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Objectives: Despite recent efforts, the reinjury rate following anterior cruciate ligament (ACL) reconstruction remains high, with documented reports of up to 30%. According to retrospective evidence, high posterior tibial slope (≥12°) has been identified as an anatomic risk factor contributing increased graft reinjury rates. Surgeons are therefore exploring the effectiveness of slope reducing high tibial osteotomy (SRO) as a means of modifying this potential risk factor. While cadaveric models suggest that this surgical procedure decreases the forces across the ACL graft, there are few clinical trials examining its' safety and clinical effectiveness in patient samples. Therefore, the purpose of this study is to compare functional performance and graft reinjury rates between patients undergoing ACL reconstruction surgery with SRO versus matched controls undergoing isolated ACL reconstruction. We hypothesized that patients undergoing ACL reconstruction with SRO would exhibit similar performance outcomes with a low failure rate when compared to their matched counterparts. Methods: A retrospective matched-case control study was conducted in accordance with the 'Strengthening the Reporting of Observational Studies in Epidemiology' guidelines for patients undergoing ACL reconstruction (Figure 1), utilizing a single surgeon database (n=1978). The experimental group (ACL+SRO) consisted of patients ages 18-50 years old that were at least 24-months out of ACL reconstruction with a concomitant SRO. Patients were age, sex, and revision-matched to a cohort of individuals undergoing isolated ACL reconstruction. Exclusion criteria consisted of contralateral knee injury (<24 months prior to surgery), isolated coronal-plane high tibial osteotomy, and multiligamentous knee injury. Patient demographics and surgical data were obtained, including pre/postoperative posterior tibial slope (o) for the ACL+SRO group and presurgery activity levels. Data were gathered at return to sports and included knee range of motion, single-leg balance, single-leg hop testing, and self-reported International Knee Documentation Committee and ACL-Return to Sports After Injury (ACL-RSI) scores. Complications and injury surveillance was conducted throughout the postoperative follow-up period. Primary outcome measures included the Single Assessment Numeric Scale (SANE), and graft failure rates at two-years. Secondary outcomes included return to sport rate and level of participation, and postoperative complications (infection, loss of motion, deep vein thrombosis, etc). Generalized Linear Models and chi-square analyses were conducted using SPSS (IBM, Chicago IL) to compare groups with an a-priori alpha level of.05. Results: Of the 1978 patients in the ACL registry, 48 met the study criteria and were included in the analyses (ACL+SRO group, n=24; Isolated ACL group, n=24). Baseline comparisons revealed that the ACL+SRO group had a higher bodyweight (200.9 ±35.1 vs 179.7 ±33.9, P <.001) and subsequent higher body mass index (29.7 ±4.6 vs 26.7 ±5.0, P =.044), Table 1. Additional baseline differences included ACL graft type, and staged procedures (P <.05, Table 2). The mean preoperative posterior tibial slope was 17.0° ±2.7° and 7.0° ±2.2° following SRO (mean diff: -10.0°, P <.001). Table 3 depicts the comparisons at return to sport, with the ACL+SRO group demonstrating longer time to return (P <.001) and lower ACL-RSI scores (P =.027). At 2 years, there were no statistical differences in SANE score (85.3 ±7.3 vs 88.2 ±9.7, P =.349), graft reinjury rate (0.0% vs 0.0%, P = 1.000), rate of return to sports (85.7% vs 91.7%, P =.844), or level of return to sports between groups with 45.8% (n=11) of the ACL+SRO group returning to a level I or II cutting and pivoting sport versus 54.2% (n=13) in the Isolated ACL group (P =.656). There were no reported postoperative infections or deep vein thromboses in either group (P >.05). Conclusions: The current study suggests that SRO in the setting of ACL reconstruction for large posterior tibial slope deformities is effective at correcting malalignment, restoring objective and self-reported function, and avoiding graft failure out to 2 years. This procedure also holds promise to allow a majority of patients to return to various levels of sporting activities. To our knowledge, this is the first comparative study examining the return to sports and 2-year outcomes of this population to a matched isolated ACL cohort. While these data do provide evidence for ongoing investigation, we recommend the performance of larger clinical trials to confirm these results. [ABSTRACT FROM AUTHOR]

Objectives: Few studies have examined the viability of the quadriceps tendon autograft as a revision graft option following failed primary bone-patellar tendon-bone (PT) autograft reconstruction. Potential concerns include further disruption to the knee extensor mechanism, inhibition of the quadriceps muscle, and increased complication and reinjury rates. The purpose of this study was to assess knee extension strength, functional outcomes, patient reported outcomes, and return to play after revision ACL reconstruction using free quadriceps tendon autograft after a failed primary reconstruction using bone-patellar tendon-bone (PT) autograft. Methods: A retrospective case series was conducted in accordance with Strengthening the Reporting of OBservational Studies in Epidemiology (STROBE) guidelines using a prospective single surgeon ACL database (n = 1,514) that included 48 patients receiving revision ACL reconstruction using free QT autograft after failure of primary PT autograft ACL reconstruction from 2015-2019. Exclusion criteria are listed in Figure 1, and included ages <15 years or > 55 years, bi-cruciate ligament injuries, and meniscal allograft transplant. Baseline patient demographics and surgical variables were collected and included preinjury level of function (Marx Score). Functional and self-reported outcomes were obtained at the time of return to play and consisted of: single-leg squat symmetry, hip abduction strength, single-leg hop tests, agility testing, and isokinetic knee extension strength (60°, 180°, and 300°/sec). Self-reported outcomes at the time of return to play included the International Knee Disability Committee (IKDC-2000) scale and Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) psychological readiness survey. Return to play was defined as the time (mo) required to reach a threshold of 90% limb symmetry on objective functional testing compared to the contralateral extremity and ultimately, the surgeon's discretion. Injury and complication surveillance was conducted for 2-years postoperatively, and patients were contacted via email or phone survey at 24-months to obtain functional status and single answer numeric evaluation (SANE) scores. Descriptive statistics were calculated using SPSS (version 26, IBM Inc, NY, USA). Results: Baseline patient demographics are listed in Table 1 for the 48 patients (mean age 23.9 ±9.5 years; 14/34 female/male) enrolled in the study. Isokinetic knee extension strength was 84.3 ±17.1% at 60°/sec, 88.6 ±16.4% at 180°/sec, and 92.0 ±19.5% at 300°/sec. The mean knee function SANE score at 2-years was 88.9 ±12.2%. All patients went through return to play testing prior to returning to sport. The mean time to return to play was 8.9 ±1.8 mo, and the mean 24-month assessment was conducted at 24.6 ±2.3 mo. Limb symmetry index scores ranged from 94.1%-102.6% across all objective functional tests (Table 2), and self-reported knee function via the IKDC-2000 was 86.3±16.8. Three patients were lost to follow up (6.3%) at 2-years, and of the 45 patients remaining in the study, 3 sustained graft reinjuries (6.7%). Two-year complications are listed in Table 3, and included meniscal tear (2.2%), DVT (4.4%), loss of motion requiring surgical lysis of adhesions (4.4%), anterior knee pain (11.1%), and symptomatic removal of hardware (2.2%). Conclusions: Free quadriceps tendon autograft is a viable autograft option for revision ACL reconstruction for failed PT autograft allowing return to high function without compromising knee extension strength with a low failure and complication rate. Two-year graft reinjury rates for revision ACL reconstruction with free QT autograft are similar or favorable to other autograft options previously reported in the literature in a revision setting. Additionally, functional outcomes are comparable to revision reconstructions using PT autograft and good to excellent outcomes can be obtained Table 1. Patient Demographics Fig 1. Study Design Table 2. Level of Return to Sport Table 3. Return to Play Functional Performance Outcomes [ABSTRACT FROM AUTHOR]