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Regarding “Intraoperative Hoffa Fracture During Primary ACL Reconstruction: Can Hamstring Graft and Tunnel Diameter Be Too Large?”

      To the Editor:
      I read with interest the case report by Werner and Miller
      • Werner B.C.
      • Miller M.D.
      Intraoperative Hoffa fracture during primary ACL reconstruction: Can hamstring graft and tunnel diameter be too large?.
      in the May 2014 issue of Arthroscopy. As the patient in the case report, I appreciate the publication and hope that increased awareness of the importance of tailoring graft size to the size of the patient will result in more nuanced surgical repair plans to prevent similar adverse events.
      However, as the patient in question, I would like to correct one significant detail regarding the outcome of the case. The authors wrote that “knee stability one year postoperatively remained excellent and she had returned to full activities.” This statement is inaccurate because 15 months postoperatively, I am unable to run or participate in activities that involve significant valgus or varus stresses to the knee. Simple activities such as descending stairs remain painful. I am motivated to correct this statement so as to further emphasize the goal of the article: urging more individualized approaches to graft size selection in ACL repairs to hopefully further prevent future similar complications. There is limited research on the correlation between graft size and patient gender and BMI.
      • Magnussen R.A.
      • Lawrence J.T.
      • West R.L.
      • Toth A.P.
      • Taylor D.C.
      • Garrett W.E.
      Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft.
      • Park S.Y.
      • Oh H.
      • Park S.
      • Lee J.H.
      • Lee S.H.
      • Yoon K.H.
      Factors predicting hamstring tendon autograft diameters and resulting failure rates after anterior cruciate ligament reconstruction.
      While recent studies have suggested lower overall failure rates with grafts of greater than 8 mm, it may be prudent to avoid generalization when treating patients at either end of the spectrum.

      References

        • Werner B.C.
        • Miller M.D.
        Intraoperative Hoffa fracture during primary ACL reconstruction: Can hamstring graft and tunnel diameter be too large?.
        Arthroscopy. 2014; 30: 645-650
        • Magnussen R.A.
        • Lawrence J.T.
        • West R.L.
        • Toth A.P.
        • Taylor D.C.
        • Garrett W.E.
        Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft.
        Arthroscopy. 2012; 28: 526-531
        • Park S.Y.
        • Oh H.
        • Park S.
        • Lee J.H.
        • Lee S.H.
        • Yoon K.H.
        Factors predicting hamstring tendon autograft diameters and resulting failure rates after anterior cruciate ligament reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2013; 21: 1111-1118

      Linked Article

      • Intraoperative Hoffa Fracture During Primary ACL Reconstruction: Can Hamstring Graft and Tunnel Diameter Be Too Large?
        ArthroscopyVol. 30Issue 5
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          Intraoperative fracture during tunnel placement in primary anterior cruciate ligament (ACL) reconstruction is rarely reported. To our knowledge, this is the first case report of an intraoperative distal femoral coronal plane (Hoffa) fracture that occurred during independent femoral tunnel drilling and dilation in a primary ACL reconstruction. The patient was treated with open reduction and internal fixation, without compromise of graft stability and with good recovery of function. We discuss the potential ramifications of such a complication in the context of the current emphasis placed on large graft and femoral tunnel sizes.
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      • Author's Reply
        ArthroscopyVol. 30Issue 9
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          Thank you for the opportunity to respond to this letter. We appreciate and are sensitive to the concerns of the patient expressed in her letter. We also share her interest in avoiding the complication described in our case report in the future. We apologize that we mischaracterized her outcome to note that “she had returned to full activities” and appreciate that she has taken the time and effort to point that out. In fact, we have recently initiated a formal evaluation of functional and strength testing after ACL reconstruction at our university, and this patient showed major quadriceps deficits when she was tested (after the article was published).
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