Kneeling difficulty is common following anterior cruciate ligament reconstruction with hamstring autograft and correlates with outcome measures

Minimally Invasive Bone-Patellar Tendon-Bone Graft Harvest Is Associated With Less Frequent Anterior Knee Pain at Rest Than Hamstring Graft Harvest After Anterior Cruciate Ligament Reconstruction at the 1-Year Follow-Up

Purpose

To compare the incidence of postoperative anterior knee pain at rest and during "knee walking" in patients who had anterior cruciate ligament reconstruction (ACLR) surgery with hamstring tendon (HT) grafts versus bone-patellar tendon-bone (BPTB) grafts harvested using a minimally invasive double-incision technique with autografting of the bone harvest defects.

Methods

Adult patients who had undergone an ACLR and had completed a questionnaire enquiring about anterior knee symptoms at a minimum of 1 year postoperatively were identified. Two groups were compared: 1) patients who had received a BPTB graft harvested using a minimally invasive double-incision technique with autografting of the bone harvest defects, and 2) patients who had received a HT graft.

Results

A total of 142 adult patients were included: 88 had a BPTB graft and 54 had a HT graft. The prevalence of anterior knee pain at rest was 10% in the BPTB group and 28% in the HT group (P = .006). Overall, knee walking scores were worse in the BPTB group when compared to the HG group, but the difference in the proportions of patients who found it impossible to knee-walk was not statistically significant (17% vs 6%; P = .069).

Conclusions

Our results showed that pain at rest was less in the BTPB group compared to the HT group contradicting historic literature. In addition, there was no statistically significant difference between the 2 grafts when comparing the proportion of patients who found it "impossible" to knee-walk.

Level of Evidence

Level III, retrospective comparative study.

Radiological maturation and clinical results of double-bundle and single-bundle anterior cruciate ligament reconstruction. A 5-year prospective case-controlled trial

INTRODUCTION

The aim of the study was to make a prospective comparison of the radiological and clinical outcomes of patients undergoing single-bundle and double-bundle anterior cruciate ligament (ACL) reconstruction.

METHOD

This prospective, case-controlled study included 65 patients, separated into 2 groups as 33 patients undergoing single bundle (SB), and 32 patients undergoing double bundle (DB) ACL reconstruction. The patients were evaluated clinically using the International Knee Documentation Committee (IKDC) and the Lysholm knee scores. Stability was evaluated with the KT-1000 Arthrometer Measurement, the Lachman and pivot shift tests. Magnetic resonance images (MRI) at 1 and 5 years postoperatively were evaluated by a musculoskeletal radiologist. All the operations were performed by a single surgeon and the clinical evaluations were made by an independent researcher.

RESULTS

Evaluation was made of a total of 53 patients (SB: 28, DB: 25). No statistically significant difference was determined between the groups regarding the postoperative IKDC and Lysholm scores. The pivot shift tests were negative in the DB group and positive in two patients of the SB group. The Lachman test was negative in all the patients. No significant difference was determined between the groups. No statistically significant difference was determined between the two groups in respect of the arthrometer measurements. In the SB group, revision surgery was performed in two patients due to graft failure. No graft failure findings were determined in the DB group, and no statistically significant difference was determined between the groups in respect of graft failure. On the MRIs taken at 1 year postoperatively, the ACL was seen to be hyperintense in 16 patients in the DB group and 6 patients in the SB group (p = 0.004). On the 5-year MRIs, ACL hypointensity could not be seen in three patients of the SB group and two of the DB group, with no difference determined between the groups (p > 0.05).

CONCLUSION

In the 5-year follow-up period, no difference was determined between patients undergoing SB ACL reconstruction and those undergoing DB ACL reconstruction regarding clinical scores, knee stability, and MRI findings, but graft maturation occurs later the patients undergoing DB reconstruction.

Revision anterior cruciate ligament reconstruction and outcomes with different autografts in a population with kneeling customs

OBJECTIVES

This study was designed to evaluate, compare the mid-term functional outcome of revision anterior cruciate ligament reconstruction (ACLR) using different autografts and assess the cause of failure of primary ACLR in an Omani population with kneeling customs.

MATERIALS AND METHODS

Patients with failed primary ACLR who underwent revision ACLR using autografts were included in this retrospective study. The cause of primary ACLR failure and the functional outcome was assessed using the Tegner-Lyholm knee score and compared among bone patella tendon-bone (BPTB), quadriceps tendon (QT), semitendinosus gracilis (STG) autografts used.

RESULTS

One hundred two patients (102 male) were included in the study with a minimum follow-up of 2 years. Thirty-one patients underwent revision with BPTB, 34 with STG and 19 with QT autografts. Majority of the patients (70.23%) achieved good-to-excellent functional outcome based on their Tegner-Lysholm scores. The functional outcome of different autografts was comparable to each other based on Kruskal-Wallis test. The causes of primary ACLR failure were failure due to trauma in 58.33% of patients, technical failure in 22.61% of patients, and nontraumatic failure in 19.04% of patients.

CONCLUSIONS

The functional outcome of revision ACLR in this Middle Eastern Asian Omani population was good-to-excellent, with the patients experiencing no difficulty in performing activities of daily living, including kneeling activities. The outcome of different autografts, BTPB, QT, STSG is similar in high knee flexion patients with no autograft found to be superior. The findings of this study add to the literature on functional outcomes after primary and revision ACLR in a customary kneeling population.

LEVEL OF EVIDENCE III

Rehabilitation Principles to Consider for Anterior Cruciate Ligament Repair

CONTEXT

Injury to the anterior cruciate ligament (ACL) is among the most common orthopaedic injuries, and reconstruction of a ruptured ACL is a common orthopaedic procedure. In general, surgical intervention is necessary to restore stability to the injured knee, and to prevent meniscal damage. Along with surgery, intense postoperative physical therapy is needed to restore function to the injured extremity. ACL reconstruction (ACLR) has been the standard of care in recent decades, and advances in surgical technology have reintroduced the prospect of augmented primary repair of the native ACL via a variety of methods.

EVIDENCE ACQUISITION

A search of PubMed database of articles and reviews available in English was performed through 2020. The search terms ACLR, anterior cruciate ligament repair, bridge enhanced acl repair, suture anchor repair, dynamic intraligamentary stabilization, internal bracing, suture ligament augmentation, and internal brace ligament augmentation were used.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 5.

RESULTS

No exact consensus exists on effective rehabilitation protocols after ACL repair techniques, as the variation in published protocols seem even greater than the variation in those for ACLR. For some techniques such as internal bracing and dynamic interligamentary stabilization, it is likely permissible for the patients to progress to full weightbearing and discontinue bracing sooner. However, caution should be applied with regard to earlier return to sport than after ACLR as to minimize risk for retear.

CONCLUSION

More research is needed to address how physical therapies must adapt to these innovative repair techniques. Until that is accomplished, we recommend that physical therapists understand the differences among the various ACL surgery techniques discussed here and work with the surgeons to develop a rehabilitation protocol for their mutual patients.

STRENGTH OF RECOMMENDATION TAXONOMY (SORT)

C.

Insufficient evidence to support peroneus longus tendon over other autografts for primary anterior cruciate ligament reconstruction: a systematic review

IMPORTANCE

Graft choice for anterior cruciate ligament reconstruction (ACLR) remains a subject of interest among orthopaedic surgeons because no ideal graft has yet been found. Peroneus longus tendon (PLT) has emerged as an alternative autograft for reconstruction in kneeling populations and in simultaneous anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries.

OBJECTIVE

To evaluate the current evidence on the outcome of primary ACLR with PLT autograft in adults and donor ankle morbidity, in addition to determining the average PLT graft dimensions from published studies.

EVIDENCE REVIEW

Two independent reviewers searched PubMed, CENTRAL, EMBASE, Scopus and Virtual Health Library databases using the terms "anterior cruciate ligament," "peroneus longus" and "fibularis longus" alone and in combination with Boolean operators AND/OR. Studies evaluating clinical and stability outcomes, graft-donor ankle morbidity and graft dimensions of PLT in ACLR were included. Methodological quality was assessed using the Modified Coleman Methodology Score (mCMS). A narrative analysis is presented using frequency-weighted means wherever feasible. Publication bias was assessed using the ROBIS tool.

FINDINGS

Twelve articles with intermediate-level methodological quality were included. Eight studies assessing the clinical and stability outcomes of reconstruction with PLT showed satisfactory outcomes, similar to those of hamstring tendons (HT). No studies assessed anterior knee pain as an outcome. Six studies evaluated the graft-donor ankle morbidity using general functional foot and ankle scores and non-validated tools, showing favourable outcomes. Nine studies assessed PLT graft diameter, revealing grafts consistently larger than 7 mm among the different preparation techniques, which is comparable with reports of HT grafts.

CONCLUSIONS AND RELEVANCE

The clinical and stability outcomes of ACLR with different PLT autograft preparation techniques are comparable with those of HT during short-term follow-up; however, there is insufficient evidence to support its use in the populations that motivated its implementation. Thus, stronger evidence obtained with the use of validated tools reporting negligible donor-graft ankle morbidity after PLT harvesting is required prior to recommending its routine use, despite the consistency of its dimensions.

LEVEL OF EVIDENCE

Level III.