No difference in patient reported outcomes, laxity, and failure rate after revision ACL reconstruction with quadriceps tendon compared to hamstring tendon graft: a systematic review and meta-analysis

Hamstring autografts demonstrate either similar or inferior outcomes to quadriceps or bone-patellar tendon-bone autografts in revision anterior cruciate ligament reconstruction: A systematic review of comparative studies

PURPOSE

To evaluate the clinical outcomes in patients undergoing revision anterior cruciate ligament reconstruction (r-ACLR) using hamstring tendon (HT) autografts with those using either quadriceps tendon (QT) or bone-patellar tendon-bone (BPTB) autografts or allografts.

METHODS

Three databases were searched on 8 August 2023. The authors adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, surgical details, patient-reported outcome measures (PROMs), rates of instability, failure and return to sport (RTS) were extracted.

RESULTS

Eleven studies comprising 859 patients were included in this review. Five studies compared HT and QT autografts. One study each reported greater IKDC scores (p = 0.04) and Tegner scores (p = 0.04) in the QT group, while one study each reported higher anterior translation (p = 0.04), rates of positive pivot shift (p = 0.03) and rates of failure (p = 0.03) in the HT group. Six studies compared HT and BPTB autografts with one study each reporting greater Lysholm scores (p = 0.02) and less side-to-side anterior laxity (p < 0.01) in the BPTB group. Two studies compared HT autografts with allografts with only one study reporting a faster time to RTS in the HT group than the allograft group (p < 0.001). All other comparisons were not significant.

CONCLUSIONS

HT autografts result in either similar or inferior outcomes in r-ACLR when compared to QT or BPTB autograft options. Allografts resulted in similar outcomes to HT autografts apart from greater time to RTS for r-ACLR.

LEVEL OF EVIDENCE

Level III.

Both Hamstring and Quadriceps Tendon Autografts Offer Similar Functional Outcomes After Arthroscopic Anterior Cruciate Ligament Reconstruction in Patients Aged 50 Years or Older

PURPOSE

To compare the outcomes of hamstring tendon (HT) and quadriceps tendon (QT) autografts for anterior cruciate ligament (ACL) reconstruction in patients aged 50 years or older in terms of patient-reported functional outcomes, graft failure rates, complications, return to sports activity, and sports preference.

METHODS

Between 2010 and 2022, prospectively collected data were obtained from an institutional database. Patients aged 50 years or older who underwent primary arthroscopic ACL reconstruction with either HT or QT autograft and had a minimum 2-year follow-up were included. Patients with concomitant meniscal, cartilage, and medial collateral ligament injuries were also included. Patients undergoing revision ACL reconstruction, those undergoing primary ACL reconstruction with a graft other than HT or QT autograft, and those with contralateral knee injuries or ipsilateral osteoarthritis (Ahlbäck stage ≥2) were excluded. Patients were evaluated in terms of the Lysholm knee score, Tegner activity level, and visual analog scale (VAS) score for pain before injury and at 2-year follow-up, as well as graft failure, QT rupture, and return to sport. The Mann-Whitney test was used to analyze unpaired samples, whereas the Friedman test was used to analyze variables over time. The χ2 statistic test was used to determine differences in categorical data between groups.

RESULTS

The number of patients in the QT and HT groups was 85 and 143, respectively. In the QT and HT groups, the mean age was 54.4 years (range, 50-65 years) and 56.4 years (range, 50-65 years), respectively, and 49% and 51% of patients were men, respectively. The 2 groups did not differ significantly in terms of age, sex, time from injury to surgery, and concomitant injuries. No significant differences in preinjury patient-reported outcome measures, consisting of the Lysholm score, Tegner activity level, and VAS pain score, were found between the 2 groups (P > .05). At the 2-year follow-up, the Lysholm knee score, Tegner activity level, and VAS pain score improved to preinjury levels and no significant differences in preinjury and 2-year follow-up functional scores were noted between the 2 groups (P > .05). Furthermore, at the 2-year follow-up, the Lysholm score and VAS pain score did not show significant differences (P = .390 and P = .131, respectively) between the QT and HT groups. Similarly, no differences in Tegner activity level were observed between the HT and QT groups at the 2-year follow-up. No significant differences in terms of the minimal clinically important difference were detected between the 2 groups for the Lysholm knee score (P = .410) and Tegner activity level (P = .420). The 2 groups did not differ in terms of patients' percentage of sports participation at baseline and at the 2-year follow-up (P > .05). A significant decrease (P = .01) in participation in skiing/snowboarding was reported in the HT group at the 2-year follow-up compared with baseline (116 patients [81%] vs 98 patients [69%]). No case of graft failure or QT rupture was reported in either group.

CONCLUSIONS

Arthroscopic ACL reconstruction using HT or QT autografts in athletically active patients aged 50 years or older provides satisfactory patient-reported functional outcomes and allows recovery of the preinjury level of activity.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Revision ACL reconstruction in female athletes: current concepts

The challenge of revision anterior cruciate ligament (ACL) reconstruction lies in its complexity, varied presentation, and technical intricacies. A successful ACL reconstruction should allow patients to safely return to preinjury activities. However, it is only sometimes simple, and many risk factors and concurrent pathologies come into play. Evaluating and analysing the cause of failure and associated conditions is paramount to addressing them effectively. Despite a plethora of research and improvements in knowledge and technology, e gaps exist in issues such as optimal techniques of revision surgery, graft options, fixation, concurrent procedures, rehabilitation and protocol for return to sports of high-level athletes. Female athletes need additional focus since they are at higher risk of re-injury, suboptimal clinical outcomes, and lower rates of return to sport following revision reconstruction. Our understanding about injury prevention and the protection of ACL grafts in female athletes needs to be improved. This review focuses on the current state of revision ACL surgery in female athletes and provides recommendations and future directions for optimising outcomes in this high-risk group.

Ten-year outcomes of anterior cruciate ligament reconstruction with hamstring tendon autograft and femoral fixation with a cortico-cancellous screw suspension device

PURPOSE

To evaluate the clinical and radiographic outcomes of anterior cruciate (ACL) reconstruction at minimum 10-year follow-up.

METHODS

Ninety-three patients who underwent primary unilateral ACL reconstruction with hamstring tendon autograft, transtibial technique and femoral cortico-cancellous screw suspension device (Athrax, Leader Medica s.r.l) between 2010 and 2012 were retrospectively reviewed. Mean follow-up was 136 months. Evaluation was performed using the International Knee Documentation Committee score (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm Knee Score and Tegner Activity Level Scale. Incidence of OA was determined by comparing standard anteroposterior and lateral weightbearing radiographs of the ACL-reconstructed and contralateral knee. Osteoarthritis severity was graded according to the Kellgren-Lawrence (KL) score.

RESULTS

Median Tegner activity level was 6 (5-7). Lysholm and IKDC scores were 100 (95-100) and 90 (86-95), respectively, KOOS was 98 (95-100). Of ACL-reconstructed knees, 41 (50%) had radiographic OA, of which 6 (7.3%) had severe OA (KL III). Of the contralateral healthy knees, 28 (34.1%) had radiographic evidence of OA. Of these 22 (26.8%) and 6 (7.3%) patients had, respectively, KL-I and KL-II. 11 patients (11.8%) underwent subsequent knee surgery: 5 (5.4%) revisions, 3 (3.2%) meniscal surgeries, 2 (2.2%) other surgeries, 1 (1.1%) contralateral ACL reconstruction.

CONCLUSIONS

The study demonstrates that ACL reconstruction with HT autograft and cortico-cancellous screw suspension device determines satisfying clinical results after 10 years of follow-up. From our cohort, a low rate of graft failure has been reported, even though almost 50% of patients present a knee OA greater or equal to grade II KL.

Effect of graft types for outcomes in revision anterior cruciate ligament reconstruction: A meta-analysis

PURPOSE

This meta-analysis was performed to compare outcomes among different types of graft for revision anterior cruciate ligament reconstruction (ACLR).

METHODS

A comprehensive search from Embase, PubMed, and Cochrane Library was performed to identify relevant articles. Studies that conducted a comparative analysis on outcomes among different types of grafts were included. A meta-analysis was performed using Review Manager 5.4 software.

RESULTS

In total, 7 non-randomized studies with a minimum 1-year follow-up were included in analysis, and all studies compared outcomes between autograft and allograft. International Knee Documentation Committee subjective knee (IKDC) scores and side-to-side anterior laxity were not significantly different between autograft and allograft. Revision ACLR with allograft had a higher risk of failure than autograft at the final follow-up (OR=2.22, 95% CI=1.55-3.18). The rates of return to pre-injury type of sport and return to same and higher level of pre-injury sport were not significantly different between autograft and allograft.

CONCLUSION

The outcomes of IKDC score, side-to-side anterior laxity, and rates of return to sport were not significantly different between autograft and allograft. Autografts provide a significantly lower risk of failure than allografts in revision ACLR.

LEVEL OF EVIDENCE

IV; meta-analysis.

Quadriceps tendon autograft has similar clinical outcomes when compared to hamstring tendon and bone-patellar tendon-bone autografts for revision ACL reconstruction: a systematic review and meta-analysis

PURPOSE

Research regarding revision anterior cruciate ligament reconstruction (RACLR) with quadriceps tendon (QT) autografts is lacking. The purpose of this study was to perform a systematic review and meta-analysis of RACLR with QT and compare its patient outcomes to RACLR with hamstring tendon (HT) and bone-patellar tendon-bone (BTB) autografts.

METHODS

Adhering to PRISMA guidelines, a search for studies using QT in RACLR was performed within PubMed, Scopus, and CINAHL from database date of inception through December 26, 2022. Primary outcomes sought included: failure rate, Lysholm scores, International Knee Documentation Committee (IKDC) scores, IKDC grades, arthrometric knee side-to-side differences (STSD), pivot shift grade, donor site morbidity, return to sport, visual analog scale (VAS) pain scores.

RESULTS

Nine studies were included consisting of 606 RACLR: 349 QT, 169 HT, and 88 BTB. Overall failure rates were 7.6% QT, 13.3% HT, and 8.7% BTB. Mean weighted Lysholm scores were 85.8 ± 3.8 QT, 82.5 ± 3.8 HT and 86.6 ± 4.5 BTB. IKDC average scores were 82.3 ± 1.6 QT, 80.1 ± 1.7 HT, and 81.7 ± 5.5BTB. Combined rates of IKDC A/B grades were 88.4% and 80.0% for QT and HT, respectively. VAS average scores were 0.9 ± 1.1 QT, 1.4 ± 0.2 HT, and 0.7 ± 0.8 for BTB. Side-to-side difference was reported for QT and HT with average values of 1.7 ± 0.6 mm and 2.1 ± 0.5 mm, respectively. Grade 0 or 1 pivot shifts were reported in 96.2% of QT patients and 91.3% of HT. Donor site morbidity, only reported for QT and HT, was 14.6 ± 9.7% and 23.6 ± 14.1%, respectively. QT resulted in a mean Tegner score of 5.9 ± 1.5 versus HT 5.7 ± 1.5. Rate of return to pivoting sports was 38.0% QT, 48.6% HT, and 76.9% BTB. Across all outcomes, there was no significant difference when comparing QT to HT, QT to BTB, and QT compared to HT and BTB combined.

CONCLUSIONS

RACLR with QT yields satisfactory patient reported outcomes, satisfactory improvement in knee laxity, expected return to sport rates, and has an overall 7.6% failure rate. Outcomes are comparative to those of HT and BTB making it an acceptable graft choice for RACLR. Surgeons should consider using QT autograft for RACLR, especially when other autografts are unavailable.

LEVEL OF EVIDENCE

IV.

Concomitant Injuries Associated With ACL Rupture in Elite Professional Alpine Ski Racers and Soccer Players: A Comparative Study With Propensity Score Matching Analysis

Background

For elite professional soccer players and alpine skiers, injuries associated with anterior cruciate ligament (ACL) rupture, such as meniscal, cartilage, or collateral ligament lesions, could result in a delayed return to sport compared with isolated ACL injury.

Purpose/Hypothesis

The purpose of the study was to provide a detailed description of associated injuries at the time of primary ACL reconstruction in elite soccer players and alpine skiers. It was hypothesized that soccer players and skiers would present different typical injury patterns due to different injury mechanisms.

Study Design

Cohort study; Level of evidence, 3.

Methods

Surgical reports and arthroscopic images of elite professional soccer players and alpine skiers who underwent primary ACL reconstruction at a single institution between January 2010 and June 2022 were analyzed retrospectively. The presence and location of multiligamentous injury, meniscal tears, and chondral lesions were compared between the athlete groups. A propensity score matching analysis with 1:1 ratio was performed between skiers and soccer players to limit the effect of selection bias.

Results

Included were ACL reconstruction data representative of 37 soccer players and 44 alpine skiers. Meniscal pathology was found in 32 (86%) soccer players and 30 (68%) skiers. Chondral injuries were reported in 11 (30%) soccer players and 15 (34%) skiers. Results of the propensity score matching analysis in 15 pairs of soccer players and skiers indicated that soccer players had a significantly higher rate of medial meniscal injuries (73% vs 27%; P = .03) and lateral posterior root tears (33% vs 0%; P = .04) compared with skiers.

Conclusion

A higher prevalence of combined chondral and meniscal injuries versus isolated ACL injuries was observed in both groups of athletes. Professional soccer players were characterized by higher prevalence of medial meniscal tears and lateral posterior root lesions compared with professional alpine skiers.