Autograft Choice in Young Female Patients: Patella Tendon versus Hamstring

Clinical Outcomes After ACL Reconstruction in Soccer (Football, Futbol) Players: A Systematic Review and Meta-Analysis

CONTEXT

The risk factors for anterior cruciate ligament (ACL) tear for athletes participating in pivoting sports includes young age and female sex. A previous meta-analysis has reported a reinjury rate of 15% after ACL reconstruction (ACLR) for athletes across all sports. To the best of the authors' knowledge, this is the first systematic review and meta-analysis of available literature reporting outcomes after ACLR in soccer players.

OBJECTIVE

To review and aggregate soccer-specific outcomes data after ACLR found in current literature to help guide a more tailored discussion regarding expectations and prognosis for soccer players seeking operative management of ACL injuries.

DATA SOURCES

A comprehensive search of publications was performed using PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and SPORTDiscus databases.

STUDY SELECTION

Inclusion criteria consisted of original studies, level of evidence 1 to 4, studies reporting clinical and patient-reported outcomes (PROs) after primary ACLR in soccer players at all follow-up length.

STUDY DESIGN

The primary outcomes of interest were graft failure/reoperation rates, ACL injury in contralateral knee, return to soccer time, and PROs.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Search of literature yielded 32 studies for inclusion that involved 3112 soccer players after ACLR.

RESULTS

The overall graft failure/reoperation rate ranged between 3.0% and 24.8% (mean follow-up range, 2.3-10 years) and the combined ACL graft failure and contralateral ACL injury rate after initial ACLR was 1.0% to 16.7% (mean follow-up range, 3-10 years); a subgroup analysis for female and male players revealed a secondary ACL injury incidence rate of 27%, 95% CI (22%, 32%) and 10%, 95% CI (6%, 15%), respectively. Soccer players were able to return to play between 6.1 and 11.1 months and the majority of PROs showed favorable scores at medium-term follow-up.

CONCLUSION

Soccer players experience high ACL injury rates after primary ACLR and demonstrated similar reinjury rates as found in previous literature of athletes who participate in high-demand pivoting sports.

Comparative Study of ACL Reconstruction With Hamstring Versus Patellar Tendon Graft in Young Women: A Cohort Study From the New Zealand ACL Registry

BACKGROUND

Young female athletes are a specific population that is at high risk of primary anterior cruciate ligament (ACL) rupture and subsequent graft failure. Despite large numbers of ACL reconstructions being carried out in young women, there is limited analysis of outcomes in this group, leading to low levels of evidence for graft choice.

PURPOSE

To assess the effect of graft choice on ACL reconstruction failure rates among young women in New Zealand.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Prospective data captured by the New Zealand ACL Registry between April 2014 and March 2022 were reviewed. Young women aged 15 to 20 years were included. The primary outcome measure was ACL graft failure during the study period, with the key independent variable being graft type, either patellar or hamstring tendon autograft. This is presented as the rate per 100 patient-years and is compared between the 2 groups using the hazard ratio generated from a Cox proportional hazards regression. Secondary outcome measures were Marx activity scores and the Knee injury and Osteoarthritis and Outcome Score patient-reported outcome measure.

RESULTS

A total of 1261 primary ACL reconstructions in young women aged 15 to 20 years were reviewed. Hamstring tendon grafts were used in 797 (63%) reconstructions and patellar tendon graft in 464 (37%) reconstructions. Patients with a hamstring tendon graft had a graft failure rate of 7.7% compared with 1.1% in patients with a patellar tendon graft (hazard ratio, 6.1; 95% CI, 2.4-15.1; P < .001). The number of failures per 100 person-years was significantly higher in the hamstring group (2.05) compared with the patellar tendon group (0.37). No difference was noted at final follow-up between the hamstring tendon and patellar tendon groups when comparing patient-reported outcome measures during the follow-up period.

CONCLUSION

In the young female population of this study, the use of a patellar tendon graft was associated with reduced risk of graft failure and was not associated with an increase in knee morbidity. This highlights the importance of informed decision-making in this high-risk population when considering ACL reconstruction graft type.

Surgeon's experience, sports participation and a concomitant MCL injury increase the use of patellar and quadriceps tendon grafts in primary ACL reconstruction: a nationwide registry study of 39,964 surgeries

PURPOSE

To investigate the influence of surgeon-related factors and clinic routines on autograft choice in primary anterior cruciate ligament reconstruction (ACLR).

METHODS

Data from the Swedish National Knee Ligament Registry (SNKLR), 2008-2019, were used to study autograft choice (hamstring; HT, patellar; PT, or quadriceps tendon; QT) in primary ACLR. Patient/injury characteristics (sex, age at surgery, activity at time of injury and associated injuries) and surgeon-/clinic-related factors (operating volume, caseload and graft type use) were analyzed. Surgeon/clinic volume was divided into tertiles (low-, mid- and high-volume categories). Multivariable logistic regression was performed to assess variables influencing autograft choice in 2015-2019, presented as the odds ratio (OR) with a 95% confidence interval (CI).

RESULTS

39,964 primary ACLRs performed by 299 knee surgeons in 91 clinics were included. Most patients received HT (93.7%), followed by PT (4.2%) and QT (2.1%) grafts. Patients were mostly operated on by high-volume (> 28 ACLRs/year) surgeons (68.1%), surgeons with a caseload of ≥ 50 ACLRs (85.1%) and surgeons with the ability to use ≥ two autograft types (85.9%) (all p < 0.001). Most patients underwent ACLR at high-volume (> 55 ACLRs/year) clinics (72.2%) and at clinics capable of using ≥ two autograft types (93.1%) (both p < 0.001). Significantly increased odds of receiving PT/QT autografts were found for ACLR by surgeons with a caseload of ≥ 50 ACLRs (OR 1.41, 95% CI 1.11-1.79), but also for injury during handball (OR 1.31, 95% CI 1.02-1.67), various other pivoting sports (basketball, hockey, rugby and American football) (OR 1.59, 95% CI 1.24-2.03) and a concomitant medial collateral ligament (MCL) injury (OR 4.93, 95% CI 4.18-5.80). In contrast, female sex (OR 0.87, 95% CI 0.77-0.97), injury during floorball (OR 0.71, 95% CI 0.55-0.91) and ACLR by mid-volume relative to high-volume surgeons (OR 0.62, 95% CI 0.53-0.73) had significantly reduced odds of receiving PT/QT autografts.

CONCLUSION

An HT autograft was used in the vast majority of cases, but PT/QT autografts were used more frequently by experienced surgeons. Prior research has demonstrated significant differences in autograft characteristics. For this reason, patients might benefit if surgery is performed by more experienced surgeons.

LEVEL OF EVIDENCE

Level III.

Graft Choice for Anterior Cruciate Ligament Reconstruction in Women Aged 25 Years and Younger: A Systematic Review

CONTEXT

Although anterior cruciate ligament (ACL) tears are relatively common in athletic populations, few studies have systematically reviewed graft choice in young women.

OBJECTIVE

To quantitatively and qualitatively examine reported outcomes for graft choice in women aged 25 years and younger undergoing primary ACL reconstruction.

DATA SOURCE

A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. An electronic search in the PubMed (includes MEDLINE) and EMBASE databases was completed using a combination of key terms.

STUDY SELECTION

Studies were included if they reported graft choice outcomes in women aged 25 years and younger.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

The following information was extracted: title, author, year of publication, number of female patients and age, graft type, follow-up, and patient-reported outcome measures. The following outcome scores were identified as being reported or not reported by each study: graft failure, contralateral ACL (CACL) rupture, IKDC (International Knee Documentation Committee), graft survival (Kaplan-Meier), Lysholm, Tegner, KT-1000, kneeling pain, return to sport, and Lachman.

RESULTS

Of 1170 identified articles, 16 met inclusion criteria, reporting on 1385 female patients aged 25 years and younger. Comparison of 655 bone-patellar tendon-bone (BPTB) versus 525 hamstring tendon (HT) autografts showed significant differences in mean failure rate between BPTB autografts (6.13% ± 2.58%) and HT autografts (17.35% ± 8.19%), P = 0.001. No statistically significant differences in CACL failure rates were found between BPTB autografts and HT autografts (P = 0.25). Pooled results for IKDC were possible in 3 of the HT autograft studies, showing a mean score of 88.31 (95% CI 83.53-93.08). Pooled Lysholm score results were possible in 2 of the HT autograft studies, showing a mean score of 93.46 (95% CI 91.90-95.01).

CONCLUSION

In female patients aged 25 years and younger, BPTB autografts showed significantly less graft failure compared with HT autografts. However, BPTB autografts had comparable patient-reported outcomes compared with HT autografts with the available data. The overall state of evidence for graft choice in female patients aged 25 years and younger is low. Future studies should report statistics by age and sex to allow for further analysis of graft choice for this specific population that is known to be more vulnerable to ACL injury.

Bench to Bedside: A Multidisciplinary Approach toward the Unknowns after ACL Injuries to Drive Individual Success

ACL injury and surgery are increasing in prevalence. Several challenges exist that can be obstacles to an individual achieving success after ACL surgery. A knowledge of these risk factors alongside a multidisciplinary collaborative team approach can result in a greater likelihood of achieving individual success after ACL surgery.

Anterior Cruciate Ligament Reconstruction With Concomitant Meniscal Repair: Is Graft Choice Predictive of Meniscal Repair Success?

Background

When meniscal repair is performed during anterior cruciate ligament (ACL) reconstruction (ACLR), the effect of ACL graft type on meniscal repair outcomes is unclear.

Hypothesis

The authors hypothesized that meniscal repairs would fail at the lowest rate when concomitant ACLR was performed with bone--patellar tendon--bone (BTB) autograft.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients who underwent meniscal repair at primary ACLR were identified from a longitudinal, prospective cohort. Meniscal repair failures, defined as any subsequent surgical procedure addressing the meniscus, were identified. A logistic regression model was built to assess the association of graft type, patient-specific factors, baseline Marx activity rating score, and meniscal repair location (medial or lateral) with repair failure at 6-year follow-up.

Results

A total of 646 patients were included. Grafts used included BTB autograft (55.7%), soft tissue autograft (33.9%), and various allografts (10.4%). We identified 101 patients (15.6%) with a documented meniscal repair failure. Failure occurred in 74 of 420 (17.6%) isolated medial meniscal repairs, 15 of 187 (8%) isolated lateral meniscal repairs, and 12 of 39 (30.7%) of combined medial and lateral meniscal repairs. Meniscal repair failure occurred in 13.9% of patients with BTB autografts, 17.4% of patients with soft tissue autografts, and 19.4% of patients with allografts. The odds of failure within 6 years of index surgery were increased more than 2-fold with allograft versus BTB autograft (odds ratio = 2.34 [95% confidence interval, 1.12-4.92]; P = .02). There was a trend toward increased meniscal repair failures with soft tissue versus BTB autografts (odds ratio = 1.41 [95% confidence interval, 0.87-2.30]; P = .17). The odds of failure were 68% higher with medial versus lateral repairs (P < .001). There was a significant relationship between baseline Marx activity level and the risk of subsequent meniscal repair failure; patients with either very low (0-1 points) or very high (15-16 points) baseline activity levels were at the highest risk (P = .004).

Conclusion

Meniscal repair location (medial vs lateral) and baseline activity level were the main drivers of meniscal repair outcomes. Graft type was ranked third, demonstrating that meniscal repairs performed with allograft were 2.3 times more likely to fail compared with BTB autograft. There was no significant difference in failure rates between BTB versus soft tissue autografts.

Registration

NCT00463099 (ClinicalTrials.gov identifier).

The Statistical Fragility of Hamstring Versus Patellar Tendon Autografts for Anterior Cruciate Ligament Reconstruction: A Systematic Review of Comparative Studies

BACKGROUND

Evidence-based medicine utilizes data to inform clinical decision making, despite the ability of a small number of outcome reversals to change statistical significance. P values are common measurements of statistical significance that possess inherent flaws. The inclusion of the fragility index (FI) and fragility quotient (FQ) may provide a clearer conveyance of statistical strength.

PURPOSE/HYPOTHESIS

The purpose was to examine the statistical stability of studies comparing hamstring tendon and bone-patellar tendon-bone autografts in primary single-bundle anterior cruciate ligament reconstruction with independent tunnel drilling. We hypothesized that the findings of these studies are vulnerable to a small number of outcome event reversals, often fewer than the number of patients lost to follow-up.

STUDY DESIGN

Systematic review.

METHODS

Comparative studies and randomized controlled trials (RCTs) published in 10 leading orthopaedic journals between 2000 and 2020 were analyzed. Statistical significance was defined as a P value ≤.05. FI for each outcome was determined by the number of event reversals necessary to alter significance. FQ was calculated by dividing the FI by the respective sample size.

RESULTS

Of the 1803 studies screened, 643 met initial search criteria, with 18 comparative studies ultimately included for analysis, 8 of which were RCTs. A total of 114 outcomes were examined. Overall, the mean (interquartile range) FI and FQ were 3.77 (2-4) and 0.040 (0.016-0.055), respectively. The FI was less than the number of patients lost to follow-up for 76.3% of outcomes.

CONCLUSION

Studies examining graft choice for anterior cruciate ligament reconstruction may not be as statistically stable as previously thought. Comparative studies and RCTs are at substantial risk for statistical fragility, with few event reversals required to alter significance. The reversal of <4 outcome events in a treatment group can alter the statistical significance of a given result; this is commonly fewer than the number of patients lost to follow-up. Future comparative study analyses might consider including FI and FQ with P values in their statistical analysis.

Patellar Fracture After ACL Reconstruction: Open Reduction and Internal Fixation with a Maxillofacial Plate: A Case Report

CASE

Patellar fractures after anterior cruciate ligament (ACL) reconstruction with a bone-patellar-tendon-bone (BPTB) autograft are a rare complication with a reported incidence of 0.2% to 2.3%. Treatment has previously been nonoperative splinting, lag screws, or a tension-band construct. We present the case of a 14-year-old adolescent girl who suffered a comminuted patella fracture 4 weeks after an ACL reconstruction using a BPTB autograft who subsequently underwent successful operative fixation through a novel technique with the use of a maxillofacial plate and screw system.

CONCLUSION

A maxillofacial plate and screw system is an effective and reliable treatment option for patellar fractures sustained after ACL reconstruction with a BPTB autograft.

Effectiveness of thicker hamstring or patella tendon grafts to reduce graft failure rate in anterior cruciate ligament reconstruction in young patients

PURPOSE

The purpose of this study was to determine the anterior cruciate ligament reconstruction (ACLR) failure rate in young patients utilizing the New Zealand (NZ) anterior cruciate ligament (ACL) Registry. The hypothesis was that the ACLR rupture rate would be lower for thicker hamstring graft and bone patellar tendon bone (BPB) grafts in comparison to the classic hamstring technique. The ACLR failure rate was assessed according to graft type and patients' sex.

METHODS

The NZ ACL registry was utilized to identify all patients aged 20 years or younger at the time of surgery who were skeletally mature and had a minimum 2-year follow-up. Graft ruptures, defined as an ACL revision, were identified according to graft type (traditional 4 strands hamstring semitendinosus and gracilis, 4 strands semitendinosus, 5-6 strands semitendinosus and gracilis, 7-8 strands semitendinosus and gracilis, bone-patella-bone graft).

RESULTS

Nine-hundred and ninety-two patients were included. At a mean follow-up of 38 months, 52 cases of graft rupture were recorded, (overall failure rate: 5.2%). The failure rate was not statistically influenced by the graft diameter. Patients with a thinner graft (< 8 mm-196 patients) had a similar failure rate (6%) to patients with a thicker graft (8 mm or more-485 patients) (6.2%). There was a lower failure rate in the BPB group (3.1%) versus all hamstrings group (6%) (ns). Finally, BPB in females had a lower failure rate than all hamstring constructs together (0% versus 5.1%; p = 0.023) CONCLUSION: In a young population traditional four-strand hamstring grafts, multiple strand configurations or BPB ACLR, whatever their size (> or < 8 mm), showed no significant difference in the failure rate in the NZ ACL registry. Female patients who had an ACL reconstruction with BPB graft had a significant lower failure rate than patients who had a hamstring graft.

LEVEL OF EVIDENCE

III.

Anatomic Anterior Cruciate Ligament Reconstruction Using Rectangular Bone-Tendon- Bone Autograft Versus Double-Bundle Hamstring Tendon Autograft in Young Female Athletes

Purpose

To assess the clinical outcomes comparing rectangular bone–tendon–bone (BTB) grafts and double-bundle hamstring tendon (HM) grafts used for anatomic anterior cruciate ligament (ACL) reconstruction in young female athletes.

Methods

From January 2014 to November 2017, young female athletes 20 years or younger who underwent primary ACL reconstructions by a single surgeon were identified. Patients with concomitant injuries, not being a regular sports participant, the existence of contralateral ACL reconstruction, and who did not have a minimum of 1-year follow-up were excluded. We searched the rate and time for return-to-play, clinical outcomes including chronological instrumental side-to-side tibial translation difference, and muscle strength. Second ACL injury rates between the 2 groups during follow-up period were evaluated.

Results

Twenty-seven BTB ACL reconstructions and 29 HM ACL reconstructions were performed. The mean follow-up periods were 35.2 months in the BTB group and 33.8 months in the HM group. The BTB group showed better knee stability in mean side-to-side translational difference via arthrometric testing of 0.6 mm in the BTB versus 1.7 mm in the HM group at 5 months (P = .01) and 1.1 mm and 2.0 mm at 12 months, respectively (P = .02). There was no significant side-by-side difference in quadriceps muscle strength ratio, but the hamstring muscle strength was significantly better in the BTB group. The graft reinjury rate in the BTB group and the HM group was 0% (0/27) and 10.3% (3/29) (P = .09), respectively. In contrast, contralateral ACL injuries occurred in 17.3% (4/27) of the BTB group and 3.5% (1/29) of the HM group (P = .12).

Conclusions

For young female athletes aged 20 years or younger, the BTB group had better knee instrumental stability than the HM group without range of motion loss or knee extensor muscle strength deficit. Although there was no statistical significance in terms of second ACL injury, we observed fewer graft rerupture and an increasing rate of contralateral ACL injuries in the BTB group.

Level of Evidence

Level III, retrospective comparative study.

A Secondary Injury Prevention Program May Decrease Contralateral Anterior Cruciate Ligament Injuries in Female Athletes: 2-Year Injury Rates in the ACL-SPORTS Randomized Controlled Trial

OBJECTIVE

To determine whether the addition of perturbation training to a secondary injury prevention program reduces the rate of second anterior cruciate ligament (ACL) injury compared to the prevention program alone.

DESIGN

Single-blinded randomized controlled trial.

METHODS

Thirty-nine female athletes who intended to return to cutting/pivoting sports were enrolled 3 to 9 months after primary anterior cruciate ligament reconstruction (ACLR). Athletes were randomized to receive a training program of either progressive strengthening, agility, plyometrics, and prevention (SAPP) (n = 20) or SAPP plus perturbation training (n = 19); each had 10 sessions over 5 weeks. Occurrence and side of second ACL injury were recorded for 2 years after primary ACLR.

RESULTS

There were 9 second ACL injuries in the 2 years after ACLR. There was no statistically significant difference in rate or side of second ACL injury between the SAPP-plus-perturbation training and SAPP groups.

CONCLUSION

Adding perturbation training to a secondary ACL injury prevention program did not affect the rate of second ACL injury in female athletes. J Orthop Sports Phys Ther 2020;50(9):523-530. Epub 1 Aug 2020. doi:10.2519/jospt.2020.9407.

Females Have Earlier Muscle Strength and Functional Recovery After Bridge-Enhanced Anterior Cruciate Ligament Repair

Background: While a sex effect on outcomes following anterior cruciate ligament (ACL) reconstruction surgery has been previously documented, less is known following bridge-enhanced ACL repair (BEAR). We hypothesized that female sex would have significantly worse early functional outcomes and higher retear rates following primary repair of the ACL enhanced with a tissue-engineered scaffold. Methods: Sixty-five patients (28 males and 37 females), age 14-35 with a complete ACL tear underwent primary repair of the ACL enhanced with a tissue-engineered scaffold (bridge-enhanced ACL repair) within 45 days of injury. International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome (KOOS) scores, as well as instrumented anteroposterior (AP) laxity through KT-1000 testing and functional outcome measures were obtained at time points up to 2 years postoperatively and compared between males and females using mixed model repeated measures analyses and chi square tests. Results: There was no significant sex difference on the postoperative IKDC Subjective Score at 3, 6, 12, or 24 months or any of the five KOOS scores at 12 and 24 months. Instrumented AP laxity testing demonstrated mean (standard deviation) side-to-side differences that were similar in the two sexes at 2 years; 1.7 (2.7) mm and 1.5 (3.7) mm in females and males, respectively, p = 0.72. At 6 months postoperatively, males had a larger deficit in hamstring strength on the operated leg (14.0% vs. 1.7%; p = 0.03) and a larger deficit in quadriceps strength on the operated leg (11.3% vs. 2.0%; p = 0.004); however, no sex difference was noted at 12 or 24 months. Females demonstrated superior single leg hop testing at 6 and 12 months ([91.3% vs. 78.1%, p = 0.001], [96.9% vs. 87.0%, p = 0.01] respectively). There were no significant sex differences on ipsilateral (males; 14.3% vs. females; 13.9%, p = 1.00) or contralateral (males; 3.6% vs. females; 2.8%, p = 1.00) ACL reinjury rates. Conclusions: Female subjects had better hamstring and quadriceps strength indices at 6 months than males as well as better hop test results at the 6 and 12-month time period. Despite this, there was no significant sex difference on patient-reported outcomes and objective AP laxity testing at time points up to 2 years postoperatively. Impact statement This is the first study comparing sex specific outcomes following the bridge-enhanced ACL repair technique (BEAR). The results of this study suggest that females have earlier recovery of both muscle strength and functional outcomes compared to their male counterparts. This is an important finding when considering future modifications to postoperative care and rehabilitation in females and males following this tissue-engineered BEAR technique.

Athletes With Bone-Patellar Tendon-Bone Autograft for Anterior Cruciate Ligament Reconstruction Were Slower to Meet Rehabilitation Milestones and Return-to-Sport Criteria Than Athletes With Hamstring Tendon Autograft or Soft Tissue Allograft : Secondary Analysis From the ACL-SPORTS Trial

OBJECTIVE

Graft choices for athletes undergoing anterior cruciate ligament reconstruction (ACLR) include bone-patellar tendon-bone (BPTB) and hamstring tendon (HT) autografts and soft tissue allografts. The objective was to assess time to meet clinical milestones by graft type in athletes who completed a return-to-sport (RTS) program after ACLR.

DESIGN

Retrospective cohort study.

METHODS

Seventy-nine athletes enrolled after ACLR (allograft, n = 18; BPTB, n = 24; HT, n = 37). Time from surgery to meet (1) enrollment criteria (12 or more weeks post surgery, 80% or greater isometric quadriceps strength index, minimal effusion, and full knee range of motion), and (2) RTS criteria (90% or greater quadriceps strength index, hop testing limb symmetry, and patient-reported outcomes) was calculated. Quadriceps strength, hop performance, and patient-reported outcomes were measured before and after training, and at 1 year post surgery. Descriptive statistics, chi-square tests, and 1-way analyses of variance (α = .05) were used to analyze differences among graft types.

RESULTS

On average, the BPTB group (28.5 ± 7.6 weeks) took longer to meet enrollment milestones than the HT (22.5 ± 7.6 weeks, P = .007) and allograft (18.9 ± 5.8 weeks, P<.001) groups. The BPTB group (44.7 ± 15.8 weeks) took longer from surgery to meet RTS criteria than the HT (32.5 ± 9.9 weeks, P = .001) and allograft (29.3 ± 9.0 weeks, P<.001) groups. After training, the quadriceps strength index was lower in the BPTB group (86.1% ± 11.4%) than it was in the HT (96.1% ± 12.9%, P = .004) and allograft (96.9% ± 5.9%, P = .009) groups.

CONCLUSION

Athletes with a BPTB autograft may take longer than athletes with an HT autograft or a soft tissue allograft to complete postoperative rehabilitation, recover quadriceps strength, and meet RTS criteria. J Orthop Sports Phys Ther 2020;50(5):259-266. Epub 27 Nov 2019. doi:10.2519/jospt.2020.9111.

Anterior Cruciate Ligament Reconstruction in Young Female Athletes: Patellar Versus Hamstring Tendon Autografts

BACKGROUND

Female athletes are 2 to 8 times more prone to anterior cruciate ligament (ACL) rupture than males. Furthermore, reinjury to the ipsilateral or contralateral knee can occur in >20% of athletes. Female sex and younger age are known risk factors for graft failure. The optimal graft choice for young females remains unknown and poorly studied.

PURPOSE/HYPOTHESIS

The authors aimed to compare clinical outcomes in young females who underwent ACL reconstruction (ACLR) with bone-patellar tendon-bone (BTB) and quadrupled hamstring (HS) autografts. It was hypothesized that no significant differences in outcomes exist between graft choices.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Female patients aged 15 to 25 years who underwent primary ACLR with BTB or HS autograft were included for review. Patients were subdivided into 2 age groups: 15 to 20 years and 21 to 25 years. The occurrence of chondral, meniscal, or ligamentous injury to either knee was recorded for comparison.

RESULTS

A total of 256 females were included (BTB, n = 175; HS, n = 81). The majority of patients were between the ages of 15 and 20 years (BTB, 80%; HS, 77.8%). Overall, graft rupture occurred in 23 patients (9%) and contralateral ACL tear occurred in 18 (7%). Subgroup analysis showed that 75% of BTB and 100% of HS graft retears occurred in females aged 15 to 20 years. Within this age group, there was a significantly lower rate of graft ruptures in the BTB group (6.4%) as compared with the HS group (17.5%, P = .02). Allograft augmentation was used in 4 of the 11 HS grafts that retore. When allograft-augmented grafts were excluded, there was no significant difference in graft failure rate between graft choices. Fifteen patients in the BTB group (12%) as opposed to 1 in the HS group (2%) reported extreme difficulty or the inability to kneel on the front of the knee (P = .04).

CONCLUSION

In females aged 15 to 20 years undergoing ACLR, BTB autograft may lead to fewer graft ruptures than HS autograft. While this difference was not observed in females aged 21 to 25 years, a larger sample may be required to accept the null hypothesis in this age group. BTB autograft significantly increased the risk of kneeling pain as compared with HS regardless of age.

Anterior Cruciate Ligament Reconstruction in Young Females: A Systematic Review of Patellar Tendon Versus Hamstring Tendon Autografts

A systematic review was performed to compare patellar tendon-bone (BTB) and hamstring tendon (HS) autografts following anterior cruciate ligament reconstruction in young females, young patients, or females. One study compared BTB and HS in young females and found a lower rate of graft failure with BTB (P<.02). Of the 11 studies that made this comparison in females, 1 reported decreased laxity in females with BTB (P=.035). Of 4 studies comparing autografts in young patients, 1 reported a decreased rate of graft failure with BTB (P=.036). Further studies making this comparison specifically in young females are warranted. [Orthopedics. 2019; 42(3):e295-e304.].

Increased knee laxity with hamstring tendon autograft compared to patellar tendon autograft: a cohort study of 5462 patients with primary anterior cruciate ligament reconstruction

PURPOSE

To compare anterior knee laxity and patient-reported outcome measures (PROMs) between anterior cruciate ligament reconstruction (ACLR) performed with bone-patellar tendon-bone (BPTB) and hamstring tendon (HT) autografts and, moreover, to study any correlation between postoperative anterior knee laxity and PROMs.

METHODS

Patients who underwent primary ACLR at Capio Artro Clinic, Stockholm, Sweden, from January 2000 to October 2015, were identified in our local database. Instrumented laxity measurements and PROMs were reviewed. The KT-1000 arthrometer, with an anterior tibial load of 134-N, was used to evaluate knee laxity preoperatively and at the 6-month follow-up. The Lysholm score was collected preoperatively and at 6 months postoperatively. The Knee injury and Osteoarthritis Outcome Score (KOOS) was collected preoperatively and at the 1-year follow-up.

RESULTS

A total of 5462 primary ACLRs, 692 BPTBs and 4770 HT autografts were included in the study. All the patients showed a significant reduction in knee laxity from preoperatively to postoperatively (BPTB group: from 3.8 ± 2.6 to 1.2 ± 2.1 mm; HT group: from 3.6 ± 3.1 to 1.8 ± 2.2 mm; P < 0.001 for both). The HT group showed a significantly increased postoperative knee laxity compared with the BPTB group (1.8 ± 2.2 vs 1.2 ± 2.1 mm; P < 0.001). The mean anterior tibial translation (ATT) reduction from preoperative to postoperative was significantly larger for the BPTB graft compared with the HT graft (2.7 ± 2.2 vs 1.7 ± 2.6 mm; P < 0.001). A significantly higher rate of "surgical failures", defined as a postoperative side-to-side (STS) difference > 5 mm, was found in the HT group compared with the BPTB group at follow-up (4.3 vs 2.4%; P < 0.001). A significantly larger improvement was found in the HT group compared with the BPTB group for the KOOS Pain (9.5 vs 8.0; P = 0.02), Activities of Daily Living (7.2 vs 5.7; P = 0.006), Sports (24.2 vs 15.3; P < 0.001) and Quality of Life (25.8 vs 22.1; P = 0.001) subscales. No significant difference regarding the mean improvement in the Lysholm knee score was found between the two grafts (BPTB group: 14.5, HT group: 14.0; n.s.). No correlation between postoperative anterior knee laxity and PROMs was found in either graft group.

CONCLUSION

Primary ACLR performed with HT autograft resulted in greater postoperative anterior knee laxity and significantly more surgical failures (STS > 5 mm) compared with BPTB autograft. The BPTB autograft showed a larger anterior knee laxity reduction (ATT reduction) in conjunction with primary ACLR. The HT autograft led to a significantly larger improvement in four of five KOOS subscales from preoperatively to the 1-year follow-up, compared with BPTB autograft. There was no association between postoperative anterior knee laxity and PROMs for either graft. The findings of the present study provide clinicians with valuable information regarding differences in knee laxity and subjective knee function between BPTB and HT autograft after primary ACLR. The use of BPTB autograft should be considered for patients with high knee stability demands.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.

Subsequent Surgery After Revision Anterior Cruciate Ligament Reconstruction: Rates and Risk Factors From a Multicenter Cohort

BACKGROUND

While revision anterior cruciate ligament reconstruction (ACLR) can be performed to restore knee stability and improve patient activity levels, outcomes after this surgery are reported to be inferior to those after primary ACLR. Further reoperations after revision ACLR can have an even more profound effect on patient satisfaction and outcomes. However, there is a current lack of information regarding the rate and risk factors for subsequent surgery after revision ACLR.

PURPOSE

To report the rate of reoperations, procedures performed, and risk factors for a reoperation 2 years after revision ACLR.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A total of 1205 patients who underwent revision ACLR were enrolled in the Multicenter ACL Revision Study (MARS) between 2006 and 2011, composing the prospective cohort. Two-year questionnaire follow-up was obtained for 989 patients (82%), while telephone follow-up was obtained for 1112 patients (92%). If a patient reported having undergone subsequent surgery, operative reports detailing the subsequent procedure(s) were obtained and categorized. Multivariate regression analysis was performed to determine independent risk factors for a reoperation.

RESULTS

Of the 1112 patients included in the analysis, 122 patients (11%) underwent a total of 172 subsequent procedures on the ipsilateral knee at 2-year follow-up. Of the reoperations, 27% were meniscal procedures (69% meniscectomy, 26% repair), 19% were subsequent revision ACLR, 17% were cartilage procedures (61% chondroplasty, 17% microfracture, 13% mosaicplasty), 11% were hardware removal, and 9% were procedures for arthrofibrosis. Multivariate analysis revealed that patients aged <20 years had twice the odds of patients aged 20 to 29 years to undergo a reoperation. The use of an allograft at the time of revision ACLR (odds ratio [OR], 1.79; P = .007) was a significant predictor for reoperations at 2 years, while staged revision (bone grafting of tunnels before revision ACLR) (OR, 1.93; P = .052) did not reach significance. Patients with grade 4 cartilage damage seen during revision ACLR were 78% less likely to undergo subsequent operations within 2 years. Sex, body mass index, smoking history, Marx activity score, technique for femoral tunnel placement, and meniscal tearing or meniscal treatment at the time of revision ACLR showed no significant effect on the reoperation rate.

CONCLUSION

There was a significant reoperation rate after revision ACLR at 2 years (11%), with meniscal procedures most commonly involved. Independent risk factors for subsequent surgery on the ipsilateral knee included age <20 years and the use of allograft tissue at the time of revision ACLR.