Patients were included in the study if the ACL graft was intact or partially torn with an exam consistent with residual or recurrent rotational instability. Residual ACL instability was determined by a pivot shift of 2 or more on examination. Patients with a grade 3 Lachman’s and partial ACL tear were treated with ACL reconstruction and not included in the study. Over time, the senior author evolved in the treatment of these patients from ACL reconstruction to ACL reconstruction with LET to isolated LET. Patients were placed into different groups based on which treatment they underwent. Clinical outcomes included recurrent meniscal tears, residual rotational instability and recurrent ACL graft tears. Patient reported outcomes (PROs) included IKDC and Lysholm scores at 6, 12, and 24 months. In athletes, we also calculated the percentage of return to play. Results: A total of 47 patients were included in the study including 19 patients in LET group, 12 patients in the ACL+LET group, and 16 patients in the ACL group. The patient demographics between the 3 groups were similar. Ligamentous laxity was identified in 42% of the LET group, 50% of the ACL+LET group and 44% of the ACL group. Partial ACL tears were identified in 63% of the LET group, 75% in the ACL+LET group and 62% of the isolated ACL group. The 6-month International Knee Documentation Committee (IKDC) and Lysholm scores were significantly higher for the isolated ACL group compared to the ACL+LET group and isolated LET groups. However, at the 12 and 24-month follow-up the LET and ACL+LET groups had significantly higher IKDC and Lysholm scores compared to the isolated ACL group (Figures 1 and 2). There was no difference between the LET group and ACL+LET group’s IKDC or Lysholm scores at time point. The ACL group showed a significantly higher percentage of patients with a post operative positive pivot shift (44%) compared to the ACL+LET group (8.3%) and isolated LET group (10.5%) at the 2-year postoperative visit (p=0.02). No difference was seen between the LET and ACL+LET groups with regards to residual pivot shift (p=0.88). Recurrent meniscal tears were significantly higher in the ACL group (31.3%) compared to the LET (5.3%) and ACL+LET (8.3%) groups (p=.04). There was no difference with regards to postoperative graft tearing with 5.3% of LET group, 0% of ACL+LET and 12.5% of the ACL group having a postoperative graft tear. There was a significantly higher rate of return to play in the LET group (90%) compared to the ACL+LET group (71.4%) and ACL group (75%). Return to play at the same or higher level was also significantly higher in the LET group (80%) compared to the ACL+LET (57.1%) and ACL group (50%). Conclusions: In patients with partially torn or intact ACL grafts with residual rotational instability and medial meniscal tears, the addition of a LET with or without revision ACL reconstruction leads to improved patient outcomes, a lower rate of residual rotational instability and recurrent meniscal tearing compared to an isolated revision ACL reconstruction. The addition of an ACL reconstruction to LET in patients with intact or partially torn ACL grafts and meniscal tearing did not decrease the rate of residual pivot shift or recurrent meniscal tears compared to an isolated LET. Isolated LET in this patient population leads to a higher return to play and play at same or higher level compared to an isolated ACL revision or ACL revision with LET. Isolated LET in this patient population is an acceptable option. [Figure: see text][Figure: see text]

Purpose To assess outcomes of arthroscopic posterior capsular release among athletes for loss of terminal extension following anterior cruciate ligament (ACL) reconstruction. Methods A retrospective review of prospectively collected data was performed for patients undergoing arthroscopic posterior capsular release for knee extension loss following ACL reconstruction between January 2014 and December 2019. Procedure indications included extension loss greater than 10° at least 3 months after ACL reconstruction that was refractory to physical therapy. Patients were included if they were involved in either high school or college athletics, had complete outcomes of interest, and had at least 2 years of follow‐up. Prospectively collected outcomes included preoperative and postoperative measurement of knee extension, International Knee Documentation Committee score, Lysholm score, return to sport data, and complications. Results Eighteen athletes with minimum 2 years of follow‐up who underwent posterior capsular release following ACL reconstruction performed by a single surgeon were included in the analysis. Patients underwent surgery at an average of 16 weeks after ACL reconstruction. Knee extension improved an average of 13.8° at 2 years’ follow‐up (prerelease mean extension deficit 15.1°, postrelease mean extension deficit 1.3°, P < .005). Improvements in the International Knee Documentation Committee score averaged 21.7 at 6 months and 35.0 at 24 months, both of which were statistically significant ( P < .001). Similarly, differences in Lysholm included a significant improvement of 23.0 and 34.2 at 6 months and 2 years, respectively ( P < .001). In total, 77.8% returned to sport at an average of 9.8 months from their primary ACL surgery and 6.5 months following posterior capsular release surgery. No infections or neurovascular complications were observed. One patient required secondary release to achieve adequate extension. Conclusions For athletes with persistent knee extension loss after ACL reconstruction, knee extension was significantly improved at 2 years following arthroscopic posterior capsular release. Substantial improvements in patient‐reported outcomes also were seen. In addition, subjects demonstrated a high rate of return to sport and return to preinjury performance levels. Level of Evidence Level IV, therapeutic case series.

Purpose To evaluate how arthroscopic meniscectomy utilization, reimbursement, physician billing practices, and patient populations have changed within the Medicare population from 2013 to 2021 at a national level and regional level. Methods The Medicare Physician & Other Practitioners database was queried for all episodes of 2‐compartment and single‐compartment arthroscopic meniscectomy between 2013 and 2021. Utilization per 10,000 beneficiaries and average inflation‐adjusted reimbursement were assessed. Physician practice styles, measured through changes in the services billed, and Medicare beneficiary demographic characteristics were extracted each year. The Kruskal‐Wallis test was performed to compare regions. Results Between 2013 and 2021, two‐compartment meniscectomy utilization per 10,000 Medicare beneficiaries declined by 54.9% and single‐compartment meniscectomy utilization declined by 54.2%. Average reimbursement declined by 9.3% and 12.5% for 2‐compartment meniscectomy and single‐compartment meniscectomy, respectively. In 2021, the South had the highest utilization of both 2‐compartment (3.8/10,000) and single‐compartment (4.7/10,000) meniscectomies while having the lowest average reimbursement for 2‐compartment meniscectomy ($383.02, P < .001). Nationally, the average number of beneficiaries per surgeon performing single‐compartment meniscectomy declined by 3.8% whereas the average number of billable services performed per beneficiary increased by 46.6%. The comorbidity risk score of these patients decreased by 8.7%, with the West having the healthiest patients in 2021. Conclusions Meniscectomy utilization and reimbursement have been declining nationally within the Medicare population. Surgeons in the South performed the most meniscectomies while having among the lowest reimbursement. The practice patterns of surgeons performing meniscectomies have been changing, with surgeons performing nearly 50% more total billable services per beneficiary while performing fewer unique billable services. Additionally, the patient population of surgeons who perform meniscectomy was healthier in 2021 than in 2013. Clinical Relevance This study highlights changes in meniscectomy utilization and reimbursement over time in the face of changing evidence of meniscectomy use in elderly patients and new Medicare legislature regarding reimbursement.

Background: The optimal graft choice for anterior cruciate ligament (ACL) reconstruction (ACLR) in the high-level cutting and pivoting athlete remains controversial. Studies have shown similar outcomes when directly comparing bone-patellar tendon-bone (BPTB) autograft versus quadriceps soft tissue (QST) autograft in the general population. However, no studies have directly compared these 2 grafts in athletes participating in cutting and pivoting sports. Hypothesis: It was hypothesized that, compared with BPTB autograft, the QST autograft would result in similar patient-reported outcomes and rates of retear, return to sport, and complications. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review was performed on athletes participating in cutting and pivoting sports (soccer, American football, lacrosse, and basketball) who underwent primary ACLR with either BPTB autograft or QST autograft chosen by the athlete between January 2015 and January 2019. The International Knee Documentation Committee (IKDC) subjective knee evaluation and Lysholm Knee Scoring Scale were used to evaluate patient-reported outcomes. Return-to-sport and complication rates were identified. Descriptive statistics were expressed using Mann-Whitney test or Student t test for continuous variables and the chi-square test for categorical variables. Results: A total of 68 athletes (32 QST, 36 BPTB) were included for analysis. The percentage follow-up was 89% (32/36) for the QST autograft group and 86% (36/42) for the BPTB autograft group. The 2-year IKDC score (QST, 90.5 ± 6.6 vs BPTB, 89.7 ± 7.8) and 2-year Lysholm score (QST, 91.3 ± 7.5 vs BPTB, 90.5 ± 8.6) were similar between groups. The percentage of athletes able to return to sport within the follow-up period was also similar (88% vs 83%; P = .63). There were 2 retears requiring revision in the BPTB group (6%) and no retears in the QST group ( P = .18). One contralateral ACL rupture occurred in the QST group (3%) and 4 in the BPTB group (11%) ( P = .21). Conclusion: The QST and BPTB autografts demonstrated similar patient-reported outcomes, return-to-sport rates, and complication rates after primary ACLR at 2-year follow-up. Both autografts appear to be reliable and consistent options for ACLR in the cutting and pivoting athlete.

Background: Meniscal root repair can improve patient outcomes significantly; however, several contraindications exist, including arthritic change to the medial or lateral tibiofemoral compartments. Purpose/Hypothesis: The purpose of this study was to evaluate the outcomes of meniscal root repair in patients with advanced patellofemoral chondromalacia (PFC). It was hypothesized that the presence of advanced PFC would not significantly affect the postoperative outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review was conducted of patients who underwent meniscal root repair with at least 2 years of follow-up data. Patients with chondromalacia as determined by arthroscopic visualization (defined as Outerbridge grade 3 or 4) were placed in the PFC group; patients with Outerbridge grade 0 to 2 chondromalacia were placed in the non-PFC group. Outcomes were measured by the Lysholm knee scoring scale and the International Knee Documentation Committee (IKDC) Subjective Knee Form. Clinical outcomes including complications were also recorded. Quantitative data between the groups were analyzed using the 2-tailed independent-samples t test. Results: Overall, this study included 81 patients (35 in the PFC group, 46 in the non-PFC group). The mean follow-up times were 25.1 months in the PFC group and 24.8 months in the non-PFC group. In both groups, Lysholm and IKDC scores improved significantly with 24-month Lysholm scores averaging 85.86 in the PFC group and 86.61 in the non-PFC group ( P = .62) and 24-month IKDC scores averaging 77.66 for the PFC group and 79.59 for the non-PFC group ( P = .45). The cohorts demonstrated similar rates of retear, arthrofibrosis, infection, and progression to total knee arthroplasty. Conclusion: The presence of advanced PFC was not associated with inferior outcomes in patients who underwent posterior meniscal root repair, and rates of recurrent tears, postoperative infection, arthrofibrosis, and conversion to total knee arthroplasty were similar between the study groups. These findings suggest that PFC may not significantly alter the results of meniscal root repair and should not be considered an absolute contraindication for this procedure.

Objectives: Despite attaining satisfactory knee function following anterior cruciate ligament (ACL) reconstruction, many athletes are unable to return to their pre-injury level of play. ACL tears are known to take a significant psychological toll on the injured athlete and an athlete’s “psychological readiness” may play a large role in their ability to return to sport. The Anterior Cruciate Ligament-Return to Sport After Injury (ACL-RSI) scale is the only questionnaire to specifically assess the psychological readiness to return to sport after ACL reconstruction. Several factors have been identified to affect an athlete’s psychological readiness to return to sport including age and sex. However, the effect of graft choice on psychological readiness to return to sport have not been studied. The purpose of this study was to evaluate the effect of graft choice on the athlete’s psychological readiness to return to sport. We hypothesized that patients undergoing ACL reconstruction with quadriceps autograft (QA) would reach higher ACL-RSI scores earlier than patients using hamstring autograft (HA) and bone-patellar tendon- bone (BTB) autografts. Methods: The study was a prospective, non-randomized study involving high-level athletes undergoing primary ACL reconstruction with or without meniscal surgery. The participants were involved in varsity high-school, college or professional sports. Each athlete was placed in a group depending on if an all- soft-tissue quadriceps autograft (QA Group), bone-patellar tendon-bone autograft (BTB Group) or hamstring autograft (HA Group) was used for their reconstruction. Graft choice was made by the athlete after the benefits and risks of each graft were discussed in detail. Over the study period, thirty consecutive athletes in each group undergoing primary ACL reconstruction with each specific graft were entered into the study. Athletes undergoing concomitant surgery other than meniscal surgery were excluded from the study. The athletes were asked to fill out the ACL-RSI scale 6-months following surgery, at the time of release to full sport and 2-years following surgery. Current literature shows an ACL-RSI score of 65 or higher as being the score that best predicts return to sport. In addition to comparing the ACL-RSI raw scores between groups, we also compared the percentage of patients reaching an ACL-RSI score of 65 (A-R 65) between the graft types. In addition, patient reported outcomes (PROs) including the International Knee Documentation Committee (IKDC) and Lysholm surveys were completed at the same time points as the ACL-RSI scores. Clinical outcomes included return to sport (RTS), RTS at the same or higher level, time to RTS and graft re-tear. All patients underwent the same rehabilitation protocol regardless of the graft used. RTS was allowed based on appropriate progression through the rehab program, quadriceps strength 90% that of the non-operated leg and triple-hop test 90% the non-operative leg. Return to sport was defined as participation in an official game within the chosen sport of the athlete. Results: The demographics between the three groups was homogenous with the overall average age of the group being 19.1 years. The study included 43.3% high school, 50% college and 6.7% professional athletes with no difference between the groups. The HA group had an ACL-RSI score of 49.2 at 6- months, 59.2 at RTP and 61.7 at the 2-year follow up. The BTB group had scores of 48.1, 64.7 and 63.1 at 6-month, RTP and 2-years postoperatively. The QA group had significantly higher scores than both the HA and BTB groups at the 6-month time period (65.3), and RTP time point (70.6) and similar scores compared to the other two groups at the 2-year follow up (72.7). The HA and BTB groups had similar ACL-RSI raw scores throughout the study. The QA group had a higher percentage of patients reaching the A-R 65 level (53.3%) compared to the HA group (23.3%) and the BTB group (13.3%) at the 6-month postoperative time point. At the RTS time point, the QA group again had a significantly higher rate of patients reaching the A-R 65 level (65.4%) than the other two groups (33.3% HA and 36% BTB group). At the 2-year time point, there was no difference between the three groups with regards to reaching the A- R 65 level. The percentage of athletes reaching the A-R 65 level was not different between the HA and BTB groups at any time point. The IKDC and Lysholm scores were similar between the three groups at all time points. The overall RTP for the study was 82.2% and RTP at the same or higher level was 62.2%. There was no significant difference in return to play between the three groups (HA group 77%, BTB group 83.3% and QA group 87%). Likewise, RTP at the same or higher level was similar between the groups at 57%, 63% and 67% for the HA, BTB and QA groups respectively. There was a significant difference between the QA group and the HA and BTB groups with respect to time to RTS. The average time to RTS for the QA group was 8.1 months compared to 10.5 months for the HA group and 9.6 months for the BTB group. All three groups showed a significant intragroup difference in the ACL-RSI score at all time points between the cohort of patients in each group who were able to return to sport at the same or higher level and those who could not. Clinically, graft re-tears occurred in 17% of the HA group, 10% of the BTB group and 0% of the QA group (p=.02). Conclusions: The QA lead to a higher ACL-RSI score and higher percentages of athletes reaching the A-R 65 level at the 6-month and RTS time points compared to both the hamstring and BTB groups. This fact may explain why the quad group was able to return to sport in significantly less time than the other two groups. The higher ACL-RSI score may be an indication of an athlete’s confidence in their reconstructed knee. This confidence after surgery may allow the athlete to break through the psychological barriers that can make return to sport difficult.

Objectives: Meniscal root tears have been shown to accelerate cartilage breakdown and increase the risk of total knee arthroplasty (TKA) if left unaddressed. Unfortunately, many patients with meniscal root tears already have associated chondromalacia which can impact surgical outcomes. The presence of advanced chondromalacia in the medial or lateral compartmentsof the knee is a known contraindication to performing meniscal root repair; however, the effect of advanced patellofemoral chondromalacia on meniscal root outcomes is not known. The purpose of this study was to compare the outcomes of meniscal root repair in patients with and without advanced patellofemoral chondromalacia (PFC). Methods: A retrospective review of prospectively collected data of patients undergoing meniscal root repair by a single surgeon was conducted between January 2016 and December 2019. Patients were included if they had undergone an isolated posterior medial or lateral meniscal root repair. The meniscal root repair was performed using a transtibial suture technique. Patients were placed into one of two groups depending on the amount of patellofemoral chondromalacia present at the time of surgery. Patients with Outerbridge grade 0-2 were placed in the Minimal Patellofemoral Chondromalacia (MPFC) Group. Patients with Outerbridge 3-4 changes found the time of surgery were placed in the Patellofemoral Chondromalacia (PFC) Group. Patients with Outerbridge 3-4 changes found in the medial or lateral compartment were excluded from the study. Lysholm Knee Scoring Scale and the International Knee Documentation (IKDC) Subjective Knee Form were collected preoperatively, 6,12 and 24 months after surgery. Clinical outcomes followed included recurrent meniscal tear, conversion to total knee arthroplasty, knee arthrofibrosis requiring manipulation under anesthesia/lysis of adhesions and infection. PASS and MCID were determined using data on meniscal repairs in other literature. Continuous data was compared using two-tailed student-T test while categorical data was compared utilizing chi-square testing. Results: A total of 27 patients made up the PFC group and 54 in the MPFC group. There was no difference between the groups with regards to age, sex, BMI or laterality of the procedure. The PFC group had 26 medial and 1 lateral meniscal root repairs. The MPFC group had 51 medial and 3 lateral repairs. The average Outerbridge score of the patella for the PFC group was 3.2 compared to 1.8 in the MPFC group (p<.001). The Outerbridge score for the trochlea in each group was 3.4 vs. 1.6 for the PFC and MPFC groups respectively (p<.001). No difference was identified between the Outerbridge score for the medial compartment for the PFC and MPFC groups (1.48 vs 1.46 respectively) or the lateral compartments (0.48 vs. 0.61 respectively). Lysholm and IKDC scores rose significantly over the pre- operative value at all time points in the study for both groups. No difference was seen between the two groups for the Lysholm or IKDC scores at any timepoint during study. PASS rates for IKDC between the two groups were similar with 6,12 and 24-month PASS rates being 66.7%, 87.5% and 81.4% respectively for the PFC group and 62.9%, 77.8% and 85.2% for the MPFC group. There was also no difference between the groups with regards to the percentage of patients reaching MCID for IKDC. The PFC group showed the percentage of patients reaching MCID to be 81.5%, 100% and 92.6% at the 6,12, and 24 month time points respectively while the MPFC group showed the percentage of patients reaching MCID to be 75.9%, 88.9% and 94.4% at the 6,12 and 24 month postoperative time points respectively. There was 1 (3.7%) recurrent tear in the PFC group and 3 (5.6%) in the MPFC group (p=.72). One patient (3.7%) in the PFC and none of the MPFC group were converted to TKA by the 2-year follow up (p=.15). Each group had 1 patient develop arthrofibrosis requiring MUA/LOA. There were no infections in the PFC group and one in the MPFC group which was a superficial wound infection that resolved after a course of oral antibiotics. Conclusions: In our series, the presence of advanced patellofemoral chondromalacia did not lead to inferior short-term outcomes in patients undergoing meniscal root repair compared to patients without patellofemoral chondromalacia. IKDC and Lysholm scores were similar between the PFC and MPFC group at all time points while scores for both groups were significantly higher than preoperative levels at all time points. The ability to reach MCID and PASS for IKDC was not significantly different between the two groups. In addition, there was not a significant difference between the two groups in the number of recurrent tears, conversion to total knee arthroplasty or complications identified. Our results show meniscal root repair can be performed in patients with severe patellofemoral chondromalacia with similar results as patients undergoing root repair without severe patellofemoral chondromalacia. Patellofemoral chondromalacia should not be considered a contraindication to meniscal root repair.

Objectives: To describe outcomes of posterior capsular release to treat knee extension deficits after anterior cruciate ligament (ACL) reconstruction in athletes. Methods: A retrospective review was performed between January 2014 and December 2019 for patients undergoing arthroscopic posterior capsular release for knee extension loss following ACL reconstruction. Patients were indicated for the procedure if they had greater than 10° of extension loss at least three months after ACL reconstruction that was refractory to physical therapy. Patients were included in the study if they were involved in either high school or college athletics, had complete outcomes of interest, and had at least two years of follow up. Collected outcomes included preoperative and postoperative measurement of knee extension, international knee documentation committee (IKDC) score, Lysholm score, return to sport data, and complications. Results: Over the study period a total of 38 arthroscopic posterior capsular releases were performed. Of these, 20 were high school or college athletes. Two of these patients did not have 2-year follow up, leaving a total of 18 patients included in the analysis. Patients underwent surgery at an average of 16 weeks after ACL reconstruction. Knee extension improved an average of 13.8° at 2-years follow up (pre- release extension deficit 15.1°, post-release extension deficit 1.3°, p < 0.005). Improvements in the IKDC score averaged 21.7 at 6 months and 35.0 at 24 months, both of which were statistically significant (p < 0.001). Similarly, differences in Lysholm included a significant improvement of 23.0 and 34.2 at 6 months and 2 years, respectively (p < 0.001). In total, 77.8% returned to sport at an average of 9.8 months from their primary surgery and 6.5 months following posterior capsular release surgery. Complications included one patient that required revision capsular release for persistent extension loss, one ACL tear of the ipsilateral knee, and two ACL tears of the contralateral knee. No infections or neurovascular injuries occurred. Conclusions: Knee extension loss after ligamentous repair surgery can have significant consequences including diminished patient satisfaction, reduced return to sport, and an increased risk of osteoarthritis development. Although arthroscopic posterior capsular release is a recognized treatment for knee extension loss, outcomes have not been reported in athletes. In our series, arthroscopic posterior capsular release resulted in significant improvement of knee extension and patient reported outcome scores at 6 month and 2 years postoperatively. Additionally, the procedure appears to be safe with few complications and only 5.6% of patients requiring repeat arthroscopy for knee extension loss. Posterior capsular release appears to be a reliable and safe treatment for athletes with persistent knee extension loss after ACL reconstruction.

Objectives: ACL reconstruction using hamstring autograft (HA) has been found to have a high re-tear rate in high risk patients including those with a Pivot shift of 2 or higher and those with generalized ligamentous laxity (GLL). Because of this, the use of lateral extra-articular tenodesis (LET) has gained traction in the sports community. Several studies have shown lower ACL graft re-tears with the addition of LET and is felt by many to be necessary when using a HA in high risk patients. However, no study has compared hamstring autograft + LET versus other graft types. The purpose of our study was to compare the surgical outcomes of HA+LET vs an all-soft-tissue quadriceps autograft (QA) without LET. We hypothesized that a QA would lead to similar graft re-tear and rotational instability rates as HA+LET. Methods: This retrospective study compared high risk patients including those with a Pivot shift of 2 or more and GLL undergoing ACL reconstruction with either a HA, HA+LET and QA. In this study, GLL was defined as patients with a Beighton score of 4 or more. Patients were included in the study if they were undergoing a primary ACL reconstruction with either hamstring autograft (HA group), hamstring autograft with extra-articular tenodesis (HA+LET group) or all-soft-tissue quadriceps autograft (QA group) and no other procedures other than meniscal work. All surgeries were performed by the senior surgeon and followed the same rehabilitation protocol after surgery regardless of what type of graft was used during the surgery. Graft choice was dependent on the when during the study the procedure was performed. Early in the study period, HA were used on most patients regardless of whether they were high risk or not. Later, HA+LET was performed due to emerging studies showing higher failure rates in high risk patients undergoing HA alone compared to those undergoing HA+LET. Finally, the senior author transitioned to using QA for most cases. Patient reported outcomes (PROs) were obtained on each patient preoperatively, 3,6,12 and 24-months after surgery. The PROs used in this study included the International Knee Documentation Committee (IKDC) and Lysholm scores. Clinical failure was defined by a patient who had a graft re-tear or those with a residual pivot shift of 2 or more after surgery. Pivot shift was tested for at the 6,12 and 24-month follow up. Other complications associated with the procedure were documented. Results: A total of 166 high risk patients underwent ACL reconstruction over the 7 year study period. There were 63 patients in the HA group, 47 in the HA+LET and 56 in the QA group. The demographics between the three groups was similar with an overall age of the patients in the study being 17.8 years. The mean Beighton score was 3.2 for the group with 24% of the population having GLL. The overall rate of Grade 2 or higher pivot was 82%. There was no difference between the groups with regards to percentage GLL or 2+pivot shift. All three groups had a higher percentage of women than men (HA group 66%; HA+LET group 62% and QA group 56%), but there was no significant difference between the groups. The QA group had a significantly larger graft diameter (9.6mm) compared to the HA group (7.9mm) and the HA+LET group (8.1mm) (p<.001). The number of meniscal repair and partial meniscectomy was similar between all three groups with 21.1% of the population undergoing meniscectomy and 48% of the entire population undergoing meniscal repair. The study was made up of 68.4% athletes for the HA group, 62.4% for the HA+LET and 72.6% for the QA group (p=.32). A significant increase in both IKDC and Lysholm scores were seen at every timepoint compared to preoperative levels. There was no difference between the three groups at any time point for either the IKDC and Lysholm scores. The preoperative IKDC score for the HA group increased from 51.7 to 90.3 at the 2-year follow-up. The HA+LET IKDC scores increased from 53.1 preoperatively to 88.4 at the 2-year follow-up. The QA group had IKDC scores of 49.8 pre op and 90.6 at 2 years. The Lysholm scores increased from 53 to 91.9, 54.8 to 89.4 and 51.9 to 92.6 preoperatively to the 2-year follow-up for the HA, HA+LET and QA groups respectively. The graft re-tear rate of the HA group was significantly higher than the HA+LET and QA groups (14.3%, 2.1% and 1.8% respectively). Residual pivot shift of 2 or more was found in 36.5% of the HA group, 14.9% in the HA+LET group and 19.6% in the QA group. The residual pivot shift in the HA group was significantly higher than the HA+LET and QA groups, but no difference was identified between the HA+LET and QA groups. Return to sport (RTS) was similar between the three groups with 80% of athletes returning to sport with HA grafts, 81% with HA+LET and 86% with QA grafts. The use of a QA in this high-risk population lead to a significantly faster RTS (8.6 months) compared to the HA and HA+LET groups; however, the addition of a LET did not lead to a shorter time to return to sport (10.7 months for the HA group and 11.7 months for the HA+LET group). There was no difference between the three groups for contralateral ACL tears, arthrofibrosis or infection. Conclusions: The use of an all-soft-tissue QA or the addition of an LET to a HA both lead to significant decreases in graft re-tear rate and residual pivot shifts of 2 or greater compared to a HA graft alone in high risk patients undergoing primary ACL reconstruction. However, the use of QA and LET do not improve the patient reported outcome scores at 2-year follow up compared to HA alone. RTS was significantly faster with QA compared to the HA and HA+LET; however, the addition of an LET to a HA did not increase the rate to which an athlete was able to return to play. In conclusion, high risk patients including those with GLL and pivot shifts greater than 2 should undergo ACL reconstruction with either a quadriceps autograft or have a LET added to a hamstring autograft.

Purpose To determine clinical and radiographic outcomes of medial collateral ligament (MCL) pie‐crusting during isolated medial meniscal root repair. Methods A retrospective review was conducted between August 2013 and December 2019 in patients undergoing isolated medial meniscal root repair. Outcomes, including International Knee Documentation Committee (IKDC) score, Lysholm score, re‐tears, MCL laxity, and conversion to total knee arthroplasty (TKA), were compared between pie crust (PC) and non‐pie crust (NPC) cohorts. Other assessments included subjective instability or stiffness, infection, and intra‐operative chondromalacia. Additionally, radiographic outcomes were compared to determine progression of medial compartment arthrosis. Results Final analysis included 97 knees, 45 in the PC, and 52 in the NPC group. IKDC and Lysholm scores were similar between both groups preoperatively and 3 months postoperatively. However, at the 6,12, and 24‐month follow up, the PC group had a significantly higher measured IKDC and Lysholm scores than the NPC group. PASS percentages for the IKDC score were significantly higher in the PC group at 6 months, 1 year, and 2 years (96.2%; P = .02) follow‐up compared to the NPC group. MCID percentages for the IKDC score were also significantly higher at the 1‐ and 2‐year (100%; P = .05) follow‐up in the PC group compared to the NPC group. There was also a significantly higher rate of recurrent medial meniscal root tears in the NPC group (4 [8.9%]) compared to the PC group (0 [ P = .03]). No MCL laxity was observed at 6 months follow‐up. Conclusions MCL pie‐crusting during isolated medial meniscal root repair can be used as an alternative surgical technique, as it leads to improved clinical and patient outcomes compared to patients who do not undergo MCL pie‐crusting in the short term. Additionally, those that underwent MCL pie‐crusting had a lower incidence of recurrent tears, and no patients experienced MCL laxity at 6 months. Level of Evidence Level III, retrospective cohort/comparative study.