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Giusto JD, Cohen D, Dadoo S, Grandberg C, Lott A, Hughes JD, Ayeni OR, Musahl V. Lateral extra-articular tenodesis may be more cost-effective than independent anterolateral ligament reconstruction: A systematic review and economic analysis. J ISAKOS 2024:S2059-7754(24)00074-9. [PMID: 38604570 DOI: 10.1016/j.jisako.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 04/04/2024] [Accepted: 04/06/2024] [Indexed: 04/13/2024]
Abstract
IMPORTANCE Anterolateral augmentation during primary anterior cruciate ligament (ACL) reconstruction (ACLR) may lower rates of ACL graft failure. However, differences in costs between two techniques, lateral extra-articular tenodesis (LET) and anterolateral ligament reconstruction (ALLR), are unclear. OBJECTIVE To perform a systematic review and subsequent cost-effectiveness analysis comparing LET versus ALLR in the setting of primary ACLR. The hypothesis was that LET is more cost-effective than ALLR. EVIDENCE REVIEW A systematic review was conducted on studies in which patients underwent primary ACLR with a concomitant LET or ALLR with minimum 24 months follow-up published between January 2013 and July 2023. Primary outcomes included ACL graft failure rates and Knee Injury and Osteoarthritis Outcome Survey-Quality of Life (KOOS-QoL) subscale scores, which were used to determine health utilities measured by quality-adjusted life years (QALYs) gained. A decision tree model with one-way and two-way sensitivity analyses compared the cost of primary ACLR with a concomitant LET, independent autograft ALLR, or independent allograft ALLR. Costs were estimated using a combination of QALYs, institution prices, literature references, and a survey sent to 49 internationally recognized high-volume knee surgeons. FINDINGS A total of 2505 knees undergoing primary ACLR with concomitant LET (n=1162) or ALLR (n=1343) were identified from 22 studies. There were 77 total ACL graft failures with comparable failure rates between patients receiving LET versus ALLR (2.9% vs. 3.2%, P=0.690). The average QALYs gained was slightly higher for those who received LET (0.77) compared to ALLR (0.75). Survey results revealed a 5 minute longer median self-reported operative time for ALLR (20 min) than LET (15 min). The estimated costs for LET, autograft ALLR, and allograft ALLR were $1,015, $1,295, and $3,068, respectively. CONCLUSIONS AND RELEVANCE Anterolateral augmentation during primary ACLR with LET is more cost-effective than independent autograft and allograft ALLR given the lower costs and comparable clinical outcomes. Surgeons may utilize this information when determining the optimal approach to anterolateral augmentation during primary ACLR, although differences in preferred technique and health care systems may influence operative efficiency and material costs. LEVEL OF EVIDENCE Systematic review; Level of evidence, IV.
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Affiliation(s)
- Joseph D Giusto
- Department of Orthopaedic Surgery, Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Dan Cohen
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Canada
| | - Sahil Dadoo
- Department of Orthopaedic Surgery, Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Camila Grandberg
- Department of Orthopaedic Surgery, Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ariana Lott
- Department of Orthopaedic Surgery, Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Canada
| | - Volker Musahl
- Department of Orthopaedic Surgery, Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
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Yuan W, Qi W, Hu T, Zhang J, An MY, Zhao G, Wang XP, Li C, Liu Y. Outcomes of RigidFix Cross Pin Fixation in Femoral and Tibial Tunnel for Anterior Cruciate Ligament Reconstruction. Orthop Surg 2024; 16:337-345. [PMID: 38088239 PMCID: PMC10834228 DOI: 10.1111/os.13934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/08/2023] [Accepted: 10/09/2023] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVES There is no clear consensus so far on which fixation method is most favorable for the tibial tunnel in anterior cruciate ligament reconstruction (ACLR). The purpose of this paper is to investigate the outcome of RigidFix cross pins fixation in the tibial tunnel and to explore the advantages of RigidFix applied both in the femoral and tibial tunnel with hamstring tendon graft in anterior cruciate ligament reconstruction. METHODS This retrospective study included 53 patients (male/female, 45/8) who underwent anterior cruciate ligament reconstruction using autologous hamstring tendons between January 2013 and December 2017 at our institute. The participants in group A (n = 36) received anterior cruciate ligament reconstruction with RigidFix cross pins fixation in both femoral and tibial tunnels, while those in group B (n = 17) with RigidFix cross pins fixation in the femoral tunnel and Interference screw fixation in the tibial tunnel. The visual analogue scale (VAS) score, International Knee Documentation Committee subjective knee form 2000 (IKDC2000) score, Lysholm knee scoring scale, Tegner activity score and the side-to-side difference were compared at 2 and 5 years postoperatively. The graft diameter, number of strands in graft and the average diameter of each strand were also compared between the two groups. The categorical parameters were analyzed by chi-square test and the continuous variables conforming to a normal distribution were analyzed by Student's t-test. RESULTS At 2 years postoperation, the VAS score (1.61 ± 0.55), side-to-side difference (1.50 ± 0.58) in group A were significantly lower than that in group B, and the IKDC2000 score (88.81 ± 3.88), Tegner activity score (6.14 ± 0.60) in group A were significantly higher than that in group B. At 5 years postoperation, the VAS score (1.64 ± 0.68), side-to-side difference (1.73 ± 0.63) in group A were significantly lower than that in group B, and the IKDC2000 score (89.09 ± 3.85), Tegner activity score (6.58 ± 0.94) in group A were slso significantly higher than that in group B. There was statistical difference in the change of the side-to-side difference between the two groups (group A vs. B, 0.22 ± 0.08 vs. 0.34 ± 0.11, p < 0.001). There were also statistical differences in the graft diameter (group A vs. B, 7.83 ± 0.74 vs. 7.41 ± 0.51, p = 0,038), number of strands in graft (5.67 ± 0.72 vs. 4.00 ± 0.00, p < 0.001) and the average diameter of each strand (1.41 ± 0.22 vs. 1.85 ± 0.13, p < 0.001) between the two groups. CONCLUSION RigidFix cross pins fixation in the tibial tunnel for anterior cruciate ligament reconstruction can achieve better 5-year results when compared with the interference screw, and the hamstring tendon can be folded into a thicker graft when RigidFix cross pins were applied in both femoral and tibial tunnels.
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Affiliation(s)
- Wei Yuan
- Medical School of Chinese PLA, Beijing, China
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
- Department of Orthopedics, PLA Strategic Support Force Characteristic Medical Center, Beijing, China
| | - Wei Qi
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Tingting Hu
- The Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jia Zhang
- Medical School of Chinese PLA, Beijing, China
| | | | - Gang Zhao
- Medical School of Chinese PLA, Beijing, China
| | - Xiao-Ping Wang
- Department of Orthopedics, PLA Strategic Support Force Characteristic Medical Center, Beijing, China
| | - Chunbao Li
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yujie Liu
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
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Maginnis C, Root C, Schiavo JH, Ierulli VK, Vopat B, Mulcahey MK. Analysis of Graft Types Augmented With an Internal Brace for ACL Reconstruction: A Systematic Review. Am J Sports Med 2024:3635465231196157. [PMID: 38269417 DOI: 10.1177/03635465231196157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
BACKGROUND New techniques are being developed to decrease the failure rate of anterior cruciate ligament (ACL) grafts and prevent revision surgery. One such technique involves high-strength suture tape (ST), also referred to as internal bracing. Recent literature has highlighted the use of ST for ACL reconstruction, but no study has compared ST augmentation between graft types. PURPOSE To compare the use of ST augmentation for ACL reconstruction based on the type of graft used (ie, bone-patellar tendon-bone [BPTB], quadriceps, hamstring). STUDY DESIGN Systematic review; Level of evidence, 5. METHODS An online search of multiple databases was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and was completed April 2022 to identify studies related to ST augmentation of ACL grafts. RESULTS Of 926 studies identified, 10 met inclusion criteria. Five studies (50%) used hamstring tendon (HT), 3 (30%) used quadriceps tendon (QT), 1 (10%) used BPTB, and 1 (10%) used both HT and QT grafts. HT autografts augmented with ST had decreased dynamic and peak elongation (15%-56%), increased load to failure, and increased initial and final dynamic stiffness compared with controls. There was no significant difference in postoperative physical examination findings (range of motion, Lachman, pivot shift), except that ST-augmented grafts had significantly less laxity after surgery compared with HT alone (0.8 vs 1.9 mm; P < .05). QT allografts with ST augmentation showed increased graft strength. Human QT autograft studies showed higher Knee injury and Osteoarthritis Outcome Score scores compared with controls. BPTB allografts with ST augmentation had decreased cyclic displacement by 31% (P = .015) and increased load (758 ± 128 N; P < .001) and stiffness (156 ± 23 N/mm; P = .003) compared with nonaugmented groups. The complication rate was low or showed no increase in the ST augmentation groups compared with control groups. CONCLUSION HT, QT, and BPTB grafts augmented with ST demonstrate an effective method for ACL reconstruction. All graft types with ST augmentation showed no evidence of clinical disadvantage, with some studies indicating significant biomechanical or clinical advantages compared with conventional ACL reconstruction.
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Affiliation(s)
- Connor Maginnis
- Louisiana State University School of Medicine, New Orleans, Louisiana, USA
| | - Cooper Root
- Department of Orthopaedic Surgery, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Julie H Schiavo
- Louisiana State University Health Science Center, New Orleans, Louisiana, USA
| | - Victoria K Ierulli
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Bryan Vopat
- Department of Orthopaedic Surgery, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, Maywood, Illinois, USA
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Minoli C, Travi M, Monti C, Ferrua P, Puce M, Radaelli S, Menon A, Tassi AL, Randelli PS. A fast, easy and reliable method for hamstrings graft size prediction in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2023; 31:4430-4436. [PMID: 37468620 PMCID: PMC10471637 DOI: 10.1007/s00167-023-07510-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 07/07/2023] [Indexed: 07/21/2023]
Abstract
PURPOSE The aim of this study is to describe and validate a simple and reliable method to pre-operatively predict the size of the ACL graft in the double strand technique with autologous semitendinosus-gracilis tendons on the same MRI used for ACL rupture diagnosis. METHODS The study included 92 patients, with a median age of 31 years (IQR 26-41 years), 73/92 (79%) of whom were males. All patients that underwent an ACL reconstruction with doubled ST + GT between 2017 and 2022 were counted in the study. RESULTS Overall, the median predicted graft diameter from MR imaging was similar to the actual graft diameter with no significant differences (n.s.). Regarding the comparison between predicted and actual graft size, concordance was 78/92 (85%, 95% CI 76-91%), with κ = 0.797 which corresponds to a level of agreement defined as "Strong". Tendon sizes calculated on pre-operative MRI were evaluated both with intra-observer and inter-observer reliability demonstrating a statistically reproducible method. The predicted graft was then compared to the reported one with a statistically significant reliability found. CONCLUSION This study can help the surgeons to perform a fast pre-operative planning of an ACL reconstruction for graft selection. If the planned graft with ST and GT is smaller than 8 mm, the clinician can decide to switch to a different type of graft or plan a different graft preparing technique and, therefore, reduce the risk of post-operative ligament re-rupture. The method proposed is reliable and reproducible. The major strength of the planning technique proposed is that it relies on data that are already available for the clinician before surgery, without the need of further analysis. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- C Minoli
- U.O.C. Week Surgery, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122, Milan, Italy
- Scuola di Specializzazione in Ortopedia e Traumatologia, Università degli Studi di Milano, Via Festa del Perdono 7, 20122, Milan, Italy
| | - M Travi
- Department of Reconstructive Surgery of Osteo-Articular Infections, IRCCS Istituto Ortopedico Galeazzi, 20100, Milan, Italy
- Scuola di Specializzazione in Ortopedia e Traumatologia, Università degli Studi di Milano, Via Festa del Perdono 7, 20122, Milan, Italy
| | - C Monti
- MD PhD, Post-Graduation School in Radiodiagnostics Università degli Studi di Milano, Milan, Italy
| | - P Ferrua
- U.O.C. 1 Clinica ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122, Milan, Italy
- Laboratory of Applied Biomechanics, Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133, Milan, Italy
| | - Marco Puce
- U.O.C. Week Surgery, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122, Milan, Italy.
- Scuola di Specializzazione in Ortopedia e Traumatologia, Università degli Studi di Milano, Via Festa del Perdono 7, 20122, Milan, Italy.
| | - S Radaelli
- U.O.C. Week Surgery, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122, Milan, Italy
| | - A Menon
- U.O.C. 1 Clinica ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122, Milan, Italy
- Laboratory of Applied Biomechanics, Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133, Milan, Italy
- Scuola di Specializzazione in Statistica Sanitaria e Biometria, Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
| | - A L Tassi
- U.O.C. Week Surgery, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122, Milan, Italy
| | - P S Randelli
- U.O.C. 1 Clinica ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122, Milan, Italy
- Laboratory of Applied Biomechanics, Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133, Milan, Italy
- Research Center for Adult and Pediatric Rheumatic Diseases (RECAP-RD), Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133, Milan, Italy
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van der List JP. Editorial Commentary: What to Reinforce When You Have a Small Anterior Cruciate Ligament Graft? Focus on the Anterolateral Side! Arthroscopy 2023; 39:1680-1681. [PMID: 37286286 DOI: 10.1016/j.arthro.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 06/09/2023]
Abstract
Many surgeons performing anterior cruciate ligament (ACL) reconstruction have encountered the problem of harvesting small hamstring grafts. For this situation, several options are available such as harvesting contralateral hamstring tendons, reinforce the ACL graft with allografts, take a bone-patellar tendon-bone or quadriceps graft or add an anterolateral ligament reconstruction or lateral extra-articular tenodesis. Recent studies have shown that the presence of a lateral extra-articular procedure might be more important than the thickness of an isolated ACL graft, which is reassuring news. Current evidence suggests that both anterolateral ligament reconstruction and modified Lemaire tenodesis are similar biomechanically and clinically and could solve the problem of small-diameter hamstring ACL autografts.
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