No differences found in long-term outcomes of a randomized controlled trial comparing ipsilateral versus contralateral hamstring graft in ACL reconstruction

Restoring Knee Flexor Strength Symmetry Requires 2 Years After ACL Reconstruction, But Does It Matter for Second ACL Injuries? A Systematic Review and Meta-analysis

BACKGROUND

It is unknown whether knee flexor strength recovers after anterior cruciate ligament (ACL) reconstruction with a hamstring tendon (HT) autograft and whether persistent knee flexor strength asymmetry is associated to a second ACL injury.

OBJECTIVE

We aimed to systematically review (1) whether knee flexor strength recovers after ACL reconstruction with HT autografts, and (2) whether it influences the association with a second ACL injury. A third aim was to summarize the methodology used to assess knee flexor strength.

DESIGN

Systematic review and meta-analysis reported according to PRISMA.

METHODS

A systematic search was performed using the Cochrane Library, Embase, Medline, PEDRo, and AMED databases from inception to December 2021 and until completion in January 2023. Human clinical trials written in English and conducted as randomized controlled trials, longitudinal cohort, cross-sectional, and case-control studies on patients with index ACL reconstructions with HT autografts harvested from the ipsilateral side were considered. Knee flexor strength was measured isokinetically in both the reconstructed and uninjured limb to enable the calculation of the limb symmetry index (LSI). The Risk of Bias Assessment Tool for Non-Randomized Studies was used to assess risk of bias for non-randomized studies and the revised Cochrane Risk of Bias tool was used for randomized controlled trials. For the meta-analysis, the LSI (mean ± standard error) for concentric knee flexor strength at angular velocities of 60°/second (s) and 180°/s preoperatively and at 3 months, 6 months, 12 months, and 24 months were pooled as weighted means with standard errors.

RESULTS

The search yielded 64 studies with a total of 8378 patients, which were included for the assessment of recovery of knee flexor strength LSI, and a total of 610 patients from four studies that investigated the association between knee flexor strength and second ACL injuries. At 1 year after ACL reconstruction, the knee flexor strength LSI had recovered to 89.0% (95% CI 87.3; 90.7%) and 88.3% (95% CI 85.5; 91.1%) for the velocities of 60°/s and 180°/s, respectively. At 2 years, the LSI was 91.7% (95% CI 90.8; 92.6%) and 91.2% (95% CI 88.1; 94.2%), for velocities of 60°/s and 180°/s, respectively. For the association between knee flexor strength and second ACL injuries, there was insufficient and contradictory data.

CONCLUSIONS

There was low to very low certainty of evidence indicating that the recovery of knee flexor strength LSI, defined as ≥ 90% of the uninjured side, takes up to 2 years after ACL reconstruction with HT autografts. Whether knee flexor strength deficits influence the association of second ACL injuries is still uncertain. There was considerable heterogeneity in the methodology used for knee flexor strength assessment, which together with the low to very low certainty of evidence, warrants further caution in the interpretation of our results.

REGISTRATION NUMBER

CRD42022286773.

Contralateral hamstring autografts do not provide benefit compared to ipsilateral hamstring autografts in primary or revision anterior cruciate ligament reconstruction: a systematic review

PURPOSE

To evaluate the clinical outcomes of primary or revision ACL reconstruction (ACLR) after contralateral hamstring autografts versus ipsilateral hamstring autograft harvest.

METHODS

Three databases (MEDLINE, PubMed and EMBASE) were searched from inception to April 27th, 2023 for studies investigating contralateral hamstring autografts in primary or revision ACLR. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, strength measures, patient-reported outcome measures (PROMs), and rates of positive Lachman test, positive pivot-shift test and graft rupture were extracted. PROMs included Lysholm, International Knee Documentation Committee (IKDC) and Tegner scores.

RESULTS

Nine studies comprising 371 patients were included in this review. In primary ACLR, there were no significant differences between contralateral and ipsilateral groups in isokinetic hamstring torque in the non-ACLR limb or isokinetic quadriceps torque in both limbs when tested at 60, 90, 120 or 180 degrees/second. Isokinetic hamstring torque in the non-ACLR limb was significantly weaker in the contralateral group at six months for primary ACLR; however, these deficits did not persist. There were no significant differences in postoperative median Tegner scores and Lysholm scores between contralateral and ipsilateral groups in primary ACLR. There were no significant differences in postoperative median Tegner, mean Lysholm and IKDC scores between groups in revision ACLR. There were no significant differences in positive Lachman, positive pivot-shift and rupture rates in primary ACLR between groups. Rates of positive Lachman and pivot-shift were slightly higher in the contralateral than ipsilateral group for revision ACLR.

CONCLUSION

Contralateral hamstring autografts results in comparable muscle strength to ipsilateral hamstring autografts, with the exception of weaker hamstring strengths in the early postoperative period. Patient-reported outcome measures were similar between the two groups across both primary and revision ACLR, with rates of instability and failure being similar between groups for primary ACLR. Contralateral hamstring grafts do not provide additional benefit when compared to ipsilateral options for either primary or revision ACLR, and should be used only in select circumstances including insufficient ipsilateral hamstring grafts or situations where quadriceps or patella autografts are not optimal.

LEVEL OF EVIDENCE

Level IV.

Contralateral grafts have comparable efficacy to ipsilateral grafts in anterior cruciate ligament reconstructions: a systematic review

PURPOSE

To perform a systematic review of the clinical outcomes of anterior cruciate ligament reconstruction using either contralateral or ipsilateral tendon autografts.

METHODS

A systematic review of literature published from inception to December 9, 2022, in multiple databases (PubMed, Embase, Scopus, and the Cochrane Library) was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews) guidelines. Two reviewers independently screened the literature, extracted the data, performed the risk of bias assessment and assessed the study quality. At least one of the following outcomes was evaluated for each study: muscle strength (isometric strength of the quadriceps or hamstring muscles, isokinetic peak flexion torque of the hamstring, or isokinetic peak extension torque of the hamstring), knee laxity examination, Lysholm score, pivot shift, International Knee Documentation Committee (IKDC) score, Knee Injury and Osteoarthritis Outcome Score (KOOS), Lachman test result, return to sports time, or incidence of complications. A random effects model was used for all analyses.

RESULTS

Four hundred scientific manuscripts were recovered in the initial search. After screening, 12 studies (2 randomized controlled trials, 9 cohort studies, and 1 case- control study) met the search criteria for the qualitative analysis. Among them, 9 cohort studies were used for the quantitative analysis. The results showed few statistically significant differences in terms of muscle strength (contralateral group versus ipsilateral group or donor site group versus ipsilateral group or donor site group versus nonoperative group), Lysholm score, and return to sports time. A comparison showed no significant differences in knee laxity, IKDC score, Tegner activity score, Lachman test score, or incidence of complication, or contralateral rupture.

CONCLUSIONS

In anterior cruciate ligament reconstruction, the contralateral autologous tendon has a similar effect as the ipsilateral autologous tendon.

Spanish Version of the Anterior Cruciate Ligament-Quality of Life Questionnaire: Translation, Cross-cultural Adaptation, and Validation

Background

The Anterior Cruciate Ligament-Quality of Life (ACL-QOL) questionnaire is a patient-reported outcome measure used to assess the effect of an anterior cruciate ligament (ACL) injury on the lives of patients. It was originally written in English, which may affect its use when completed by nonnative English speakers.

Purpose

To translate and adapt the ACL-QOL to Spanish and provide evidence of its psychometric properties.

Study Design

Cohort study (diagnosis); Level of evidence, 2.

Methods

A total of 183 patients with an ACL injury from 4 Catalan hospitals were included: 99 patients who had undergone ACL reconstruction (ACLR) completed the Spanish version of the ACL-QOL (ACL-QOL-Sp) twice (mean interval, 15.2 days) in 2 weeks for test-retest reliability, and 84 patients completed the ACL-QOL-Sp, the Lysholm knee scoring scale, the Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner Activity Scale, and the 12-item Short Form Health Survey (SF-12) before and at 4 and 9 months after ACLR to assess responsiveness. The association between the ACL-QOL-Sp and the other outcome measures was evaluated with the Spearman correlation coefficient.

Results

The ACL-QOL-Sp showed good internal consistency (Cronbach alpha = 0.96) and test-retest reliability (intraclass correlation coefficient = 0.97). The standard error of measurement was 3.6, also suggesting the precision of measurements. The smallest detectable change was 9.98 in 94% of patients. No association was found between the ACL-QOL-Sp score and the Tegner score or SF-12 mental component summary score; however, a moderate correlation was found with the overall KOOS score (r = -0.545), Lysholm score (r = 0.509), and SF-12 physical component summary score (r = 0.607). The correlation ranged from weak for the KOOS-Symptoms subscore (r = -0.290) to moderate for the KOOS-Quality of Life subscore (r = -0.698). No ceiling or floor effects were observed. The ACL-QOL-Sp showed a moderate effect size (0.73) at 4 months but a large effect size (1.70) at 9 months.

Conclusion

The ACL-QOL-Sp showed adequate internal consistency, test-retest reliability, and responsiveness in evaluating quality of life after ACLR in Spanish-speaking patients.