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Sonnery-Cottet B, Carrozzo A. Lateral Extra-Articular Tenodesis and Anterolateral Procedures. Clin Sports Med 2024; 43:413-431. [PMID: 38811119 DOI: 10.1016/j.csm.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
The treatment of rotational instability has been an intriguing challenge since the era of modern anterior cruciate ligament (ACL) surgery. Lateral extra-articular procedures (LEAPs) have emerged as a solution to this problem, particularly in high-risk populations. Several studies have shown significant benefits of combining LEAPs with ACL reconstruction, including reduced graft failure rates, improved knee stability, improved rotational stability, and higher return-to-play rates. These findings have led to an in-depth evaluation of LEAPs as lateral extra-articular tenodesis and anterolateral ligament reconstruction and their potential role in improving outcomes after ACL reconstruction.
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Affiliation(s)
- Bertrand Sonnery-Cottet
- Orthopaedic Surgery, Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hôpital Privé Jean Mermoz, Lyon, France
| | - Alessandro Carrozzo
- Orthopedic Unit, Sant'Andrea University Hospital, La Sapienza University, Rome, Italy.
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2
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Kemler B, Coladonato C, Sonnier JH, Campbell MP, Darius D, Erickson BJ, Tjoumakaris FP, Freedman KB. Evaluation of Failed ACL Reconstruction: An Updated Review. Open Access J Sports Med 2024; 15:29-39. [PMID: 38586217 PMCID: PMC10998505 DOI: 10.2147/oajsm.s427332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 03/23/2024] [Indexed: 04/09/2024] Open
Abstract
Failure rates among primary Anterior Cruciate Ligament Reconstruction (ACLR) range from 3.2% to 11.1%. Recently, there has been increased focus on surgical and anatomic considerations which predispose patients to failure, including excessive posterior tibial slope (PTS), unaddressed high-grade pivot shift, and improper tunnel placement. The purpose of this review was to provide a current summary and analysis of the literature regarding patient-related and technical factors surrounding revision ACLR, rehabilitation considerations, overall outcomes and return to sport (RTS) for patients who undergo revision ACLR. There is a convincingly higher re-tear and revision rate in patients who undergo ACLR with allograft than autograft, especially amongst the young, athletic population. Unrecognized Posterior Cruciate Ligament (PLC) injury is a common cause of ACLR failure and current literature suggests concurrent operative management of high-grade PLC injuries. Given the high rates of revision surgery in young active patients who return to pivoting sports, the authors recommend strong consideration of a combined ACLR + Anterolateral Ligament (ALL) or Lateral extra-articular tenodesis (LET) procedure in this population. Excessive PTS has been identified as an independent risk factor for ACL graft failure. Careful consideration of patient-specific factors such as age and activity level may influence the success of ACL reconstruction. Additional technical considerations including graft choice and fixation method, tunnel position, evaluation of concomitant posterolateral corner and high-grade pivot shift injuries, and the role of excessive posterior tibial slope may play a significant role in preventing failure.
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Affiliation(s)
- Bryson Kemler
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | - Carlo Coladonato
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | | | - Michael P Campbell
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | - Danielle Darius
- Department of Education, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Brandon J Erickson
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | | | - Kevin B Freedman
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
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3
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Momaya A, Harris C, Hargreaves M. Why Your Patient May Need an ACL Reconstruction Plus Lateral Extra-Articular Tenodesis Procedure. Int J Sports Phys Ther 2024; 19:251-257. [PMID: 38439781 PMCID: PMC10909304 DOI: 10.26603/001c.94015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
Anterior cruciate ligament (ACL) tears are one of the most common knee injuries experienced by active individuals engaging in cutting sports. Despite improved surgical techniques and rehabilitation, the return to sport rate and re-tear rates remain unsatisfactory. Lateral extra-articular tenodesis (LET) is a procedure that has been growing in interest when performed in conjunction with ACL reconstruction. The benefits of adding an LET procedure to an ACL surgery may include greater rotational stability, decreased re-tear rates, and improved return to play. Level of evidence: V.
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Sritharan P, Milantoni V, Abdel Khalik H, Kay J, Slawaska-Eng D, Johnson J, de Sa D. Evaluating the quality of systematic reviews of comparative studies in autograft-based anterior cruciate ligament reconstruction using the AMSTAR-2 tool: A systematic umbrella review. Knee Surg Sports Traumatol Arthrosc 2024; 32:583-598. [PMID: 38372015 DOI: 10.1002/ksa.12062] [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] [Received: 10/09/2023] [Revised: 01/04/2024] [Accepted: 01/09/2024] [Indexed: 02/20/2024]
Abstract
PURPOSE There remains a lack of consensus around autograft selection in anterior cruciate ligament reconstruction (ACLR), though there is a large body of overlapping systematic reviews and meta-analyses. Systematic reviews and their methodological quality were aimed to be further assessed, using a validated tool known as assessing the methodological quality of systematic reviews (AMSTAR-2). METHODS MEDLINE, Embase and CENTRAL were searched from inception to 23 April 2023 for systematic reviews (with/without meta-analysis) comparing primary ACLR autografts. A final quality rating from AMSTAR-2 was provided for each study ('critically low', 'low', 'moderate' or 'high' quality). Correlational analyses were conducted for ratings in relation to study characteristics. RESULTS Two thousand five hundred and ninety-eight studies were screened, and 50 studies were ultimately included. Twenty-four studies (48%) were rated as 'critically low', 17 (34%) as 'low', seven (14%) as 'moderate' and two (4%) as 'high' quality. The least followed domains were reporting on sources of funding (1/50 studies), the impact of risk of bias on results of meta-analyses (11/36 studies) and publication bias (17/36 studies). There was a significant increase in the frequency of studies graded as 'moderate' compared to 'low' or 'critically low' quality over time (p = 0.020). CONCLUSION The methodological quality of systematic reviews comparing autografts in ACLR is low, with many studies being rated lower due to commonly absent aspects of systematic review methodology such as investigating sources of funding and publication bias. More recent studies were generally more likely to be of higher quality. Authors are advised to consult AMSTAR-2 prior to conducting systematic reviews in ACLR. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Praveen Sritharan
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Vincent Milantoni
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Hassaan Abdel Khalik
- Department of Surgery, Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey Kay
- Department of Surgery, Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - David Slawaska-Eng
- Department of Surgery, Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Jansen Johnson
- Department of Surgery, Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Darren de Sa
- Department of Surgery, Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario, Canada
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Lima LHPD, Gomes JLE. Must a Knee with Anterior Cruciate Ligament Deficiency and High-grade Pivot Shift Test Present an Increase in Internal Rotation? Rev Bras Ortop 2024; 59:e82-e87. [PMID: 38524720 PMCID: PMC10957268 DOI: 10.1055/s-0044-1779316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 05/29/2023] [Indexed: 03/26/2024] Open
Abstract
Objective: Rupture of the anterior cruciate ligament (ACL) is one of the most common injuries in athletes and is often associated with damage to anterolateral structures. This combination of injuries presents itself clinically as a high-grade pivot shift test. The hypothesis of this study is that patients with ACL deficiency and high-grade pivot shift test should have an increased internal knee rotation. Methods: Twenty-two patients were tested. After effective spinal anesthesia, two tests were performed with the patient in supine position. First, the bilateral pivot shift test was performed manually, and its grade was recorded. Then, with the knee flexed to 90 degrees, the examiner drew the projection of the foot in a neutral position and in maximum internal rotation, and the angle of internal rotation was measured from the axes built between the central point of the heel and the hallux. Results: In the ACL-deficient knee, it was observed that there is a statistically significant average internal rotation (IR) delta of 10.5 degrees between the groups when not adjusted for age, and 10.6 degrees when adjusted for age. Conclusions: Knees with ACL deficiency and with pivot shift test grade I do not show increased internal rotation in relation to knees with intact ACL. Knees with ACL deficiency and with pivot shift test grades II and III show increased internal rotation in comparison to healthy knees.
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Kaarre J, Benvegnu NA, Engler ID, Nazzal EM, Zsidai B, Senorski EH, Musahl V, Samuelsson K. Metal interference screw fixation combinations show high revision rates in primary hamstring tendon ACL reconstruction. BMC Musculoskelet Disord 2024; 25:2. [PMID: 38166808 PMCID: PMC10759459 DOI: 10.1186/s12891-023-07109-y] [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: 05/08/2023] [Accepted: 12/11/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Different fixation methods in anterior cruciate ligament reconstruction (ACLR) have been associated with different revision rates, specifically in the early postoperative period. However, most previous research has either grouped together different fixation types or evaluated femoral-sided fixation or tibial-sided fixation separately. Therefore, the purpose of this study was to determine ACL revision rates for specific combinations of femoral and tibial fixation methods within 2 years of primary hamstring tendon autograft ACLR based on data from the Swedish National Knee Ligament Registry (SNKLR). METHODS Patients that underwent primary hamstring tendon autograft ACLR between 2005 and 2018 in the SNKLR were included. The collected data included patient characteristics (age, sex, body mass index [BMI]), activity at time of injury, surgical information (concomitant injuries, time from injury to surgery, fixation types at the femur and tibia), and subsequent revision ACLR. Revision rate within 2 years of the index procedure was chosen, as ACLR fixation is most likely to contribute to ACLR revision within the first 2 years, during graft maturation. RESULTS Of the 23,238 included patients undergoing primary hamstring ACLR, 581 (2.5%) underwent revision ACLR within 2 years of the index procedure. Among the combinations used for > 300 patients, the femoral metal interference screw/tibial metal interference screw fixation combination had the highest revision rate followed by metal interference screw/resorbable screw and Endobutton/AO screw fixation combinations, with respective revision rates of 4.0, 3.0, and 3.0%. The lowest revision rate within 2 years of ACLR was found in the Endobutton/metal interference screw with backup Osteosuture fixation combination, used in 433 cases, with a failure rate of 0.9%. CONCLUSION Different early ACL revision rates were found across different combinations of femoral and tibial fixation devices within 2 years of primary hamstring tendon autograft ACLR. Metal interference screw fixation, particularly when performed on both the femoral and tibial sides, most frequently resulted in revision ACLR. These findings may be helpful for surgeons in selecting appropriate fixation devices for hamstring ACLR. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Janina Kaarre
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden.
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, USA.
| | - Neilen A Benvegnu
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, USA
| | - Ian D Engler
- Central Maine Healthcare Orthopedics, Central Maine Medical Center, Auburn, ME, USA
| | - Ehab M Nazzal
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, USA
| | - Bálint Zsidai
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
| | - Eric Hamrin Senorski
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, USA
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
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Sonnier JH, Paul RW, Sando HE, Hall AT, Tjoumakaris FP, Cohen SB, Freedman KB. Patient Decision Making in Anterior Cruciate Ligament Reconstruction: A Discrete Choice Experiment Examining Graft Preference. Orthop J Sports Med 2023; 11:23259671221144983. [PMID: 36756168 PMCID: PMC9900657 DOI: 10.1177/23259671221144983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/26/2022] [Indexed: 02/05/2023] Open
Abstract
Background Bone-patellar tendon-bone (BTB) and hamstring autografts are the most common grafts used for anterior cruciate ligament (ACL) reconstruction. Patient preferences should be accounted for as a part of shared decision making. Purpose/Hypothesis The purpose of this study was to perform a discrete choice experiment that evaluated patient preferences toward ACL autografts. We hypothesized that there would be no difference in patient preferences between groups. Study Design Cross-sectional study. Methods Patients aged 18 to 25 years who underwent shoulder arthroscopy at a single institution between 2013 and 2019 were included in the study as a proxy for healthy controls. Patients with a history of ACL tear were excluded. A discrete choice experiment was developed from a literature search and used the following data points as they pertain to BTB or hamstring autograft: risk of developing a significant complication, return-to-play rate, risk of anterior knee pain with kneeling, and risk of additional surgery due to graft failure. Included patients completed a custom survey in which they were asked to choose between "surgery A" (hamstring) and "surgery B" (BTB). Results A total of 107 participants were included in the analysis. Of these participants, 39 (36.5%) chose surgery A (hamstring) and 68 (63.6%) chose surgery B (BTB). When comparing the hamstring group with the BTB group, there was no significant difference in age, sex, body mass index, race, level of education, or employment status. However, 80.5% of self-reported athletes preferred BTB (P = .008). When controlling for age, sex, and body mass index, patients in the BTB group were more likely to rate return to sport (risk ratio [RR] = 1.49 [95% CI, 1.18-1.98]; P = .001) and the risk of requiring additional surgery due to graft failure (RR = 1.26 [95% CI, 1.02-1.58]; P = .037) as highly important. Conversely, they were less likely than patients in the hamstring group to rate pain while kneeling (RR = 0.65 [95% CI, 0.98-1.05]; P < .001) and complication risk (RR = 0.75 [95% CI, 0.59-0.94]; P = .013) as important. Conclusion The study hypothesis was rejected, as patient values did affect ACL graft choice preference. Utilizing patient-selected values in a quantifiable way can benefit the shared decision-making process before ACL reconstruction.
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Affiliation(s)
| | - Ryan W. Paul
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania,
USA
| | - Hayden E. Sando
- Drexel University College of Medicine, Philadelphia, Pennsylvania,
USA
| | - Anya T. Hall
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania,
USA
| | | | - Steven B. Cohen
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania,
USA
| | - Kevin B. Freedman
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania,
USA.,Kevin B. Freedman, MD, Rothman Orthopaedics at Thomas Jefferson
University, 825 Old Lancaster Road, Suite 200, Bryn Mawr, PA 19010, USA (
) (Twitter: @RothmanOrtho)
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Chalidis B, Pitsilos C, Kitridis D, Givissis P. Graft choices for anterolateral ligament knee reconstruction surgery: Current concepts. World J Clin Cases 2022; 10:8463-8473. [PMID: 36157796 PMCID: PMC9453348 DOI: 10.12998/wjcc.v10.i24.8463] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/26/2022] [Accepted: 07/17/2022] [Indexed: 02/05/2023] Open
Abstract
The anterolateral ligament (ALL) is a primary structure of the anterolateral complex of the knee that contributes to internal rotational stability of the joint. Injury of the ALL is commonly associated with rupture of the anterior cruciate ligament. If left untreated, ALL lesions may lead to residual anterolateral rotational instability of the knee after anterior cruciate ligament reconstruction, which is a common cause of anterior cruciate ligament graft failure. The function of the ALL can be restored by lateral extraarticular tenodesis or anterolateral ligament reconstruction (ALLR). In the lateral extraarticular tenodesis procedure, a strip of the iliotibial band is placed in a non-anatomical position to restrain the internal rotation of the tibia, while in ALLR, a free graft is fixed at the insertion points of the native ALL. Gracilis and semitendinosus grafts have mainly been utilized for ALLR, but other autografts have also been suggested. Furthermore, allografts and synthetic grafts have been applied to minimize donor-site morbidity and maximize the size and strength of the graft. Nevertheless, there has been no strong evidence to fully support one method over another thus far. The present review presents a detailed description of the graft choices for ALLR and the current literature available in regard to the effectiveness and outcomes of published surgical techniques.
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Affiliation(s)
- Byron Chalidis
- 1st Orthopaedic Department, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki 57010, Greece
| | - Charalampos Pitsilos
- 2nd Orthopaedic Department, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki 54635, Greece
| | - Dimitrios Kitridis
- 1st Orthopaedic Department, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki 57010, Greece
| | - Panagiotis Givissis
- 1st Orthopaedic Department, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki 57010, Greece
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Nishida K, Gale T, Chiba D, Suntaxi F, Lesniak B, Fu F, Anderst W, Musahl V. The effect of lateral extra-articular tenodesis on in vivo cartilage contact in combined anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2022; 30:61-70. [PMID: 33580345 DOI: 10.1007/s00167-021-06480-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/25/2021] [Indexed: 01/11/2023]
Abstract
PURPOSE Lateral extra-articular tenodesis (LET) may confer improved rotational stability after anterior cruciate ligament reconstruction (ACLR). Little is known about how LET affects in vivo cartilage contact after ACLR. The aim of this study was to investigate the effect of LET in combination with ACLR (ACLR + LET) on in vivo cartilage contact kinematics compared to isolated ACLR (ACLR) during downhill running. It was hypothesised that cartilage contact area in the lateral compartment would be larger in ACLR + LET compared with ACLR, and that the anterior-posterior (A-P) position of the contact center on the lateral tibia would be more anterior after ACLR + LET than after ACLR. METHODS Twenty patients were randomly assigned into ACLR + LET or ACLR during surgery (ClinicalTrials.gov:NCT02913404). At 6 months and 12 months after surgery, participants were imaged during downhill running using biplane radiography. Tibiofemoral motion was tracked using a validated registration process. Patient-specific cartilage models, obtained from 3 T MRI, were registered to track bone models and used to calculate the dynamic cartilage contact area and center of cartilage contact in both the medial and lateral tibiofemoral compartments, respectively. The side-to-side differences (SSD) were compared between groups using a Mann-Whitney U test. RESULTS At 6 months after surgery, the SSD in A-P cartilage contact center in ACLR + LET (3.9 ± 2.6 mm, 4.4 ± 3.1 mm) was larger than in ACLR (1.2 ± 1.6 mm, 1.5 ± 2.0 mm) at 10% and 20% of the gait cycle, respectively (p < 0.01, p < 0.05). There was no difference in the SSD in cartilage contact center at 12 months after surgery. There was no difference in SSD of cartilage contact area in the medial and lateral compartments at both 6 and 12 months after surgery. There were no adverse events during the trial. CONCLUSION LET in combination with ACLR may affect the cartilage contact center during downhill running in the early post-operation phase, but this effect is lost in the longer term. This suggests that healing and neuromuscular adaptation occur over time and may also indicate a dampening of the effect of LET over time. (337 /350 words) LEVEL OF EVIDENCE: Level II.
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Affiliation(s)
- Kyohei Nishida
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan.,Biodynamics Laboratory, University of Pittsburgh, Rivertech Building Complex, 3820 South Water Street, Pittsburgh, PA, 15203, USA
| | - Tom Gale
- Biodynamics Laboratory, University of Pittsburgh, Rivertech Building Complex, 3820 South Water Street, Pittsburgh, PA, 15203, USA
| | - Daisuke Chiba
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA.,Biodynamics Laboratory, University of Pittsburgh, Rivertech Building Complex, 3820 South Water Street, Pittsburgh, PA, 15203, USA.,Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Felipe Suntaxi
- Biodynamics Laboratory, University of Pittsburgh, Rivertech Building Complex, 3820 South Water Street, Pittsburgh, PA, 15203, USA
| | - Bryson Lesniak
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Freddie Fu
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - William Anderst
- Biodynamics Laboratory, University of Pittsburgh, Rivertech Building Complex, 3820 South Water Street, Pittsburgh, PA, 15203, USA.
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
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Arida C, Tsikrikas CG, Mastrokalos DS, Panagopoulos A, Vlamis J, Triantafyllopoulos IK. Comparison of Bone-Patella Tendon-Bone and Four-Strand Hamstring Tendon Grafts for Anterior Cruciate Ligament Reconstruction: A Prospective Study. Cureus 2021; 13:e19197. [PMID: 34877191 PMCID: PMC8642134 DOI: 10.7759/cureus.19197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction To date, the proper choice of graft for anterior cruciate ligament (ACL) reconstruction remains a matter of conflict. We aimed to compare the clinical and functional outcomes of the two most commonly utilized autografts, bone-patella tendon-bone (BPTB) and four-strand hamstring tendon (HT) graft, at 6 and 12 months after surgery. Methods In a prospective randomized study, we included a total of 60 patients undergoing ACL reconstruction, thirty in BPTB and thirty in HT group. All patients were amateur athletes and were evaluated at 6 and12 months after surgery for: (a)postoperativefunctionality of the operated knee by the Tegner, the Lysholm and the International Knee Documentation Committee (IKDC) scoring scales, (b) anterior cruciate ligament (ACL) instability of the operated knee compared to the healthy contralateral knee by the KT-1000 arthrometer and (c) theextension and flexion muscle strength of the operated knee by a CYBEXisokinetic dynamometer. Results Patients in the two groups did not differ regarding demographics, and pre-injury functionality status. Significantly more patients in the HT group (n=6) compared to the BPTB group (n=1) experienced ACL re-rupture and underwent revision surgery before follow-up end (p=0.044). All patients, regardless of graft, showed significant improvement within each group of functional assessments by Lysholm, Tegner and IKDC scores, as well as of Cybex measurements -with an increase of peak torque at 60° extension and 180°extension and 60° flexion and 180° flexion- at 12 months compared to 6 months follow-up (p<0.05). However, there was no difference between the two groups regarding knee function improvement or extension measurements neither at 6 nor 12 months. Contrarily, the BPTB graft group had higher values of peak torque (Nm) at 60° and 180° flexion compared to the HT group, both at 6 (p=0.014 and 0.029, respectively) and 12 months (p=0.033 and 0.030, respectively). Postoperative stability was similar between the two groups at 12 months (p=0.519). Conclusion Both BPTB and HT grafts present with benefits and drawbacks and remain viable autograft options for primary ACL reconstruction as each has, although HT grafts seem to be more susceptible to re-rupture. The graft selection should be based on the needs and activities of each patient.
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Affiliation(s)
- Christina Arida
- Orthopaedic Department, KAT Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | | | - Dimitrios S Mastrokalos
- 1st Orthopaedic Department, Attikon Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | | | - John Vlamis
- 3rd Orthopaedic Department, KAT Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
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11
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Arida C, Mastrokalos DS, Panagopoulos A, Vlamis J, Triantafyllopoulos IK. A Systematic Approach for Stronger Documentation of Anterior Cruciate Ligament Graft Choice. Cureus 2021; 13:e19017. [PMID: 34824933 PMCID: PMC8611317 DOI: 10.7759/cureus.19017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2021] [Indexed: 11/05/2022] Open
Abstract
Numerous studies have focused on determining the optimal choice between the two most used anterior cruciate ligament (ACL) reconstruction autografts. In order to address this matter, we performed a systematic review of every meta-analysis published on the PubMed platform between 2001 and 2020, comparing the functional outcomes, the static stability parameters, as well as the postoperative and long-term complications of the patellar tendon (BPTB) autograft and hamstrings (HT). We retrieved a total of 26 meta-analyses that met our criteria, and the characteristics and outcomes of every meta-analysis, as well as subgroup analysis regarding the type of the study design, number of strands of HT autograft, and fixation method, were extensively recorded. The majority of the meta-analyses showed that there were no significant differences between BPTB and HT in terms of functional outcomes and static stability parameters while HT autografts seem to be superior to BPTB regarding kneeling pain and anterior knee pain. Other outcomes seem to be affected by the number of strands of the HT autograft, the fixation technique, and the type of study design, indicating superiority of the four-strand HT autograft with the use of an extra-cortical button fixation. Overall, there is no clear superiority of BPTB over HT autografts for ACL reconstruction, as both types present similar outcomes in the majority of postoperative parameters. Autograft selection should be individualized according to each patient's needs and more RCTs are warranted in order to reach safer results on the appropriate autograft type.
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Affiliation(s)
- Christina Arida
- 3rd Orthopaedic Department, KAT Hospital, National and Kapodistrian University of Athens Medical School, Athens, GRC
| | - Dimitrios S Mastrokalos
- 1st Orthopaedic Department, Attikon Hospital, National and Kapodistrian University of Athens Medical School, Athens, GRC
| | | | - John Vlamis
- 3rd Orthopaedic Department, KAT Hospital, National and Kapodistrian University of Athens Medical School, Athens, GRC
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Rojas G, Perelli S, Ibanez M, Formagnana M, Ormazabal I, Monllau JC. Effect of Modified Lemaire Anterolateral Extra-articular Tenodesis on the Magnetic Resonance Imaging Maturity Signal of Anterior Cruciate Ligament Hamstring Graft. Am J Sports Med 2021; 49:2379-2386. [PMID: 34133234 DOI: 10.1177/03635465211018858] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Lateral extra-articular tenodesis (LET) is one of the most widely used procedures to restore anterolateral stability. Clinical outcomes after the addition of LET to anterior cruciate ligament (ACL) reconstruction (ACLR) have been widely investigated; however, the potential influence of LET on the ACL ligamentization process has not been examined. PURPOSE/HYPOTHESIS The purpose was to use 10-month postoperative magnetic resonance imaging (MRI) scans to determine whether the maturity of grafts after hamstring autograft ACLR was affected by concomitant LET. The hypothesis was that when modified Lemaire lateral extra-articular tenodesis (MLLET) was performed, the MRI parameters of ACL graft maturity would be modified. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS The study included patients treated between December 2017 and December 2018 who had undergone anatomic 3-strand hamstring tendon autograft ACLR, with or without concomitant MLLET, and had undergone MRI 10 months postoperatively. Thus, the study included 30 patients who had isolated ACLR and 22 patients who had ACLR plus MLLET. The 2 groups were comparable based on all criteria analyzed. To evaluate graft maturity, the signal-to-noise quotient (SNQ) was measured in 3 regions of interest of the proximal, midsubstance, and distal ACL graft. Lower SNQ ratios indicate less water content and, theoretically, better maturity and healing of the graft. RESULTS The mean ± SD for SNQ was 4.62 ± 4.29 (range, 3.12-6.19) in the isolated ACLR group and 7.59 ± 4.68 (range, 4.38-8.04) in the ACLR plus MLLET group (P = .012). Upon comparing the mean values of the 3 portions between the 2 groups, we found a significant difference between the 2 groups for the proximal and middle portions (P = .007 and P = .049, respectively) but no difference in the distal portion (P = .369). CONCLUSION At the 10-month follow-up, hamstring tendon autografts for anatomic ACLR with MLLET did not show the same MRI signal intensity compared with isolated hamstring anatomic ACLR.
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Affiliation(s)
- Gonzalo Rojas
- Department of Orthopaedic Surgery, Hospital Regional de Talca, Talca, Chile.,Universidad Católica del Maule, Talca, Chile
| | - Simone Perelli
- Institut Català de Traumatologia i Medicina de l'Esport (ICATME)-Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain.,Department of Surgery and Morphologic Science, Orthopaedic Surgery Service, Universitat Autònoma de Barcelona, Hospital del Mar, Barcelona, Spain
| | - Maximiliano Ibanez
- Institut Català de Traumatologia i Medicina de l'Esport (ICATME)-Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mario Formagnana
- Institut Català de Traumatologia i Medicina de l'Esport (ICATME)-Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain.,Department of Orthopaedic Surgery, E. Agnelli Hospital, Pinerolo, Italy
| | - Inmaculada Ormazabal
- Radiology Department, Hospital Universitari Quiron Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Carlos Monllau
- Institut Català de Traumatologia i Medicina de l'Esport (ICATME)-Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain.,Department of Surgery and Morphologic Science, Orthopaedic Surgery Service, Universitat Autònoma de Barcelona, Hospital del Mar, Barcelona, Spain
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Marmura H, Getgood AMJ, Spindler KP, Kattan MW, Briskin I, Bryant DM. Validation of a Risk Calculator to Personalize Graft Choice and Reduce Rupture Rates for Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2021; 49:1777-1785. [PMID: 33945339 DOI: 10.1177/03635465211010798] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament reconstructions (ACLRs) fail at an alarmingly high rate in young active individuals. The Multicenter Orthopaedic Outcomes Network (MOON) knee group has developed an autograft risk calculator that uses patient characteristics and lifestyle to predict the probability of graft rupture if the surgeon uses a hamstring tendon (HT) or a bone-patellar tendon-bone (BPTB) graft to reconstruct the ligament. If validated, this risk calculator can be used during the shared decision-making process to make optimal ACLR autograft choices and reduce rupture rates. The STABILITY 1 randomized clinical trial offers a large, rigorously collected data set of similar young active patients who received HT autograft with or without lateral extra-articular tenodesis (LET) for ACLR. PURPOSE/HYPOTHESIS The purpose was to validate the ACLR graft rupture risk calculator in a large external data set and to investigate the utility of BPTB and LET for ACLR. We hypothesized that the risk calculator would maintain adequate discriminative ability and calibration in the external STABILITY 1 data set when compared with the initial MOON development data set. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 1. METHODS The model predictors for the risk calculator include age, sex, body mass index, sport played at the time of injury, Marx Activity Score, preoperative knee laxity, and graft type. The STABILITY 1 trial data set was used for external validation. Discriminative ability, calibration, and diagnostic test validity of the model were assessed. Finally, predictor strength in the initial and validation samples was compared. RESULTS The model showed acceptable discriminative ability (area under the curve = 0.73), calibration (Brier score = 0.07), and specificity (85.3%) to detect patients who will experience a graft rupture. Age, high-grade preoperative knee laxity, and graft type were significant predictors of graft rupture in young active patients. BPTB and the addition of LET to HT were protective against graft rupture versus HT autograft alone. CONCLUSION The MOON risk calculator is a valid predictor of ACLR graft rupture and is appropriate for clinical practice. This study provides evidence supporting the idea that isolated HT autografts should be avoided for young active patients undergoing ACLR. REGISTRATION NCT00463099 (MOON); NCT02018354 (STABILITY 1) (ClinicalTrials.gov identifiers).
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Affiliation(s)
- Hana Marmura
- Faculty of Health Sciences, Western University, London, Ontario, Canada.,Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada.,Bone and Joint Institute, Western University, London, Ontario, Canada.,Lawson Research, London Health Sciences Centre, London, Ontario, Canada
| | - Alan M J Getgood
- Faculty of Health Sciences, Western University, London, Ontario, Canada.,Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada.,Bone and Joint Institute, Western University, London, Ontario, Canada.,Lawson Research, London Health Sciences Centre, London, Ontario, Canada.,Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Kurt P Spindler
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael W Kattan
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Isaac Briskin
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Dianne M Bryant
- Faculty of Health Sciences, Western University, London, Ontario, Canada.,Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada.,Bone and Joint Institute, Western University, London, Ontario, Canada.,Lawson Research, London Health Sciences Centre, London, Ontario, Canada.,Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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14
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Zhao L, Lu M, Deng M, Xing J, He L, Wang C. Outcome of bone-patellar tendon-bone vs hamstring tendon autograft for anterior cruciate ligament reconstruction: A meta-analysis of randomized controlled trials with a 5-year minimum follow-up. Medicine (Baltimore) 2020; 99:e23476. [PMID: 33235137 PMCID: PMC7710199 DOI: 10.1097/md.0000000000023476] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 09/19/2020] [Accepted: 10/31/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Many systematic reviews have compared the short-term outcomes of anterior cruciate ligment (ACL)reconstruction with hamstring and patellar tendon autograft,but few differences have been observed. The purpose of this meta-analysis was to compare the medium-term outcome of bone-patellar tendon-bone and hamstring tendon autograft for anterior cruciate ligament reconstruction in terms of clinical function, knee stability, postoperativecomplications, and osteoarthritis changes. METHODS This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The PubMed, Embase, and the Cochrane Library databases were searched from inception to November 2, 2019. This meta-analysis included only randomized controlled trials that compared BPTB and HT autografts for ACL reconstruction with a 5-year minimum follow-up. The Cochrane Collaboration's risk-of-bias tool was used to estimate the risk-of-bias for all included studies. RevMan 5.3 software was used to performed statistical analysis of the outcomes. RESULTS Fifteen RCTs, involving 1298 patients (610 patients in the BPTB group and 688 patients in the HT group) were included. In terms of clinical function, no significant difference was found in the objective International Knee Documentation Committee score (OR = 0.94, 95%CI: 0.64-1.37, P = .75), Lysholm knee score (MD = -2.26, 95%CI: -4.56 to 0.05, P = .06), return to preinjury activity level (OR = 1.01, 95%CI: 0.67-1.52, P = .96), and Tegner activity level (OR = 0.03, 95%CI: -0.36 to 0.41, P = .89). There was no statistically significant difference in the Lachman test (OR = 0.86, 95%CI: 0.5-1.32, P = .50), pivot-shift test (OR = 0.68, 95%CI: 0.44-1.06, P = .09), and side-to-side difference (MD = -0.32, 95%CI: -0.81 to 0.16, P = .19). As for postoperative complications and OA changes, there were no statistically significant difference in flexion loss (OR = 1.09, 95%CI: 0.47-2.54, P = .85) and OA changes (OR = 0.76, 95%CI: 0.52-1.10, P = .15), but we found significant differences in favor of the HT group in the domains of kneeling pain (OR = 1.67, 95%CI: 1.04-2.69, P = .03), anterior knee pain (OR = 2.90, 95%CI: 1.46-5.77, P = .002), and extension loss (OR = 1.75, 95%CI: 1.12-2.75, P = .01). There was a significant difference in favor of the BPTB group in the domain of graft failure (OR = 0.59, 95%CI: 0.38-0.91, P = .02). CONCLUSIONS Based on the results above, HT autograft is comparable with the BPTB autograft in terms of clinical function, postoperative knee stability, and OA changes, with a medium-term follow-up. The HT autograft for ACL reconstruction carries a lower risk of complications, such as anterior knee pain, kneeling pain, and extension loss, but an increased incidence of graft failure. Patients should be informed of the differences when deciding on graft choice with their physician.
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Affiliation(s)
- Lilian Zhao
- Department of Sports Medicine, Foshan Hospital of Traditional Chinese Medicine, Guangzhou University of Chinese Medicine, Foshan
| | - Mingfeng Lu
- Department of Sports Medicine, Foshan Hospital of Traditional Chinese Medicine, Guangzhou University of Chinese Medicine, Foshan
| | - Mingcong Deng
- Second School of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jisi Xing
- Department of Sports Medicine, Foshan Hospital of Traditional Chinese Medicine, Guangzhou University of Chinese Medicine, Foshan
| | - Lilei He
- Department of Sports Medicine, Foshan Hospital of Traditional Chinese Medicine, Guangzhou University of Chinese Medicine, Foshan
| | - Changbing Wang
- Department of Sports Medicine, Foshan Hospital of Traditional Chinese Medicine, Guangzhou University of Chinese Medicine, Foshan
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15
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He X, Yang XG, Feng JT, Wang F, Huang HC, He JQ, Hu YC. Clinical Outcomes of the Central Third Patellar Tendon Versus Four-strand Hamstring Tendon Autograft Used for Anterior Cruciate Ligament Reconstruction: A Systematic Review and Subgroup Meta-analysis of Randomized Controlled Trials. Injury 2020; 51:1714-1725. [PMID: 32482429 DOI: 10.1016/j.injury.2020.05.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 05/07/2020] [Accepted: 05/10/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND The most frequently used auto-grafts for ACL reconstruction (ACLR) are bone-patellar tendon-bone (BPTB) and four-strand hamstring tendon (4S-HT), but significant controversy exists about which graft is better. This study aimed to compare the knee outcomes following ACLR with BPTB and 4S-HT autografts. METHODS Subgroup meta-analyses were performed basing on available randomised controlled trials (RCTs) according to different follow-up intervals. 23 RCTs were eligible for inclusion, involving 933 participants in each treatment group. RESULTS Only short-term (≤2 years) knee anteroposterior and rotational stability were significantly poorer with 4S-HT when compared to BPTB autograft, as judged by side-to-side difference on knee laxity (WMD=-0.50, 95%CI -0.81~-0.18, p=0.002) and pivot-shift test (OR=0.58, 95%CI 0.39~0.88, p=0.010), respectively. The IKDC objective grade was evident to be in favour of 4S-HT group in mid-term (3-5 years) follow-up (OR=0.63, 95%CI 0.43~0.92, p=0.017). Several donor-site related complications, including anterior knee pain, pain with kneeling and extension deficit, were more frequent in BPTB autograft group, while lower short-term iskinetic peak flexion torques both at 60°/S (WMD=8.93, 95%CI 7.88~9.99, p<0.001) and 240°/S (WMD=11.63, 95%CI 9.92~13.34, p<0.001) were caused by HT harvesting. CONCLUSION BPTB was associated with inferior mid- to long-term (>5 years) knee functional outcomes, and increased frequency of donor-site complications. In contrast, only short-term knee laxity was increased for 4S-HT autograft, which is expected to be improved by providing more conservative rehabilitation protocol and aperture fixation methods.
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Affiliation(s)
- Xin He
- Department of Orthopedic Oncology, Tianjin Hospital, 300211, Tianjin, China
| | - Xiong-Gang Yang
- Graduate School, Tianjin Medical University, 300070, Tianjin, China
| | - Jiang-Tao Feng
- Graduate School, Tianjin Medical University, 300070, Tianjin, China
| | - Feng Wang
- Graduate School, Tianjin Medical University, 300070, Tianjin, China
| | - Hong-Chao Huang
- the Fourth Department of Spine Surgery, Tianjin Hospital, 300211, Tianjin, China
| | - Jin-Quan He
- the First Department of Ankle Surgery, Tianjin Hospital, 300211, Tianjin, China
| | - Yong-Cheng Hu
- Department of Orthopedic Oncology, Tianjin Hospital, 300211, Tianjin, China.
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16
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Crum RJ, de Sa D, Kanakamedala AC, Obioha OA, Lesniak BP, Musahl V. Aperture and Suspensory Fixation Equally Efficacious for Quadriceps Tendon Graft Fixation in Primary ACL Reconstruction: A Systematic Review. J Knee Surg 2020; 33:704-721. [PMID: 30959537 PMCID: PMC7683008 DOI: 10.1055/s-0039-1685160] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This review is aimed to compare suspensory and aperture quadriceps tendon autograft femoral and tibial fixations in primary anterior cruciate ligament reconstruction (ACL-R), and the clinical outcomes and complication profiles of each fixation method. Greater understanding of the optimal graft fixation technique for quadriceps tendon (QT) autografts may assist surgeons in improving outcomes after ACL-R. PubMed, Embase, and Medline were searched from database inception to September 2017, and again to July 2018, and identified 3,670 articles, 21 studies of which satisfied inclusion/exclusion criteria. Across included studies, 1,155 QT ACL-R patients (mean age, 28.7 years [range, 15-59 years], with mean postoperative follow-up of 36.1 months [range, 3.4-120 months]), were analyzed. Suspensory fixation on both sides demonstrated a higher percentage of patients (81.7%) achieving the highest rating of "A or B" on the International Knee Documentation Committee (IKDC) knee ligament examination form compared with aperture fixation on both sides (67.7%). Moreover, suspensory fixation had a lower side-to-side difference in anterior laxity (1.6 mm) when compared with aperture fixation (2.3 mm). Among studies which reported graft failure, all of which employed aperture fixation, the rate was 3.2%. Across available data, primary ACL-R using QT grafts appears to have successful short-term outcomes with a short-term graft failure rate of 3% independent of fixation method. While there is limited data regarding the comparison of aperture and suspensory soft-tissue quadriceps tendon (SQT) fixation in ACL-R, the findings of this systematic review suggest that suspensory fixation and aperture fixation in both the femoral and tibial tunnels are equally efficacious based on clinical outcome data on IKDC grade and measured laxity. This is a level IV, systematic review study.
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Affiliation(s)
- Raphael J Crum
- Department of Orthopaedic Surgery, Center for Sports Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Darren de Sa
- Department of Orthopaedic Surgery, McMaster Children’s Hospital, 1200 Main Street West, Hamilton, Ontario, Canada
| | - Ajay C Kanakamedala
- Department of Orthopaedic Surgery, New York University Langone Orthopaedic Hospital, New York, New York
| | - Obianuju A Obioha
- Department of Orthopaedic Surgery, Center for Sports Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Bryson P Lesniak
- Department of Orthopaedic Surgery, Center for Sports Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Volker Musahl
- Department of Orthopaedic Surgery, Center for Sports Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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17
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Getgood A, Hewison C, Bryant D, Litchfield R, Heard M, Buchko G, Hiemstra LA, Willits KR, Firth A, MacDonald P. No Difference in Functional Outcomes When Lateral Extra-Articular Tenodesis Is Added to Anterior Cruciate Ligament Reconstruction in Young Active Patients: The Stability Study. Arthroscopy 2020; 36:1690-1701. [PMID: 32147485 DOI: 10.1016/j.arthro.2020.02.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/05/2020] [Accepted: 02/12/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the functional outcomes of patients included in the Stability Study randomized controlled trial comparing anterior cruciate ligament reconstruction (ACLR) alone with ACLR with lateral extra-articular tenodesis (LET) at 6, 12, and 24 months postoperatively. METHODS Six hundred eighteen patients undergoing ACLR, all under the age of 25 years either returning to contact pivoting sport or displaying signs of high-grade rotatory laxity or generalized ligamentous laxity, were randomly assigned to receive ACLR alone or ACLR plus LET. A total of 356 of these patients were randomized at centers participating in the functional assessments. Our primary outcome was Limb Symmetry Index, calculated using a series of 4-hop tests at 6, 12, and 24 months postoperatively. Secondary outcome measures included pain, patient-reported function, and isokinetic strength testing. RESULTS We found no statistically significant difference in the proportion of patients either unwilling or unfit to complete the hop testing in the ACLR alone or ACLR with LET group at 6 months (40 vs 40 respectively; P = 1.00), 12 months (25 vs 27; P = .76), and 24 months (21 vs 23; P = .87). Of those who completed hop testing, there were no statistically significant differences between groups in Limb Symmetry Index at 6, 12, or 24 months. Self-reported function (Lower Extremity Functional Score) significantly favored the ACLR alone group at 3 (P = .01) and 6 months (P = .02) postoperative but was similar by 12 months postoperative. Pain scores (P4) also showed a statistically significant difference in favor of the ACL alone group, but this also resolved by 6 months. Quadriceps peak torque (P = .03) and average power (P = .01) were also significantly different in favor of the ACLR alone group at 6 months postoperative; however, these were similar between groups by 12 months postoperative (P = .11 and P = .32, respectively). CONCLUSIONS The addition of a LET to ACLR results in slightly increased pain, a mild reduction in quadriceps strength, and reduced subjective functional recovery up to 6 months postoperatively. However, these differences do not have any impact on objective function as measured by hop test limb symmetry index. LEVEL OF EVIDENCE I, Randomized Controlled Trial.
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Affiliation(s)
- Alan Getgood
- Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada.
| | | | - Dianne Bryant
- Lawson Health Research Institute, London, Ontario, Canada; Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada
| | - Robert Litchfield
- Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada
| | - Mark Heard
- Banff Sport Medicine, Banff, Alberta, Canada
| | - Greg Buchko
- Banff Sport Medicine, Banff, Alberta, Canada
| | | | - Kevin R Willits
- Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada
| | - Andrew Firth
- Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada
| | - Peter MacDonald
- Pan Am Clinic, University of Manitoba, Winnipeg, Manitoba, Canada
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18
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Kruppa P, Flies A, Wulsten D, Collette R, Duda GN, Schaser KD, Becker R, Kopf S. Significant Loss of ACL Graft Force With Tibial-Sided Soft Tissue Interference Screw Fixation Over 24 Hours: A Biomechanical Study. Orthop J Sports Med 2020; 8:2325967120916437. [PMID: 32440520 PMCID: PMC7225828 DOI: 10.1177/2325967120916437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Tibial-sided graft fixation is thought to be critical for the success of anterior cruciate ligament (ACL) reconstruction. Nevertheless, little is known about the graft force after fixation during the first 24 hours after surgery or the influence of screw diameter and length during this time. Purpose To investigate the force, over the course of 24 hours, in soft tissue grafts secured with a tibial interference screw and to evaluate the effect of different screw diameters (7, 8, and 9 mm) and lengths (25 and 30 mm) on the force in these grafts. Study Design Controlled laboratory study. Methods Quadruple-strand flexor tendon grafts were fixed with bioabsorbable interference screws in 60 porcine tibiae. Grafts were pretensioned at 80 N over 10 minutes, and screws were inserted outside-in while a preload force of 80 N was applied. Different screw lengths (25 and 30 mm) and diameters (7, 8, and 9 mm), resulting in 6 groups with 10 specimens each, were tested. After release of the preload, graft force was recorded over 24 hours. Results A significant decrease in graft force progressed in all groups over the 24-hour period. In total, a median loss of 75 N (IQR, 68-79 N) compared with the initial loading force was observed. Compared with the loading force of 80 N, this corresponded to a median loss of 91%. No significant differences in the remaining graft force could be found among the 6 different screw length and diameter groups after 10 minutes, 100 minutes, or 24 hours. Conclusion Graft force in soft tissue grafts secured with a tibial interference screw decreased substantially over the first 24 hours after fixation. Neither the screw diameter nor the screw length affected the decrease in graft force. This raises substantial questions regarding the remaining fixation strength in vivo. Clinical Relevance It should not be expected that ACL reconstruction can mechanically restabilize an injured knee as would an intact ACL. Reconstructed knees should be protected from mechanical overload in the early postoperative period.
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Affiliation(s)
- Philipp Kruppa
- Department of Plastic, Aesthetic and Reconstructive Microsurgery/Hand Surgery, Hospital Ernst von Bergmann, Potsdam, Germany.,Julius-Wolff-Institute, Charité-University Medicine Berlin, Berlin, Germany
| | - Anne Flies
- Julius-Wolff-Institute, Charité-University Medicine Berlin, Berlin, Germany
| | - Dag Wulsten
- Julius-Wolff-Institute, Charité-University Medicine Berlin, Berlin, Germany
| | - Robert Collette
- Department of Anesthesiology and Intensive Care, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Georg N Duda
- Julius-Wolff-Institute, Charité-University Medicine Berlin, Berlin, Germany
| | - Klaus-Dieter Schaser
- Department of Orthopedic and Trauma Surgery, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Roland Becker
- Center of Orthopaedics and Traumatology, Brandenburg Medical School Theodor Fontane, University Hospital Brandenburg an der Havel, Brandenburg an der Havel, Germany
| | - Sebastian Kopf
- Julius-Wolff-Institute, Charité-University Medicine Berlin, Berlin, Germany.,Center of Orthopaedics and Traumatology, Brandenburg Medical School Theodor Fontane, University Hospital Brandenburg an der Havel, Brandenburg an der Havel, Germany
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19
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Evaluating for Tunnel Convergence in Anterior Cruciate Ligament Reconstruction With Modified Lemaire Tenodesis: What Is the Best Tunnel Angle to Decrease Risk? Arthroscopy 2020; 36:776-784. [PMID: 31864816 DOI: 10.1016/j.arthro.2019.08.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 08/10/2019] [Accepted: 08/14/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to analyze postoperative computed tomography (CT) scan evaluations of patients who had undergone a combined anterior cruciate ligament (ACL) reconstruction and modified Lemaire anterolateral tenodesis (ALT) with femoral fixation through a bony tunnel. METHODS Postoperative CT scans of 52 patients who had undergone combined ACL and ALT were prospectively evaluated. ACL femoral tunnels were drilled through an anteromedial portal in the center of the native footprint. An ALT fixation tunnel was drilled 5 mm proximal to the lateral epicondyle, aiming at an inclination of 30° proximally and 30° anteriorly. Two independent observers evaluated the CT scans measuring any degree of collision, the shortest distance between the tunnels, and the inclination of the ALT tunnels. Measurements were carried out at both the cortical level and on a plane passing 1 cm deeper in the lateral condyle. RESULTS At the level of the cortex, no convergence of the tunnels was identified. In 14 of 52 cases (26.9%), the shortest distance between the tunnels was less than 5 mm. Tunnel collision occurred in 8 of 52 cases (15.4%), and the bone bridge between the tunnels was less than 5 mm in 11 cases (21.1%) when the measurements were made on the deeper plane. When the inclination on the axial plane was less than 15°, a collision always (P < .001) occurs. When it was more than 20°, no collision occurred (P < .001). No correlation between convergence and the inclination of the ALT tunnel on the coronal plane was detected. CONCLUSIONS To fix a modified Lemaire ALT through a femoral tunnel avoiding any interference with an anatomic femoral ACL tunnel, we recommend that the femoral tunnel be drilled with an inclination of at least 20° anteriorly. LEVEL OF EVIDENCE IV, therapeutic case series.
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20
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Getgood AMJ, Bryant DM, Litchfield R, Heard M, McCormack RG, Rezansoff A, Peterson D, Bardana D, MacDonald PB, Verdonk PCM, Spalding T, Willits K, Birmingham T, Hewison C, Wanlin S, Firth A, Pinto R, Martindale A, O'Neill L, Jennings M, Daniluk M, Boyer D, Zomar M, Moon K, Pritchett R, Payne K, Fan B, Mohan B, Buchko GM, Hiemstra LA, Kerslake S, Tynedal J, Stranges G, Mcrae S, Gullett L, Brown H, Legary A, Longo A, Christian M, Ferguson C, Mohtadi N, Barber R, Chan D, Campbell C, Garven A, Pulsifer K, Mayer M, Simunovic N, Duong A, Robinson D, Levy D, Skelly M, Shanmugaraj A, Howells F, Tough M, Spalding T, Thompson P, Metcalfe A, Asplin L, Dube A, Clarkson L, Brown J, Bolsover A, Bradshaw C, Belgrove L, Millan F, Turner S, Verdugo S, Lowe J, Dunne D, McGowan K, Suddens CM, Declercq G, Vuylsteke K, Van Haver M. Lateral Extra-articular Tenodesis Reduces Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-Year Outcomes From the STABILITY Study Randomized Clinical Trial. Am J Sports Med 2020; 48:285-297. [PMID: 31940222 DOI: 10.1177/0363546519896333] [Citation(s) in RCA: 324] [Impact Index Per Article: 81.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Persistent anterolateral rotatory laxity after anterior cruciate ligament (ACL) reconstruction (ACLR) has been correlated with poor clinical outcomes and graft failure. HYPOTHESIS We hypothesized that a single-bundle, hamstring ACLR in combination with a lateral extra-articular tenodesis (LET) would reduce the risk of ACLR failure in young, active individuals. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS This is a multicenter, prospective, randomized clinical trial comparing a single-bundle, hamstring tendon ACLR with or without LET performed using a strip of iliotibial band. Patients 25 years or younger with an ACL-deficient knee were included and also had to meet at least 2 of the following 3 criteria: (1) grade 2 pivot shift or greater, (2) a desire to return to high-risk/pivoting sports, (3) and generalized ligamentous laxity (GLL). The primary outcome was ACLR clinical failure, a composite measure of rotatory laxity or a graft rupture. Secondary outcome measures included the P4 pain scale, Marx Activity Rating Scale, Knee injury Osteoarthritis and Outcome Score (KOOS), International Knee Documentation Committee score, and ACL Quality of Life Questionnaire. Patients were reviewed at 3, 6, 12, and 24 months postoperatively. RESULTS A total of 618 patients (297 males; 48%) with a mean age of 18.9 years (range, 14-25 years) were randomized. A total of 436 (87.9%) patients presented preoperatively with high-grade rotatory laxity (grade 2 pivot shift or greater), and 215 (42.1%) were diagnosed as having GLL. There were 18 patients lost to follow-up and 11 who withdrew (~5%). In the ACLR group, 120/298 (40%) patients sustained the primary outcome of clinical failure, compared with 72/291 (25%) in the ACLR+LET group (relative risk reduction [RRR], 0.38; 95% CI, 0.21-0.52; P < .0001). A total of 45 patients experienced graft rupture, 34/298 (11%) in the ACLR group compared with 11/291 (4%) in the ACL+LET group (RRR, 0.67; 95% CI, 0.36-0.83; P < .001). The number needed to treat with LET to prevent 1 patient from graft rupture was 14.3 over the first 2 postoperative years. At 3 months, patients in the ACLR group had less pain as measured by the P4 (P = .003) and KOOS (P = .007), with KOOS pain persisting in favor of the ACLR group to 6 months (P = .02). No clinically important differences in patient-reported outcome measures were found between groups at other time points. The level of sports activity was similar between groups at 2 years after surgery, as measured by the Marx Activity Rating Scale (P = .11). CONCLUSION The addition of LET to a single-bundle hamstring tendon autograft ACLR in young patients at high risk of failure results in a statistically significant, clinically relevant reduction in graft rupture and persistent rotatory laxity at 2 years after surgery. REGISTRATION NCT02018354 ( ClinicalTrials.gov identifier).
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Affiliation(s)
- Alan M J Getgood
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Dianne M Bryant
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Robert Litchfield
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Mark Heard
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Robert G McCormack
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alex Rezansoff
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Devin Peterson
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Davide Bardana
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Peter B MacDonald
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Peter C M Verdonk
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Tim Spalding
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Kevin Willits
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Trevor Birmingham
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Chris Hewison
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Stacey Wanlin
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Andrew Firth
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Ryan Pinto
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Ashley Martindale
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Lindsey O'Neill
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Morgan Jennings
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Michal Daniluk
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Dory Boyer
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Mauri Zomar
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Karyn Moon
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Raely Pritchett
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Krystan Payne
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Brenda Fan
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Bindu Mohan
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Gregory M Buchko
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Laurie A Hiemstra
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Sarah Kerslake
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Jeremy Tynedal
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Greg Stranges
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Sheila Mcrae
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - LeeAnne Gullett
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Holly Brown
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alexandra Legary
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alison Longo
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Mat Christian
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Celeste Ferguson
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Nick Mohtadi
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Rhamona Barber
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Denise Chan
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Caitlin Campbell
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alexandra Garven
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Karen Pulsifer
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Michelle Mayer
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Nicole Simunovic
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Andrew Duong
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - David Robinson
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - David Levy
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Matt Skelly
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Ajaykumar Shanmugaraj
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Fiona Howells
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Murray Tough
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Tim Spalding
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Pete Thompson
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Andrew Metcalfe
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Laura Asplin
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alisen Dube
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Louise Clarkson
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Jaclyn Brown
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alison Bolsover
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Carolyn Bradshaw
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Larissa Belgrove
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Francis Millan
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Sylvia Turner
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Sarah Verdugo
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Janet Lowe
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Debra Dunne
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Kerri McGowan
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Charlie-Marie Suddens
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Geert Declercq
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Kristien Vuylsteke
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Mieke Van Haver
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
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Markolf KL, Wang D, Joshi NB, Cheung E, Petrigliano FA, McAllister DR. Cyclic testing of tibialis tendon allografts for anterior cruciate ligament reconstruction using suture-post versus spiked washer tibial fixation. Clin Biomech (Bristol, Avon) 2019; 70:8-15. [PMID: 31377634 DOI: 10.1016/j.clinbiomech.2019.07.025] [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] [Received: 05/30/2018] [Revised: 07/01/2019] [Accepted: 07/23/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose of this study was to directly compare spiked washer and suture-post tibial-sided fixation techniques used for anterior cruciate ligament reconstruction by measuring anterior tibial translation during cyclic tests. METHODS Fresh-frozen human knees were tested using a robotic system that applied 250 cycles of anterior-posterior tibial force (134 N) at 30° flexion, while recording tibial translation. Ten intact knees were tested to collect baseline data for native specimens. A single knee was selected to test ligament reconstructions using doubled tibialis tendon allografts. All grafts were fixed proximally using an EndoButton™, and the tibial end of the graft was fixed with either a spiked washer or with a suture post placed at two different locations (near and distant) relative to the tibial tunnel. FINDINGS Mean first cycle translation for intact knees was 4.8 (sd 1.8) mm; means after reconstruction were 2.6 (sd 0.9) mm (spiked washer), 10.1 (sd 1.9) mm (suture post near), and 10.4 (sd 1.5) mm (suture post distant). Corresponding means for translation increase over 250 cycles were 0.3 (sd 0.2) mm, 3.6 (sd 1.3) mm, 7.2 mm (sd 0.9) mm, and 8.0 (sd 1.3) mm. All mean increases (first cycle and cyclic) after ACL reconstruction were significantly greater than those for the intact knees, and all means with a suture post were significantly greater than those with a spiked washer. There were no significant differences between mean translations for near and distant suture post locations. INTERPRETATION Use of suture post fixation for anterior cruciate ligament reconstruction is questioned since increases in anterior tibial translation could lead to excessive post-operative knee laxity and possibly early clinical failure.
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Affiliation(s)
- Keith L Markolf
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, 76-143 CHS, Los Angeles, CA 90095, USA.
| | - Dean Wang
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, 76-143 CHS, Los Angeles, CA 90095, USA
| | - Nirav B Joshi
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, 76-143 CHS, Los Angeles, CA 90095, USA
| | - Edward Cheung
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, 76-143 CHS, Los Angeles, CA 90095, USA
| | - Frank A Petrigliano
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, 76-143 CHS, Los Angeles, CA 90095, USA
| | - David R McAllister
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, 76-143 CHS, Los Angeles, CA 90095, USA
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Getgood A, Bryant D, Firth A. The Stability study: a protocol for a multicenter randomized clinical trial comparing anterior cruciate ligament reconstruction with and without Lateral Extra-articular Tenodesis in individuals who are at high risk of graft failure. BMC Musculoskelet Disord 2019; 20:216. [PMID: 31092226 PMCID: PMC6521537 DOI: 10.1186/s12891-019-2589-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 04/25/2019] [Indexed: 12/22/2022] Open
Abstract
Background The purpose of anterior cruciate ligament reconstruction (ACLR) is to restore stability to the knee. Persistent rotational laxity following ACLR has been correlated with poor outcome and graft failure. We hypothesize that anterolateral complex reconstruction by way of a Modified Lemaire Lateral Extra-articular Tenodesis (LET) in combination with single bundle ACLR would reduce the risk of persistent rotatory laxity in young individuals who are deemed as being at high risk of failure. We will conduct a pragmatic, multicenter, randomized clinical trial comparing standard single bundle hamstring ACLR with combined ACLR and LET. Methods Six-hundred patients (300 per group) aged 25 years or less with an ACL deficient knee that meet two of the following three criteria will be included: 1) Grade 2 pivot shift or greater; 2) Returning to high risk cutting or pivoting sports; 3) Generalized ligamentous laxity. Participants will be seen at 3-months, 6-months, 12-months and 24-months post-operatively. The primary outcome measure is graft failure requiring revision ACLR or symptomatic instability associated with a positive asymmetric pivot shift indicating persistent rotational laxity. Patients will complete secondary outcome measures at each follow-up visit including patient-reported outcome measures, functional and biomechanical testing, and magnetic resonance imaging. Discussion This protocol is the first adequately powered randomized clinical trial investigating the effects of augmenting ACLR with an LET in patients at high-risk of graft failure. The successful completion of this trial has the potential to change surgical practice and provide evidence for the role of the LET in ACLR. Trial registration The trial is registered at ClinicalTrials.gov: NCT02018354, 23-12-2013.
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Affiliation(s)
- Alan Getgood
- Orthopaedic Sport Medicine Fellowship Director, Fowler Kennedy Sport Medicine Clinic, 3M Centre, University of Western Ontario, 1151 Richmond St., London, ON, N6A 3K7, Canada
| | - Dianne Bryant
- Faculty of Health Sciences, Elborn College, University of Western Ontario, Room 1438, 1201 Western Rd, London, ON, N6C 1H1, Canada
| | - Andrew Firth
- Fowler Kennedy Sport Medicine Clinic, 3M Centre, University of Western Ontario, 1151 Richmond St, London, ON, N6A 3K7, Canada.
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Cerciello S, Batailler C, Darwich N, Neyret P. Extra-Articular Tenodesis in Combination with Anterior Cruciate Ligament Reconstruction. Clin Sports Med 2018; 37:87-100. [DOI: 10.1016/j.csm.2017.07.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Schuette HB, Kraeutler MJ, Houck DA, McCarty EC. Bone-Patellar Tendon-Bone Versus Hamstring Tendon Autografts for Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review of Overlapping Meta-analyses. Orthop J Sports Med 2017; 5:2325967117736484. [PMID: 29152522 PMCID: PMC5680945 DOI: 10.1177/2325967117736484] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Previous meta-analyses have compared bone-patellar tendon-bone (BPTB) with hamstring tendon (HT) autografts for primary anterior cruciate ligament reconstruction (ACLR). PURPOSE To conduct a systematic review of overlapping meta-analyses comparing BPTB with HT autografts for ACLR to determine which meta-analyses provide the best available evidence. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS A systematic review was performed by searching the PubMed and Cochrane Library databases. Search words included "anterior cruciate ligament" AND "patellar tendon" AND "hamstring tendon" AND "meta-analysis." Results were reviewed to determine study eligibility. Patient outcomes and postoperative complications were extracted from the included meta-analyses. Meta-analysis quality was assessed using the Oxman-Guyatt and Quality of Reporting of Meta-analyses (QUOROM) scores. The Jadad decision algorithm was then utilized to determine which meta-analyses provided the best level of evidence. RESULTS Sixteen meta-analyses containing an average of 1396 patients met the eligibility criteria. Most studies found BPTB autografts to provide superior stability but more postoperative complications, such as anterior knee pain and kneeling pain. Studies by Gabler et al (2016), Mohtadi et al (2011), and Xie et al (2015) received the highest Oxman-Guyatt and QUOROM scores, and therefore, these meta-analyses proved to provide the highest level of evidence. Additionally, Xie et al was selected as the highest-quality study in this systematic review based on the Jadad decision algorithm. CONCLUSION The current best evidence suggests that ACLR with BPTB autografts provides superior static knee stability and that there are fewer postoperative complications in ACLR with HT autografts.
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Affiliation(s)
- Hayden B. Schuette
- Department of Orthopedics, University of Colorado School of Medicine, Department of Orthopedics, Aurora, Colorado, USA
| | - Matthew J. Kraeutler
- Department of Orthopaedic Surgery, Seton Hall–Hackensack Meridian School of Medicine, South Orange, New Jersey, USA
| | - Darby A. Houck
- Department of Orthopedics, University of Colorado School of Medicine, Department of Orthopedics, Aurora, Colorado, USA
| | - Eric C. McCarty
- Department of Orthopedics, University of Colorado School of Medicine, Department of Orthopedics, Aurora, Colorado, USA
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Browning WM, Kluczynski MA, Curatolo C, Marzo JM. Suspensory Versus Aperture Fixation of a Quadrupled Hamstring Tendon Autograft in Anterior Cruciate Ligament Reconstruction: A Meta-analysis. Am J Sports Med 2017; 45:2418-2427. [PMID: 28068159 DOI: 10.1177/0363546516680995] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hamstring grafts have become a popular choice for anterior cruciate ligament (ACL) reconstruction; however, the most effective means of fixation of these soft tissue grafts is unknown. PURPOSE To determine whether suspensory or aperture fixation of hamstring tendon autografts provides better stability and clinical outcomes in ACL reconstruction. STUDY DESIGN Meta-analysis. METHODS A literature search of studies reporting single-bundle ACL reconstructions using 4-stranded hamstring tendon autografts with aperture or suspensory fixation with a minimum 24-month follow-up was conducted. Stability and clinical outcomes were compared for aperture versus suspensory fixation. Knee stability was measured with the Lachman or pivot-shift test or KT-1000 arthrometer side-to-side difference (SSD), and outcomes were determined with the International Knee Documentation Committee (IKDC), Tegner, and Lysholm scores as well as graft failures. A random-effects model with a pooled estimate for the between-study variance was used to estimate proportions or means for each outcome and its corresponding 95% CI. RESULTS Forty-one studies were included, of which 20 utilized suspensory fixation techniques and 21 utilized aperture fixation techniques. A >3-mm SSD was seen more often in the aperture group than the suspensory group, which was statistically significant ( P < .0001), but there was no significant difference between groups for a >5-mm SSD ( P = .53). The aperture group demonstrated significantly more graft ruptures than did the suspensory group ( P = .03). There were no statistically significant differences in Lachman grade 0 ( P = .76), grade 1 ( P = .89), and grade 2 ( P = .55) or pivot-shift grade 0 ( P = .72), grade 1 ( P = .97), and grade 2 ( P = .28). There was no statistically significant difference in mean continuous IKDC ( P = .80), Tegner ( P = .34), or Lysholm ( P = .84) scores. CONCLUSION This meta-analysis demonstrated improved overall arthrometric stability and fewer graft ruptures using suspensory fixation compared with aperture fixation of a quadrupled hamstring tendon autograft in ACL reconstruction. There were no differences in IKDC, Lysholm, Lachman, and pivot-shift outcomes between suspensory and aperture fixation.
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Affiliation(s)
| | - Melissa A Kluczynski
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Christian Curatolo
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - John M Marzo
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
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Ciccotti MC, Secrist E, Tjoumakaris F, Ciccotti MG, Freedman KB. Anatomic Anterior Cruciate Ligament Reconstruction via Independent Tunnel Drilling: A Systematic Review of Randomized Controlled Trials Comparing Patellar Tendon and Hamstring Autografts. Arthroscopy 2017; 33:1062-1071.e5. [PMID: 28359669 DOI: 10.1016/j.arthro.2017.01.033] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 12/29/2016] [Accepted: 01/05/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To collect the highest level of evidence comparing anatomic anterior cruciate ligament (ACL) reconstruction via independent tunnel drilling using bone-patellar tendon-bone (BTB) and hamstring tendon (HT) autografts in terms of clinical outcome and failure rate. METHODS We performed a systematic review of clinical trials that randomized patients to ACL reconstruction with either BTB or HT autografts with a minimum 2-year follow-up. Only trials using independent tunnel drilling, including outside-in and anteromedial portal techniques, for both autografts were eligible for inclusion, whereas all transtibial studies were excluded. Study design, demographics, surgical technique, rehabilitation protocol, and clinical outcomes were compiled. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Quality assessment was performed using the Coleman Methodological Scale (CMS). RESULTS Six published studies reporting on 5 randomized controlled trials (RCTs) met the inclusion criteria. No study reported a difference in rerupture rate between BTB and HT. BTB-reconstructed knees experienced a greater incidence of anterior knee pain or crepitus in 2/7 trials and radiographic evidence of degenerative change in 3/7 trials. HT-reconstructed knees had increased instrumented laxity in 2/7 trials and less knee flexion strength postoperatively. CONCLUSIONS This study collects all available Level I and II evidence for anatomic ACL reconstruction using BTB and HT grafts. According to the data presented in these studies, clinical outcome scores and failure rates showed no differences for anatomic reconstruction using either autograft. However, in some studies, BTB-reconstructed knees experienced a greater incidence of anterior knee pain and radiographic evidence of degenerative change, and in others, HT-reconstructed knees had increased laxity and less knee flexion strength. In our opinion, both BTB and HT autografts remain valid options for ACL reconstruction when using anatomic drilling techniques, providing a stable knee with reliable return to activity. LEVEL OF EVIDENCE Level II, systematic review of Level I and II studies.
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Affiliation(s)
| | - Eric Secrist
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Fotios Tjoumakaris
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Michael G Ciccotti
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Kevin B Freedman
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A..
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Credibility and quality of meta-analyses addressing graft choice in anterior cruciate ligament reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc 2017; 25:538-551. [PMID: 27544274 DOI: 10.1007/s00167-016-4282-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 08/03/2016] [Indexed: 12/29/2022]
Abstract
PURPOSE This systematic review examined the methodological credibility and quality of reporting of all meta-analyses which have compared bone-patellar tendon-bone (BPTB) versus hamstring tendon (HT) for anterior cruciate ligament (ACL) reconstruction (ACLR). METHODS EMBASE, MEDLINE, and The Cochrane Library were systematically searched, and two reviewers independently assessed eligibility, credibility according to the Users' Guide to medical literature, and completeness of reporting according to the preferred reporting items for systematic review and meta-analyses (PRISMA) checklist. Inter-rater agreement was quantified using Kappa, and we used Pearson's correlation coefficient to evaluate potential associations. RESULTS Seventeen meta-analyses were identified comparing BPTB versus HT for ACLR. The majority of meta-analyses were published in 2011 (5; 29 %), and North America was the most common continent of publication (6; 35 %). The three most commonly reported outcomes were stability (82 %), complications (76 %), and function (return to sport, IKDC score) (71 %). The median number of satisfactorily reported items in the Users' Guide was three out of seven (IQR 2-4). The median number of satisfactorily reported items in PRISMA for the meta-analyses was 20 out of 27 (IQR 19-22). CONCLUSION The credibility of the meta-analyses comparing BPTB versus HT autograft for ACLR although limited is improving with time. Earlier studies had limited methodological rigour; however, the more recent studies have shown promise in improved methodology. The study findings suggest that decisions should be made on a case-to-case basis with coordination of patient factors and preferences as well as surgeon experience on the background of the best available evidence. LEVEL OF EVIDENCE IV.
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Wytrykowski K, Swider P, Reina N, Murgier J, Laffosse JM, Chiron P, Cavaignac E. Cadaveric Study Comparing the Biomechanical Properties of Grafts Used for Knee Anterolateral Ligament Reconstruction. Arthroscopy 2016; 32:2288-2294. [PMID: 27161509 DOI: 10.1016/j.arthro.2016.03.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 03/02/2016] [Accepted: 03/02/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To measure the biomechanical properties (maximum load, stiffness, and elongation) of the anterolateral ligament (ALL), gracilis, and iliotibial band (ITB) within the same subject. METHODS Thirteen unpaired knees were used (7 women, 6 men). The donors had a mean age at death of 54 years (range: 37 to 70 years). The mechanical properties of two types of ALL grafts were evaluated: ITB and two-strand gracilis. The mechanical properties of ALL were also measured. Validated methods were used to perform the tensile tests to failure and to record the results. Student's t-test was used to compare the various samples. RESULTS The maximum load to failure was 141 N (±40.6) for the ALL, 200.7 N (±48.7) for the gracilis, and 161.1 N (±27.1) for the ITB. Only the gracilis had a significantly higher failure load than ITB and ALL (P = .001 and P = .03). The stiffness was 21 N mm-1 (±8.2) for the ALL, 131.7 N mm-1 (±43.7) for the gracilis, and 39.9 N mm-1 (±6) for the ITB. The elongation at failure was 6.2 mm (±3.2) for the ALL, 19.9 mm (±6.5) for the gracilis, and 20.8 mm (±14.7) for the ITB. CONCLUSIONS The gracilis had the highest maximum load to failure. The ITB's mechanical properties most closely resemble those of the ALL. CLINICAL RELEVANCE The biomechanical properties of each potential ALL graft can be factored in when deciding which type of graft to use.
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Affiliation(s)
- Karine Wytrykowski
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital P.P.R., Toulouse, France
| | - Pascal Swider
- Laboratoire de Biomécanique, Université Paul Sabatier, Toulouse, France
| | - Nicolas Reina
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital P.P.R., Toulouse, France
| | - Jérôme Murgier
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital P.P.R., Toulouse, France
| | - Jean Michel Laffosse
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital P.P.R., Toulouse, France; Laboratoire de Biomécanique, Université Paul Sabatier, Toulouse, France
| | - Philippe Chiron
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital P.P.R., Toulouse, France
| | - Etienne Cavaignac
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital P.P.R., Toulouse, France.
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Vundelinckx B, Herman B, Getgood A, Litchfield R. Surgical Indications and Technique for Anterior Cruciate Ligament Reconstruction Combined with Lateral Extra-articular Tenodesis or Anterolateral Ligament Reconstruction. Clin Sports Med 2016; 36:135-153. [PMID: 27871655 DOI: 10.1016/j.csm.2016.08.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
After anterior cruciate ligament (ACL) rupture, anteroposterior and rotational laxity in the knee causes instability, functional symptoms, and damage to other intra-articular structures. Surgical reconstruction aims to restore the stability in the knee, and to improve function and ability to participate in sports. It also protects cartilage and menisci from secondary injuries. Because of persistent rotational instability after ACL reconstruction, combined intra-articular and extra-articular procedures are more commonly performed. In this article, an overview of anatomy, biomechanical studies, current gold standard procedures, techniques, and research topics are summarized.
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Affiliation(s)
- Bart Vundelinckx
- Department of Surgery, Fowler Kennedy Sport Medicine Clinic, Western University, 3M Centre, 1151 Richmond Street, London, Ontario N6A 3K7, Canada
| | - Benjamin Herman
- Department of Surgery, Fowler Kennedy Sport Medicine Clinic, Western University, 3M Centre, 1151 Richmond Street, London, Ontario N6A 3K7, Canada
| | - Alan Getgood
- Department of Surgery, Fowler Kennedy Sport Medicine Clinic, Western University, 3M Centre, 1151 Richmond Street, London, Ontario N6A 3K7, Canada
| | - Robert Litchfield
- Department of Surgery, Fowler Kennedy Sport Medicine Clinic, Western University, 3M Centre, 1151 Richmond Street, London, Ontario N6A 3K7, Canada.
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Ferreira MDC, Zidan FF, Miduati FB, Fortuna CC, Mizutani BM, Abdalla RJ. Reconstrução dos ligamentos cruzado anterior e anterolateral com flexores enlaçados – Nota técnica. Rev Bras Ortop 2016. [DOI: 10.1016/j.rbo.2015.08.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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Ferreira MDC, Zidan FF, Miduati FB, Fortuna CC, Mizutani BM, Abdalla RJ. Reconstruction of anterior cruciate ligament and anterolateral ligament using interlinked hamstrings - technical note. Rev Bras Ortop 2016; 51:466-70. [PMID: 27517028 PMCID: PMC4974096 DOI: 10.1016/j.rboe.2015.08.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 08/25/2015] [Indexed: 01/26/2023] Open
Abstract
Recent anatomical and biomechanical studies on the anterolateral ligament (ALL) of the knee have shown that this structure has an important function in relation to joint stability, especially when associated with anterior cruciate ligament (ACL) injury. However, the criteria for its reconstruction have not yet been fully established and the surgical techniques that have been described present variations regarding anatomical points and fixation materials. This study presents a reproducible technique for ALL and ACL reconstruction using hamstring tendons, in which three interference screws are used for fixation.
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Affiliation(s)
- Marcio de Castro Ferreira
- Hospital do Coração, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil
- Hospital Renascença, Departamento de Cirurgia de Joelho, Osasco, SP, Brazil
| | | | | | - Caio Cesar Fortuna
- Hospital do Coração, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil
- Hospital Renascença, Departamento de Cirurgia de Joelho, Osasco, SP, Brazil
| | | | - Rene Jorge Abdalla
- Hospital do Coração, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil
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Alazzawi S, Sukeik M, Ibrahim M, Haddad FS. Surgical treatment of anterior cruciate ligament injury in adults. Br J Hosp Med (Lond) 2016; 77:227-31. [DOI: 10.12968/hmed.2016.77.4.227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Sulaiman Alazzawi
- Specialty Registrar in the Trauma and Orthopaedic Department, Royal London Hospital, London E1 1BB
| | - Mohamed Sukeik
- Specialty Registrar in the Trauma and Orthopaedic Department, Princess Alexandra Hospital, Harlow, Essex
| | - Mazin Ibrahim
- Specialty Registrar in the Trauma and Orthopaedic Department, University College Hospital, London
| | - Fares S Haddad
- Consultant Orthopaedic Surgeon, Divisional Clinical Director of Surgical Specialties and Director of the Institute of Sport, Exercise & Health, University College Hospital, London
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Anderson MJ, Browning WM, Urband CE, Kluczynski MA, Bisson LJ. A Systematic Summary of Systematic Reviews on the Topic of the Anterior Cruciate Ligament. Orthop J Sports Med 2016; 4:2325967116634074. [PMID: 27047983 PMCID: PMC4794976 DOI: 10.1177/2325967116634074] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND There has been a substantial increase in the amount of systematic reviews and meta-analyses published on the anterior cruciate ligament (ACL). PURPOSE To quantify the number of systematic reviews and meta-analyses published on the ACL in the past decade and to provide an overall summary of this literature. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS A systematic review of all ACL-related systematic reviews and meta-analyses published between January 2004 and September 2014 was performed using PubMed, MEDLINE, and the Cochrane Database. Narrative reviews and non-English articles were excluded. RESULTS A total of 1031 articles were found, of which 240 met the inclusion criteria. Included articles were summarized and divided into 17 topics: anatomy, epidemiology, prevention, associated injuries, diagnosis, operative versus nonoperative management, graft choice, surgical technique, fixation methods, computer-assisted surgery, platelet-rich plasma, rehabilitation, return to play, outcomes assessment, arthritis, complications, and miscellaneous. CONCLUSION A summary of systematic reviews on the ACL can supply the surgeon with a single source for the most up-to-date synthesis of the literature.
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Affiliation(s)
| | | | | | | | - Leslie J. Bisson
- The State University of New York at Buffalo, Buffalo, New York, USA
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Webster KE, Feller JA, Hartnett N, Leigh WB, Richmond AK. Comparison of Patellar Tendon and Hamstring Tendon Anterior Cruciate Ligament Reconstruction: A 15-Year Follow-up of a Randomized Controlled Trial. Am J Sports Med 2016; 44:83-90. [PMID: 26578718 DOI: 10.1177/0363546515611886] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Numerous studies have compared patellar tendon (PT) and hamstring tendon (HS) anterior cruciate ligament (ACL) reconstructions in the short to midterm, but fewer long-term results have been published. HYPOTHESIS There will be no difference in functional outcome between ACL reconstruction performed with PT and HS grafts, but PT grafts will have more donor site morbidity. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS Sixty-five patients undergoing ACL reconstruction were randomized to receive either a PT graft or a 4-strand HS graft. Early results were reported at 4, 8, 12, 24, and 36 months. Forty-seven patients (22 of 31 PT and 25 of 34 HS) were reviewed at a mean of 15.3 years. RESULTS Four graft ruptures (1 PT, 3 HS) and 6 contralateral ACL injuries (4 PT, 2 HS) occurred in the group that was reviewed. There was no statistically significant difference between the groups for any of the variables measured. There was a similar incidence of anterior knee pain and kneeling pain in both groups. The previously observed increased extension deficit in the PT group at 3 years was not present at 15 years, and there was no significant between-group difference in knee laxity. A higher proportion of patients in the PT group were participating in sport on a weekly basis (73% PT, 48% HS; P = .05). There was no difference in the degree of osteoarthritis between the groups. CONCLUSION This randomized controlled trial showed that HS and PT ACL reconstructions have comparable results at an average 15-year follow-up. Contrary to the study hypothesis, some of the graft differences seen at earlier review were not present at 15 years, and patients with PT grafts were more active in sport participation. Overall, both graft types provided good long-term subjective and objective outcomes.
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Affiliation(s)
- Kate E Webster
- School of Allied Health, La Trobe University, Melbourne, Australia
| | - Julian A Feller
- OrthoSport Victoria, Epworth HealthCare, Melbourne, Australia
| | - Nigel Hartnett
- OrthoSport Victoria, Epworth HealthCare, Melbourne, Australia
| | - Warren B Leigh
- OrthoSport Victoria, Epworth HealthCare, Melbourne, Australia
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Biuk E, Zelić Z, Rapan S, Ćurić G, Biuk D, Radić R. Analysis of biomechanical properties of patellar ligament graft and quadruple hamstring tendon graft. Injury 2015; 46 Suppl 6:S14-7. [PMID: 26596414 DOI: 10.1016/j.injury.2015.10.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Two types of transplant are commonly used in the surgical management of anterior cruciate ligament lesions: the central part of the patellar ligament and quadruple tendons of the gracilis muscle and semitendinosus muscle. AIMS The aim of this study was to determine the biomechanical characteristics of patellar ligament transplants and transplants of the quadruple tendons of the hamstring muscles under tensile force in the laboratory, and to compare the results in each group of samples. MATERIALS AND METHODS The study comprised 160 specimens: 40 specimens of gracilis muscle tendons, 40 of semitendinosus muscle tendons, 40 of quadruple tendons and 40 of the patellar ligament, approximately equally distributed according to sex, age (50-70 years) and the side of the body from which the specimen had been taken. RESULTS The working curve analysis of the specimens under tensile load of a maximum force of 30N showed the least elongation (0.31%) in the quadruple tendon, followed by the gracilis muscle tendon (1.48%) and patellar ligament tendon (3.91%). CONCLUSIONS The quadruple tendon specimen showed greater strength and higher elasticity compared with the patellar ligament specimen, which proved the starting hypothesis.
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Affiliation(s)
- Egon Biuk
- Department of Orthopaedics, Osijek University Hospital, Josipa Huttlera 4, HR-31000 Osijek, Croatia; Department of Orthopaedics, Faculty of Medicine, JJ Strossmayer University of Osijek, Cara Hadrijana 10 E, HR-31000 Osijek, Croatia.
| | - Zoran Zelić
- Department of Orthopaedics, Osijek University Hospital, Josipa Huttlera 4, HR-31000 Osijek, Croatia; Department of Orthopaedics, Faculty of Medicine, JJ Strossmayer University of Osijek, Cara Hadrijana 10 E, HR-31000 Osijek, Croatia
| | - Saša Rapan
- Department of Orthopaedics, Osijek University Hospital, Josipa Huttlera 4, HR-31000 Osijek, Croatia; Department of Orthopaedics, Faculty of Medicine, JJ Strossmayer University of Osijek, Cara Hadrijana 10 E, HR-31000 Osijek, Croatia
| | - Goran Ćurić
- Department of Biochemistry, Faculty of Medicine, JJ Strossmayer University of Osijek, Cara Hadrijana 10 E, HR-31000 Osijek, Croatia
| | - Dubravka Biuk
- Department of Ophthalmology, Osijek University Hospital, Josipa Huttlera 4, HR-31000 Osijek, Croatia; Department of Ophtalmology, Faculty of Medicine, JJ Strossmayer University of Osijek, Cara Hadrijana 10 E, HR-31000 Osijek, Croatia
| | - Radivoje Radić
- Department of Anatomy and Neuroscience, Faculty of Medicine, JJ Strossmayer University of Osijek, Cara Hadrijana 10 E, HR-31000 Osijek, Croatia
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Biuk E, Zelić Z, Rapan S, Lovric I, Biuk D, Radic R. Histological analysis of cross-sectional area of quadruple hamstring tendons and patellar ligament samples in relation to age and gender. Injury 2015; 46 Suppl 6:S1-4. [PMID: 26603614 DOI: 10.1016/j.injury.2015.10.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
AIMS The middle of the patellar ligament and the quadruple hamstring tendons (gracilis and semitendinosus) are two types of graft predominantly used in anterior cruciate ligament (ACL) reconstruction. The aim of this study was to determine the morphometric characteristics of patellar ligament grafts and hamstring tendon grafts and to compare the results according to subject age and gender. MATERIALS AND METHODS The study was conducted on a total of 120 samples: 40 of gracilis tendon, 40 of semitendinosus tendon and 40 of patellar ligament, distributed equally according to gender, age (50-75 years) and the side of the body from which the sample was harvested. RESULTS Morphometric and histological analyses showed that patellar ligament samples had less cross-sectional area than quadruple tendon samples (49.29 mm(2) compared with 51.46 mm(2), respectively). Sexual dimorphism was noticed in distal cross-sections of gracilis tendons (p=0.09), cross-sections of quadruple tendons (p=0.07) and patellar ligament samples (p=0.01) because of different muscular build. CONCLUSIONS All samples obtained from male subjects had larger cross-sectional areas compared with the samples taken from females. Furthermore, samples obtained from subjects aged 60 years or under had larger cross-sectional areas than samples obtained from subjects aged at least 61 years for all types of graft.
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Affiliation(s)
- Egon Biuk
- Department of Orthopaedics, Osijek University Hospital, Josipa Huttlera 4, HR-31000 Osijek, Croatia; Department of Orthopaedics, Faculty of Medicine, JJ Strossmayer University of Osijek, Cara Hadrijana 10 E, HR-31000 Osijek, Croatia.
| | - Zoran Zelić
- Department of Orthopaedics, Osijek University Hospital, Josipa Huttlera 4, HR-31000 Osijek, Croatia; Department of Orthopaedics, Faculty of Medicine, JJ Strossmayer University of Osijek, Cara Hadrijana 10 E, HR-31000 Osijek, Croatia
| | - Saša Rapan
- Department of Orthopaedics, Osijek University Hospital, Josipa Huttlera 4, HR-31000 Osijek, Croatia; Department of Orthopaedics, Faculty of Medicine, JJ Strossmayer University of Osijek, Cara Hadrijana 10 E, HR-31000 Osijek, Croatia
| | - Ivan Lovric
- Clinic for Surgery, Osijek University Hospital, Josipa Huttlera 4, HR-31000 Osijek, Croatia; Department of Surgery, Faculty of Medicine, JJ Strossmayer University of Osijek, Cara Hadrijana 10 E, HR-31000 Osijek, Croatia
| | - Dubravka Biuk
- Department of Ophthalmology, Osijek University Hospital, Josipa Huttlera 4, HR-31000 Osijek, Croatia; Department of Ophtalmology, Faculty of Medicine, JJ Strossmayer University of Osijek, Cara Hadrijana 10 E, HR-31000 Osijek, Croatia
| | - Radivoje Radic
- Department of Anatomy and Neuroscience, Faculty of Medicine, JJ Strossmayer University of Osijek, Cara Hadrijana 10 E, HR-31000 Osijek, Croatia
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Spencer L, Burkhart TA, Tran MN, Rezansoff AJ, Deo S, Caterine S, Getgood AM. Biomechanical analysis of simulated clinical testing and reconstruction of the anterolateral ligament of the knee. Am J Sports Med 2015; 43:2189-97. [PMID: 26093007 DOI: 10.1177/0363546515589166] [Citation(s) in RCA: 178] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anatomic anterolateral ligament (ALL) reconstruction has been proposed to assist anterior cruciate ligament (ACL) reconstruction in controlling anterolateral rotational laxity of the knee. However, the biomechanical effects have not been reported. PURPOSE (1) To investigate the effect of ALL transection on rotational knee kinematics and (2) to determine the effect on knee biomechanics of ALL reconstruction procedures compared with lateral extra-articular tenodesis (LET). STUDY DESIGN Controlled laboratory study. METHODS A total of 12 cadaveric knee specimens were tested in the following sequence: (1) ACLintact, (2) anteromedial bundle of ACL sectioned (ACLamb), (3) complete ACL sectioned (ACLfull), (4) ALL sectioned (ALLsec), (5) anatomic ALL reconstruction (ALLanat), and (6) LET. Biomechanical anterior drawer and Lachman tests were performed in which a 90-N load was applied to the posterior tibia, and anterior translation was measured. A combined load to simulate the early phase of the pivot-shift test was executed in which a 5-N·m internal rotation moment was applied to a fully extended knee; anterior translation and internal rotation were measured. RESULTS Anterior translation increased across conditions for the biomechanical tests. Internal rotation during the simulated early-phase pivot-shift test was significantly different between ACLfull and ALLsec. Anatomic ALL reconstruction did not significantly reduce internal rotation or anterior translation during the simulated early-phase pivot-shift test. After LET, a significant decrease in anterior translation was found. There was no evidence of overconstraint of the knee with either anatomic ALL reconstruction or LET. CONCLUSION The ALL demonstrated a role in controlling anterolateral laxity. LET had a composite effect in governing both anterior and rotational laxity. Anatomic ALL reconstruction did not reduce anterolateral rotational laxity. CLINICAL RELEVANCE Profiling the biomechanical characteristics of anterolateral reconstruction is integral to understanding the implications and potential benefit of such an additional procedure to ACL reconstruction.
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Affiliation(s)
- Luke Spencer
- Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada
| | - Timothy A Burkhart
- Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada
| | - Michael N Tran
- Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada
| | | | - Shaneel Deo
- Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada
| | - Scott Caterine
- Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada. Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Alan M Getgood
- Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada.
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Bitun PB, Miranda CR, Escudero RB, Araf M, de Souza DG. Comparação dos enxertos para reconstrução anatômica do LCA: patelar versus semitendíneo/grácil. Rev Bras Ortop 2015. [DOI: 10.1016/j.rbo.2013.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Bitun PB, Miranda CR, Escudero RB, Araf M, de Souza DG. Comparison of grafts for anatomical reconstruction of the ACL: patellar versus semitendinosus/gracilis. Rev Bras Ortop 2015; 50:50-6. [PMID: 26229896 PMCID: PMC4519648 DOI: 10.1016/j.rboe.2015.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Accepted: 10/24/2013] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To compare the functional results from surgical treatment for anatomical reconstruction of the anterior cruciate ligament (ACL) with a single band, using two types of autologous grafts. METHODS Twenty-seven patients who underwent anatomical reconstruction of the ACL by means of the Chambat technique were evaluated prospectively. They were divided into two groups: A, with 14 patients, using grafts from flexor tendons; and B, with 13 patients, using grafts from the patellar tendon. In both groups, fixation was performed using an absorbable interference screw. RESULTS Based on the Lysholm score, group A presented a mean score of 71.6 in the first month, while B presented 75. At the end of the sixth month, both groups presented 96.6. Evaluation of the total IKDC showed that in the first month, the majority of the patients, both in group A (85.7%) and in group B (76.9%), presented a knee assessment that was close to normal. In the sixth month, 92.9% of group A had normal presentations, and 100% of group B. CONCLUSION According to the Lysholm functional evaluation and the IKDC subjective assessment, there was no statistically significant difference in the results between the groups, and the results were better in the sixth month.
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Affiliation(s)
- Patrícia Barros Bitun
- Dr. Carmino Caricchio Municipal Hospital, Municipal Hospital Administrative Authority of São Paulo, São Paulo, SP, Brazil
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Uozumi Y, Nagamune K, Nakano N, Nagai K, Nishizawa Y, Hoshino Y, Matsushita T, Kuroda R, Kurosaka M. A Three-Dimensional Evaluation of EndoButton Displacement Direction After Anterior Cruciate Ligament Reconstruction in CT Image Using Tunnel Axis. JOURNAL OF ADVANCED COMPUTATIONAL INTELLIGENCE AND INTELLIGENT INFORMATICS 2014. [DOI: 10.20965/jaciii.2014.p0830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The goal of this study was to propose a threedimensional evaluation of the EndoButton displacement direction after anterior cruciate ligament reconstruction in the multidetector-row computed tomography (MDCT) image by using the tunnel axis. The proposed method was applied experimentally to six subjects. The result of the simulated experiment revealed that the proposed method could analyze EndoButton displacement direction satisfactorily because the error was less than that of the MDCT image resolution. The clinical experiment results revealed displacement relative to the tunnel between time-zero and the followup point. We conclude that the proposed method can quantitatively evaluate the EndoButton displacement direction from the raw MDCT image after anterior cruciate ligament reconstruction; further, our findings suggest that the EndoButton was displaced relative to the tunnel between time-zero and the follow-up point.
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Andernord D, Björnsson H, Petzold M, Eriksson BI, Forssblad M, Karlsson J, Samuelsson K. Surgical Predictors of Early Revision Surgery After Anterior Cruciate Ligament Reconstruction: Results From the Swedish National Knee Ligament Register on 13,102 Patients. Am J Sports Med 2014; 42:1574-82. [PMID: 24778266 DOI: 10.1177/0363546514531396] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND An important objective of anterior cruciate ligament (ACL) registries is to detect and report early graft failure and revision surgery after ACL reconstruction. PURPOSE To investigate surgical variables and identify predictors of revision surgery after ACL reconstruction. STUDY DESIGN Prospective cohort study; Level of evidence, 2. METHODS This prospective cohort study was based on data from the Swedish National Knee Ligament Register during the years 2005 through 2011. Eight surgical variables were investigated: graft selection, graft width, single-bundle or double-bundle techniques, femoral graft fixation, tibial graft fixation, injury-to-surgery interval, injuries to menisci, and injuries to cartilage. The primary endpoint was the 2-year incidence of revision surgery. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated and adjusted for confounders by use of multivariate statistics. RESULTS A total of 13,102 patients were included (5541 women [42%] and 7561 men [58%]; P < .001). Hamstring tendon autografts accounted for 90% (11,764 patients) of all reconstructions, of which 96% were performed with a single-bundle technique (11,339 patients). Patellar tendon autografts accounted for the remaining 10% (1338 patients). At index reconstruction, observed injuries to menisci and cartilage were common (40% and 28%, respectively). The overall 2-year incidence of revision surgery was 1.60% (women, 1.57%; men, 1.63%; P = .854). Patients with metal interference screw fixation of a semitendinosus tendon autograft on the tibia had a significantly reduced risk of early revision surgery (RR = 0.32; 95% CI, 0.12-0.90; P = .031). CONCLUSION Metal interference screw fixation of a semitendinosus tendon autograft on the tibia was an independent predictor of significantly lower 2-year incidence of revision surgery. Graft selection, graft width, a single-bundle or a double-bundle technique, femoral graft fixation, the injury-to-surgery interval, and meniscus injury were not predictors of early revision surgery.
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Affiliation(s)
- Daniel Andernord
- Vårdcentralen Gripen, Karlstad, Sweden Primary Care Research Unit, Centre for Clinical Research, County Council of Värmland, Karlstad, Sweden Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Haukur Björnsson
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Max Petzold
- Akademistatistik-Centre for Applied Biostatistics, Occupational and Environmental Medicine, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Bengt I Eriksson
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Magnus Forssblad
- Capio Artro Clinic AB, Stockholm, Sweden Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden
| | - Jón Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
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42
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Abstract
With the rising number of anterior cruciate ligament (ACL) reconstructions performed, revision ACL reconstruction is increasingly common nowadays. A broad variety of primary and revision ACL reconstruction techniques have been described in the literature. Recurrent instability after primary ACL surgery is often due to non-anatomical ACL graft reconstruction and altered biomechanics. Anatomical reconstruction must be the primary goal of this challenging revision procedure. Recently, revision ACL reconstruction has been described using double bundle hamstring graft. Successful revision ACL reconstruction requires an exact understanding of the causes of failure and technical or diagnostic errors. The purpose of this article is to review the causes of failure, preoperative evaluation, graft selection and types of fixation, tunnel placement, various types of surgical techniques and clinical outcome of revision ACL reconstruction.
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43
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Meuffels DE, Poldervaart MT, Diercks RL, Fievez AWFM, Patt TW, van Hart CP, Hammacher ER, van Meer F, Goedhart EA, Lenssen AF, Muller-Ploeger SB, Pols MA, Saris DBF. Guideline on anterior cruciate ligament injury. Acta Orthop 2012; 83:379-86. [PMID: 22900914 PMCID: PMC3427629 DOI: 10.3109/17453674.2012.704563] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
The Dutch Orthopaedic Association has a long tradition of development of practical clinical guidelines. Here we present the recommendations from the multidisciplinary clinical guideline working group for anterior cruciate ligament injury. The following 8 clinical questions were formulated by a steering group of the Dutch Orthopaedic Association. What is the role of physical examination and additional diagnostic tools? Which patient-related outcome measures should be used? What are the relevant parameters that influence the indication for an ACL reconstruction? Which findings or complaints are predictive of a bad result of an ACL injury treatment? What is the optimal timing for surgery for an ACL injury? What is the outcome of different conservative treatment modalities? Which kind of graft gives the best result in an ACL reconstruction? What is the optimal postoperative treatment concerning rehabilitation, resumption of sports, and physiotherapy? These 8 questions were answered and recommendations were made, using the "Appraisal of Guidelines for Research and Evaluation" instrument. This instrument seeks to improve the quality and effectiveness of clinical practical guidelines by establishing a shared framework to develop, report, and assess. The steering group has also developed 7 internal indicators to aid in measuring and enhancing the quality of the treatment of patients with an ACL injury, for use in a hospital or practice.
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Affiliation(s)
- Duncan E Meuffels
- The Dutch Orthopaedic Association (Nederlandse Orthopaedische Vereniging (NOV))
| | | | - Ron L Diercks
- The Dutch Orthopaedic Association (Nederlandse Orthopaedische Vereniging (NOV))
| | - Alex WFM Fievez
- The Dutch Orthopaedic Association (Nederlandse Orthopaedische Vereniging (NOV))
| | - Thomas W Patt
- The Dutch Orthopaedic Association (Nederlandse Orthopaedische Vereniging (NOV))
| | - Cor P van Hart
- The Dutch Society for Arthroscopy (Nederlandse Vereniging voor Arthroscopie (NVA))
| | - Eric R Hammacher
- The Association of Surgeons of the Netherlands (Nederlandse Vereniging voor Heelkunde (NVvH))
| | - Fred van Meer
- The Dutch Society of Rehabilitation (Vereniging van Revalidatieartsen (VRA))
| | - Edwin A Goedhart
- The Society for Sports Medicine (Vereniging voor Sportgeneeskunde (VSG))
| | - Anton F Lenssen
- The Royal Dutch Society for Physiotherapy (Koninklijke Genootschap voor Fysiotherapie (KNGF))
| | - Sabrina B Muller-Ploeger
- The Department of Professional Quality, the Dutch Association of Medical Specialists (Orde van Medisch Specialisten), the Netherlands
| | - Margreet A Pols
- The Department of Professional Quality, the Dutch Association of Medical Specialists (Orde van Medisch Specialisten), the Netherlands
| | - Daniel B F Saris
- The Dutch Orthopaedic Association (Nederlandse Orthopaedische Vereniging (NOV))
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44
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Dheerendra SK, Khan WS, Singhal R, Shivarathre DG, Pydisetty R, Johnstone D. Anterior cruciate ligament graft choices: a review of current concepts. Open Orthop J 2012; 6:281-6. [PMID: 22888379 PMCID: PMC3415142 DOI: 10.2174/1874325001206010281] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 02/09/2012] [Accepted: 03/07/2012] [Indexed: 12/21/2022] Open
Abstract
The graft choice for anterior cruciate ligament (ACL) reconstruction continues to be controversial. There are several options available for the treating surgeon, including Bone Patellar Tendon Bone (BPTB) grafts, Hamstring tendon (HT) grafts, allografts and synthetic grafts. Within the last decade there have been several comparative trials and meta-analysis, which have failed to provide an answer with regards to the best graft available. The aim of this review is to understand the current concepts in graft choices for ACL reconstruction.
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Affiliation(s)
- Sujay K Dheerendra
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Prescot Street, Liverpool, Merseyside, L7 8XP, UK
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45
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Getgood A, Spalding T. The evolution of anatomic anterior cruciate ligament reconstruction. Open Orthop J 2012; 6:287-94. [PMID: 22905073 PMCID: PMC3415664 DOI: 10.2174/1874325001206010287] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 03/02/2012] [Accepted: 03/10/2012] [Indexed: 02/08/2023] Open
Abstract
Anterior cruciate ligament reconstruction has evolved significantly since the early 1900's, back when an emphasis was placed on repair and not reconstruction. Over the past century, the technique has evolved from intra-articular non anatomic reconstruction, to extra articular reconstruction, back to intra articular (performed arthroscopically), to now, the advent of anatomic insertion site restoration. This review will aim to illustrate the changes that have occurred, describing the rational for this process, based upon anatomical, radiological, biomechanical and clinical studies, all of which have aimed to improve patient function following ACL injury.
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Affiliation(s)
- Alan Getgood
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Walsgrave, Coventry, CV2 2DX, UK
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46
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de Pádua VBC, Maldonado H, Vilela JCR, Provenza AR, Monteiro C, de Oliveira Neto HC. COMPARATIVE STUDY OF ACL RECONSTRUCTION WITH ANATOMICAL POSITIONING OF THE TUNNELS USING THE PATELLAR TENDON VERSUS HAMSTRING TENDON. Rev Bras Ortop 2012; 47:50-6. [PMID: 27027082 PMCID: PMC4799339 DOI: 10.1016/s2255-4971(15)30345-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 11/07/2011] [Indexed: 01/10/2023] Open
Abstract
Objective: To compare ACL reconstruction with anatomical positioning of the tunnels using the hamstring or patellar tendons. Methods: We prospectively evaluated 52 patients who underwent ACL reconstruction using the Chambat's technique, with anatomical positioning of the tunnels drilled outside in. They were divided into group A, with 27 patients, using the patellar tendon as a graft, and group B, with 25 patients, using the hamstring. Results: In group A 26 patients were very satisfied or satisfied and 1 unhappy, in group B. 25 patients were very satisfied or satisfied with the procedure (p = 0.990). According to the Lysholm scale, group A had a mean score of 96.11 and group B, 95.32 (p=0.594). In relation to preoperative IKDC, 100% of the patients in group A and 92% of those in group B were IKDC C or D (p = 0.221); in the assessment with a minimum of two-year follow-up, 96% of group A and 92% of group B were IKDC A or B (p = 0.256). The Lachman test, pivot shift, return to sports activities, and the comparative difference in anterior translation (RolimeterTM) also showed no statistically significant difference. In group A, 5 patients (18.5%) were unable to kneel on a hard surface, whereas no patient in group B had this complaint. Conclusion: The anterior cruciate ligament reconstruction presents similar results using the hamstring or patellar tendon with anatomical positioning of the tunnels. Drilling the femoral tunnel outside in is a reproducible and accurate option in the correct placement the femoral tunnel.
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Affiliation(s)
| | - Hilário Maldonado
- Titular Professor of Orthopedics and Traumatology, Marília Medical School (FAMEMA), Marília, SP, Brazil
| | | | - Alexandre Ribeira Provenza
- Third-year Residents in the Orthopedics Service, Santa Casa de Misericórdia de Marília, Marília, SP, Brazil
| | - Cleverson Monteiro
- Third-year Residents in the Orthopedics Service, Santa Casa de Misericórdia de Marília, Marília, SP, Brazil
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47
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Mohtadi NGH, Chan DS, Dainty KN, Whelan DB. Patellar tendon versus hamstring tendon autograft for anterior cruciate ligament rupture in adults. Cochrane Database Syst Rev 2011; 2011:CD005960. [PMID: 21901700 PMCID: PMC6465162 DOI: 10.1002/14651858.cd005960.pub2] [Citation(s) in RCA: 161] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Reconstruction of the anterior cruciate ligament (ACL) commonly involves patellar tendon (PT) or hamstring tendon(s) (HT) autografts. There is no consensus with respect to the choice between these two grafts in ACL surgery. OBJECTIVES This review compared the outcomes of ACL reconstruction using PT versus HT autografts in ACL deficient patients. SEARCH STRATEGY We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (April 2008), the Cochrane Central Register of Controlled Trials (2008, Issue 2), MEDLINE (1966 to April 10 2008), EMBASE (1980 to April 10 2008), conference proceedings and reference lists. No language restrictions were applied. SELECTION CRITERIA Randomized and quasi-randomized controlled trials comparing outcomes (minimum two year follow-up) following ACL reconstruction using either PT or HT autografts in skeletally mature adults, irrespective of the number of bundles, fixation method or incision technique. DATA COLLECTION AND ANALYSIS After independent study selection, the four authors independently assessed trial quality and risk of bias, and extracted data using pre-developed forms. Trial authors were contacted for additional data and information. Risk ratios with 95% confidence intervals were calculated for dichotomous outcomes, and mean differences and 95% confidence intervals for continuous outcomes. MAIN RESULTS Nineteen trials providing outcome data for 1597 young to middle-aged adults were included. Many trials were at high risk of bias reflecting inadequate methods of randomization, lack of blinding and incomplete assessment of outcome.Pooled data for primary outcomes, reported in a minority of trials, showed no statistically significant differences between the two graft choices for functional assessment (single leg hop test), return to activity, Tegner and Lysholm scores, and subjective measures of outcome. There were also no differences found between the two interventions for re-rupture or International Knee Documentation Committee scores. There were inadequate long-term results, such as to assess the development of osteoarthritis.All tests (instrumental, Lachman, pivot shift) for static stability consistently showed that PT reconstruction resulted in a more statically stable knee compared with HT reconstruction. Conversely, patients experienced more anterior knee problems, especially with kneeling, after PT reconstruction. PT reconstructions resulted in a statistically significant loss of extension range of motion and a trend towards loss of knee extension strength. HT reconstructions demonstrated a trend towards loss of flexion range of motion and a statistically significant loss of knee flexion strength. The clinical importance of the above range of motion losses is unclear. AUTHORS' CONCLUSIONS There is insufficient evidence to draw conclusions on differences between the two grafts for long-term functional outcome. While PT reconstructions are more likely to result in statically stable knees, they are also associated with more anterior knee problems.
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Affiliation(s)
- Nicholas GH Mohtadi
- University of CalgaryOrthopaedic SurgerySport Medicine Centre2500 University Drive NWCalgaryCanadaT2N 1N4
| | - Denise S Chan
- University of CalgarySport Medicine Centre2500 University Drive NWCalgaryCanadaT2N 1N4
| | - Katie N Dainty
- University of TorontoInstitute of Medical Science7213 Medical Sciences Building1 King's College CircleTorontoCanadaM5S 1A8
| | - Daniel B Whelan
- St. Michael's HospitalDivision of Orthopaedics, Department of Surgery55 Queen Street ESuite 800TorontoCanadaM5C 1R6
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48
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Barrera Oro F, Sikka RS, Wolters B, Graver R, Boyd JL, Nelson B, Swiontkowski MF. Autograft versus allograft: an economic cost comparison of anterior cruciate ligament reconstruction. Arthroscopy 2011; 27:1219-25. [PMID: 21820267 DOI: 10.1016/j.arthro.2011.04.008] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Revised: 04/14/2011] [Accepted: 04/21/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to compare the costs associated with anterior cruciate ligament (ACL) reconstruction with either bone-patellar tendon-bone (BPTB) autograft or BPTB allograft. METHODS Surgical costs are reported, including supply costs, based on invoice costs per item used per procedure, and personnel costs calculated as cost per minute. All operations were performed at an ambulatory surgery center between March 2005 and March 2006. A total of 160 patients underwent primary ACL reconstruction with either BPTB autograft (n = 106) or BPTB allograft (n = 54). Procedure cost data were retrieved from a financial management database and divided into various categories for comparison of the 2 groups. Payment data were provided by the surgery center's billing office. RESULTS The total mean cost per case was $4,147 ± $943 in the allograft group compared with $3,154 ± $704 in the autograft group; this was statistically significant (P < .001). The mean operating room time was 12 minutes greater in autograft cases (P = .006). Supply costs comprised a mean of 58.7% of total expenses in the autograft group and 72.2% in the allograft group. CONCLUSIONS Allograft reconstruction of the ACL was significantly more expensive than autograft reconstruction. LEVEL OF EVIDENCE Level II, economic analysis.
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49
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Magnussen RA, Carey JL, Spindler KP. Does autograft choice determine intermediate-term outcome of ACL reconstruction? Knee Surg Sports Traumatol Arthrosc 2011; 19:462-72. [PMID: 20953764 PMCID: PMC3745218 DOI: 10.1007/s00167-010-1277-z] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Accepted: 09/14/2010] [Indexed: 02/05/2023]
Abstract
PURPOSE Many clinical studies and systematic reviews have compared the short-term (2 years) outcomes of ACL reconstruction with hamstring and patellar tendon autograft. Few differences have been observed, with the exception of increased kneeling pain with patellar tendon grafts. The goal of this systematic review is to determine whether there are differences in clinical, patient-reported, or radiographic outcomes based on graft choice at a minimum of 5 years after ACL reconstruction. METHODS A systematic review was performed to identify all prospective outcome studies comparing patellar tendon and hamstring autograft ACL reconstruction with minimum follow-up of at least 5 years. Seven studies were identified and meta-analysis of select data determined to be sufficiently homogenous was performed (failure and laxity). RESULTS Five randomized controlled trials and two prospective cohorts comparing hamstring and patellar tendon autografts were identified. Clinical assessment [failure rate, International Knee Documentation Committee (IKDC) class, Lachman, pivot shift, and KT 1000 testing] showed no difference between grafts. Patient-reported outcomes (Lysholm, Cincinnati, and IKDC) showed no difference. Both anterior knee pain (3/3 studies) and kneeling pain (4/4 studies) were more frequent in the patellar tendon group. However, the patient-reported outcomes in these studies were not different. Radiographic evidence of osteoarthritis was inconsistent between autograft choices. CONCLUSION This level II systematic review demonstrates no difference in major clinical results between graft types with the exception of increased anterior knee and kneeling pain. There exists a potential for increased incidence of osteoarthritis in the patellar tendon group but increased sample size is required. These longer-term outcomes are similar to results of prior systematic reviews with two-year follow-up.
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Affiliation(s)
| | - James L. Carey
- Vanderbilt Sports Medicine, MCE South Tower, Suite 4200, 1215 21 Avenue South, Nashville, TN 37232
| | - Kurt P. Spindler
- Vanderbilt Sports Medicine, MCE South Tower, Suite 4200, 1215 21 Avenue South, Nashville, TN 37232
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50
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Danieli MV, Padovani CR. Comparação entre parafuso de interferência e transcondilar na reconstrução do LCA. ACTA ORTOPEDICA BRASILEIRA 2011. [DOI: 10.1590/s1413-78522011000600003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJETIVO: A fixação femoral na reconstrução do Ligamento Cruzado Anterior (LCA) com enxerto de tendões flexores pode variar muito de acordo com a disposição dos materiais e a experiência do cirurgião. Porém os trabalhos que comparam os sistemas de fixação são efetuados na maioria das vezes em cadáveres ou em animais, sem avaliar os resultados clínicos, prejudicando sua comparação com pacientes humanos vivos. Neste artigo avaliamos o resultado clínico de dois métodos de fixação do enxerto ao fêmur (parafuso de interferência de titânio e parafuso transcondilar de titânio) para saber se, do ponto de vista clinico e subjetivo, há diferença entre estes métodos. MÉTODOS: Foram selecionados 40 pacientes com lesão do LCA sendo que 20 pacientes tiveram seu enxerto fixado ao fêmur com parafuso de interferência e 20 com parafuso transcondilar. Todos foram reavaliados com no mínimo dois anos de pós operatório para medição da gaveta anterior, Pivot Shift e teste de Lachman, além da obtenção dos questionário de Lysholm e IKDC (International Knee Documentation Committee). RESULTADOS: Os resultados não foram estatisticamente diferentes para os critérios avaliados. CONCLUSÃO: As duas formas de fixação são eficientes para esta técnica dentro dos parâmetros estabelecidos. Nível de Evidência II, Estudo Prospectivo Comparativo.
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