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Bram JT, Stevens AC, Greenberg E, DeFrancesco CJ, Gans I, Parisien RL, Ganley TJ. Postoperative Strength Differences at Short-Term Follow-Up Vary Based on Autograft Harvest Site After Adolescent Transphyseal Anterior Cruciate Ligament Reconstruction. Arthroscopy 2024; 40:1591-1598. [PMID: 37898305 DOI: 10.1016/j.arthro.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 10/30/2023]
Abstract
PURPOSE To compare the clinical and patient-reported outcomes of adolescent patients who underwent anterior cruciate ligament reconstruction (ACLR) with quadriceps tendon (QT) versus hamstring tendon (HT) autograft. METHODS This was a retrospective cohort study of adolescent patients aged 18 years or younger treated at a single tertiary care children's hospital who underwent primary transphyseal ACLR using QT or HT between January 2018 and December 2019. All patients had minimum 6-month follow-up. Outcomes included isokinetic strength testing, postoperative Patient-Reported Outcomes Measurement Information System and International Knee Documentation Committee scores, and complications; these were compared between the QT and HT cohorts. RESULTS A total of 84 patients (44 HT and 40 QT patients) were included. The QT cohort had a higher proportion of male patients (62.5% vs 34.1%, P = .01). At 3 months, HT patients had a lower hamstring-quadriceps (H/Q) strength ratio (60.7 ± 11.0 vs 79.5 ± 18.6, P < .01) and lower Limb Symmetry Index in flexion (85.6 ± 16.1 vs 95.5 ± 15.7, P = .01) whereas QT patients had a lower Limb Symmetry Index in extension (67.3 ± 9.5 vs 77.4 ± 10.7, P < .01). The H/Q ratio at 6 months was lower in HT patients (59.4 ± 11.5 vs 66.2 ± 7.5, P < .01). Patient-Reported Outcomes Measurement Information System and International Knee Documentation Committee scores were not different at 3 months or latest follow-up. QT patients had more wound issues (20.0% vs 2.3%, P = .01). Patients receiving HT autograft had more ipsilateral knee injuries (18.2% vs 2.5%, P = .03), but there was no difference in graft failure for ACLR using HT versus QT (9.1% vs 2.5%, P = .36). CONCLUSIONS There were no differences in patient-reported outcome measures between patients receiving QT autografts and those receiving HT autografts. Patients with QT grafts had more postoperative wound issues but a lower rate of ipsilateral knee complications (graft failure or meniscal tear). Differences in quadriceps and hamstring strength postoperatively compared with the contralateral limb were observed for adolescent ACLR patients receiving QT and HT autografts, respectively. This contributed to higher H/Q ratios seen at 3 and 6 months postoperatively for patients receiving QT autografts. LEVEL OF EVIDENCE Level III, retrospective comparative therapeutic study.
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Affiliation(s)
- Joshua T Bram
- Division of Orthopaedics, The Hub for Clinical Collaboration, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Alexandra C Stevens
- Division of Orthopaedics, The Hub for Clinical Collaboration, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Elliot Greenberg
- Department of Physical Therapy, Specialty Care and Surgery Center, Bucks County, The Children's Hospital of Philadelphia, Chalfont, Pennsylvania, U.S.A
| | - Christopher J DeFrancesco
- Division of Orthopaedics, The Hub for Clinical Collaboration, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Itai Gans
- Division of Orthopaedics, The Hub for Clinical Collaboration, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Robert L Parisien
- Division of Orthopaedics, The Hub for Clinical Collaboration, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Theodore J Ganley
- Division of Orthopaedics, The Hub for Clinical Collaboration, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A..
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Ebert JR, Calvert ND, Radic R. A Prospective Randomized Controlled Trial Investigating Quadriceps Versus Hamstring Tendon Autograft in Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2024; 52:660-669. [PMID: 38284303 PMCID: PMC10905979 DOI: 10.1177/03635465231222279] [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: 07/15/2023] [Accepted: 11/06/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND Numerous graft options are available when undertaking anterior cruciate ligament (ACL) reconstruction (ACLR), although a lack of high-quality evidence exists comparing quadriceps (QT) and hamstring (HT) autografts. PURPOSE To investigate patient outcomes in patients undergoing HT versus QT ACLR. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS After recruitment and randomization, 112 patients (HT = 55; QT = 57) underwent ACLR. Patients were assessed pre- and postoperatively (6 weeks and 3, 6, 12, and 24 months), with a range of patient-reported outcome measures (PROMs), graft laxity (KT-1000 arthrometer; primary outcome variable), active knee flexion and extension range of motion (ROM), peak isokinetic knee extensor and flexor strength, and a 6-hop performance battery. Limb symmetry indices (LSIs) were calculated for strength and hop measures. Secondary procedures, ACL retears, and contralateral ACL tears were reported. RESULTS All PROMs and knee ROM measures significantly improved (P < .0001), and no other group differences (P > .05) were observed-apart from the Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) score, which was significantly better in the HT group at 3 (P = .008), 6 (P = .010), and 12 (P = .014) months. No significant changes were observed in side-to-side laxity from 6 to 24 months (P = .105), and no group differences were observed (P = .487) at 6 (HT mean, 1.2; QT mean, 1.3), 12 (HT mean, 1.1; QT mean, 1.3), and 24 (HT mean, 1.1; QT mean, 1.2) months. While the HT group demonstrated significantly greater (P < .05) quadriceps strength LSIs at 6 and 12 months, the QT group showed significantly greater (P < .05) hamstring strength LSIs at 6, 12, and 24 months. The HT group showed significantly greater (P < .05) LSIs for the single horizontal (6 months), lateral (6 and 12 months), and medial (6 months) hop tests for distance. Up until 24 months, 1 patient (QT at 22 months) had a retear, with 2 contralateral ACL tears (QT at 19 months; HT at 23 months). Secondary procedures included 5 in the HT group (manipulation under anesthesia, notch debridement, meniscal repair, and knee arthroscopy for scar tissue) and 6 in the QT group (notch debridement, meniscal repair, knee arthroscopy for scar tissue, tibial tubercle transfer, and osteochondral autologous transplantation). CONCLUSION Apart from the ACL-RSI, the 2 autograft groups compared well for PROMs, knee ROM, and laxity. However, greater hamstring strength LSIs were observed for the QT cohort, with greater quadriceps strength (and hop test) LSIs in the HT cohort. The longer-term review will continue to evaluate return to sports and later-stage reinjury between the 2 graft constructs. REGISTRATION ACTRN12618001520224p (Australian New Zealand Clinical Trials Registry).
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Affiliation(s)
- Jay R. Ebert
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Perth, Western Australia, Australia
- HFRC Rehabilitation Clinic, Perth, Western Australia, Australia
- Perth Orthopaedic & Sports Medicine Research Institute, Perth, Western Australia, Australia
| | - Nicholas D. Calvert
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Perth, Western Australia, Australia
- Perth Orthopaedic & Sports Medicine Research Institute, Perth, Western Australia, Australia
- Department of Orthopaedics, Royal Perth Hospital, Perth, Western Australia, Australia
- Perth Orthopaedic & Sports Medicine Centre, Perth, Western Australia, Australia
| | - Ross Radic
- Perth Orthopaedic & Sports Medicine Research Institute, Perth, Western Australia, Australia
- Department of Orthopaedics, Royal Perth Hospital, Perth, Western Australia, Australia
- Perth Orthopaedic & Sports Medicine Centre, Perth, Western Australia, Australia
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
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Meena A, Farinelli L, Hoser C, Abermann E, Hepperger C, Patralekh MK, Herbort M, Fink C. Primary Versus Revision ACL Reconstruction Using Quadriceps Autograft: A Matched-Control Cohort Study. Orthop J Sports Med 2024; 12:23259671231224501. [PMID: 38313755 PMCID: PMC10836136 DOI: 10.1177/23259671231224501] [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: 07/18/2023] [Accepted: 08/10/2023] [Indexed: 02/06/2024] Open
Abstract
Background The incidence of anterior cruciate ligament (ACL) reconstruction is increasing, and quadriceps tendon (QT) autograft is gaining popularity for both primary and revision ACL reconstruction. Purpose To evaluate the differences in the patient-reported functional outcomes, concomitant injuries, and graft failure in primary versus revision ACL surgery using QT autograft. Study Design Cohort study; Level of evidence, 3. Methods A total of 376 patients with primary ACL reconstruction and 138 patients with revision ACL reconstruction were retrospectively retrieved from a prospectively collected ACL registry. A minimally invasive technique was used for QT autograft harvesting. The surgical procedure and rehabilitation protocol were identical in both groups. To maintain a homogeneous cohort for the study, the groups were matched by age, sex, and preinjury outcome scores (Lysholm knee score, Tegner activity level, and visual analog scale [VAS] for pain). Initial baseline assessments of outcome scores were compared with scores collected at the 2-year postoperative mark. Results The mean age of the primary group and revision group was 32.9 ± 10.2 years (range, 18-55 years) and 32.3 ± 9.9 years (range, 19-55 years) respectively. Significant preinjury to postoperative improvements were noted in Lysholm (88.2 ± 16.4 vs 83.5 ± 15.0; P = .007) and VAS pain (0.9 ± 1.3 vs 1.5 ± 1.6; P = .001) scores after primary ACL reconstruction compared with revision reconstruction. However, no significant difference was found in Tegner activity level (6.7 ± 1.8 vs 5.9 ± 1.8; P > .430). Primary ACL injury was associated with significantly higher concomitant medial collateral ligament injuries (P = .019), while the revision group was associated with significantly higher concomitant cartilage (P = .001) and meniscal (P = .003) injuries. A significantly higher graft failure rate was noted in the revision group compared with the primary ACL reconstruction group (13.0% vs 5.6%; P = .005). Conclusion Both primary and revision ACL reconstruction with QT autograft had acceptable functional outcomes. The primary group had better outcomes than the revision group, possibly due to the lower prevalence of meniscal and cartilage injuries in the primary group compared with the revision group. The revision group was associated with higher graft failure than the primary group. QT autograft is a viable graft choice for both primary and revision ACL reconstruction.
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Affiliation(s)
- Amit Meena
- Gelenkpunkt–Sports and Joint Surgery, FIFA Medical Center of Excellence, Innsbruck, Austria
- Research Unit for Orthopedic Sports Medicine and Injury Prevention (OSMI), Private University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria
| | - Luca Farinelli
- Clinical Orthopedics, Department of Clinical and Molecular Sciences. Università Politecnica delle Marche, Ancona, Italy
| | - Christian Hoser
- Gelenkpunkt–Sports and Joint Surgery, FIFA Medical Center of Excellence, Innsbruck, Austria
- Research Unit for Orthopedic Sports Medicine and Injury Prevention (OSMI), Private University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria
| | - Elisabeth Abermann
- Gelenkpunkt–Sports and Joint Surgery, FIFA Medical Center of Excellence, Innsbruck, Austria
- Research Unit for Orthopedic Sports Medicine and Injury Prevention (OSMI), Private University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria
| | - Caroline Hepperger
- Gelenkpunkt–Sports and Joint Surgery, FIFA Medical Center of Excellence, Innsbruck, Austria
| | - Mohit Kumar Patralekh
- Central Institute of Orthopedics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Mirco Herbort
- Research Unit for Orthopedic Sports Medicine and Injury Prevention (OSMI), Private University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria
- OCM Clinic, Munich, Germany
| | - Christian Fink
- Gelenkpunkt–Sports and Joint Surgery, FIFA Medical Center of Excellence, Innsbruck, Austria
- Research Unit for Orthopedic Sports Medicine and Injury Prevention (OSMI), Private University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria
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Vivekanantha P, Nedaie S, Hassan Z, Abdel Khalik H, Carsen S, Nagai K, Hoshino Y, de Sa D. Contralateral hamstring autografts do not provide benefit compared to ipsilateral hamstring autografts in primary or revision anterior cruciate ligament reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc 2023; 31:5641-5651. [PMID: 37864773 DOI: 10.1007/s00167-023-07597-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/18/2023] [Indexed: 10/23/2023]
Abstract
PURPOSE To evaluate the clinical outcomes of primary or revision ACL reconstruction (ACLR) after contralateral hamstring autografts versus ipsilateral hamstring autograft harvest. METHODS Three databases (MEDLINE, PubMed and EMBASE) were searched from inception to April 27th, 2023 for studies investigating contralateral hamstring autografts in primary or revision ACLR. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, strength measures, patient-reported outcome measures (PROMs), and rates of positive Lachman test, positive pivot-shift test and graft rupture were extracted. PROMs included Lysholm, International Knee Documentation Committee (IKDC) and Tegner scores. RESULTS Nine studies comprising 371 patients were included in this review. In primary ACLR, there were no significant differences between contralateral and ipsilateral groups in isokinetic hamstring torque in the non-ACLR limb or isokinetic quadriceps torque in both limbs when tested at 60, 90, 120 or 180 degrees/second. Isokinetic hamstring torque in the non-ACLR limb was significantly weaker in the contralateral group at six months for primary ACLR; however, these deficits did not persist. There were no significant differences in postoperative median Tegner scores and Lysholm scores between contralateral and ipsilateral groups in primary ACLR. There were no significant differences in postoperative median Tegner, mean Lysholm and IKDC scores between groups in revision ACLR. There were no significant differences in positive Lachman, positive pivot-shift and rupture rates in primary ACLR between groups. Rates of positive Lachman and pivot-shift were slightly higher in the contralateral than ipsilateral group for revision ACLR. CONCLUSION Contralateral hamstring autografts results in comparable muscle strength to ipsilateral hamstring autografts, with the exception of weaker hamstring strengths in the early postoperative period. Patient-reported outcome measures were similar between the two groups across both primary and revision ACLR, with rates of instability and failure being similar between groups for primary ACLR. Contralateral hamstring grafts do not provide additional benefit when compared to ipsilateral options for either primary or revision ACLR, and should be used only in select circumstances including insufficient ipsilateral hamstring grafts or situations where quadriceps or patella autografts are not optimal. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
| | - Soroush Nedaie
- Michael DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Zackariyah Hassan
- Michael DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Hassaan Abdel Khalik
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Center, 1200 Main St West, Hamilton, ON, L8S 4L8, Canada
| | - Sasha Carsen
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Kanto Nagai
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Center, 1200 Main St West, Hamilton, ON, L8S 4L8, Canada.
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Ashy C, Bailey E, Hutchinson J, Brennan E, Bailey R, Michael Pullen W, Xerogeanes JW, Slone HS. Quadriceps tendon autograft has similar clinical outcomes when compared to hamstring tendon and bone-patellar tendon-bone autografts for revision ACL reconstruction: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2023; 31:5463-5476. [PMID: 37804345 DOI: 10.1007/s00167-023-07592-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 09/11/2023] [Indexed: 10/09/2023]
Abstract
PURPOSE Research regarding revision anterior cruciate ligament reconstruction (RACLR) with quadriceps tendon (QT) autografts is lacking. The purpose of this study was to perform a systematic review and meta-analysis of RACLR with QT and compare its patient outcomes to RACLR with hamstring tendon (HT) and bone-patellar tendon-bone (BTB) autografts. METHODS Adhering to PRISMA guidelines, a search for studies using QT in RACLR was performed within PubMed, Scopus, and CINAHL from database date of inception through December 26, 2022. Primary outcomes sought included: failure rate, Lysholm scores, International Knee Documentation Committee (IKDC) scores, IKDC grades, arthrometric knee side-to-side differences (STSD), pivot shift grade, donor site morbidity, return to sport, visual analog scale (VAS) pain scores. RESULTS Nine studies were included consisting of 606 RACLR: 349 QT, 169 HT, and 88 BTB. Overall failure rates were 7.6% QT, 13.3% HT, and 8.7% BTB. Mean weighted Lysholm scores were 85.8 ± 3.8 QT, 82.5 ± 3.8 HT and 86.6 ± 4.5 BTB. IKDC average scores were 82.3 ± 1.6 QT, 80.1 ± 1.7 HT, and 81.7 ± 5.5BTB. Combined rates of IKDC A/B grades were 88.4% and 80.0% for QT and HT, respectively. VAS average scores were 0.9 ± 1.1 QT, 1.4 ± 0.2 HT, and 0.7 ± 0.8 for BTB. Side-to-side difference was reported for QT and HT with average values of 1.7 ± 0.6 mm and 2.1 ± 0.5 mm, respectively. Grade 0 or 1 pivot shifts were reported in 96.2% of QT patients and 91.3% of HT. Donor site morbidity, only reported for QT and HT, was 14.6 ± 9.7% and 23.6 ± 14.1%, respectively. QT resulted in a mean Tegner score of 5.9 ± 1.5 versus HT 5.7 ± 1.5. Rate of return to pivoting sports was 38.0% QT, 48.6% HT, and 76.9% BTB. Across all outcomes, there was no significant difference when comparing QT to HT, QT to BTB, and QT compared to HT and BTB combined. CONCLUSIONS RACLR with QT yields satisfactory patient reported outcomes, satisfactory improvement in knee laxity, expected return to sport rates, and has an overall 7.6% failure rate. Outcomes are comparative to those of HT and BTB making it an acceptable graft choice for RACLR. Surgeons should consider using QT autograft for RACLR, especially when other autografts are unavailable. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Cody Ashy
- Department of Orthopaedics and Physical Medicine, Clinical Sciences Building, CSB, Medical University of South Carolina, 96 Jonathan Lucas Street, MSC Code: 708, Charleston, SC, 29425, USA.
| | - Evan Bailey
- College of Medicine, Medical University of South Carolina, Charleston, USA
| | - Joshua Hutchinson
- College of Medicine, Medical University of South Carolina, Charleston, USA
| | - Emily Brennan
- MUSC Libraries, Medical University of South Carolina, Charleston, USA
| | | | - William Michael Pullen
- Department of Orthopaedics and Physical Medicine, Clinical Sciences Building, CSB, Medical University of South Carolina, 96 Jonathan Lucas Street, MSC Code: 708, Charleston, SC, 29425, USA
| | | | - Harris S Slone
- Department of Orthopaedics and Physical Medicine, Clinical Sciences Building, CSB, Medical University of South Carolina, 96 Jonathan Lucas Street, MSC Code: 708, Charleston, SC, 29425, USA
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Marcaccio SE, Morrissey PJ, Testa EJ, Fadale PD. Role of Quadriceps Tendon Autograft in Primary and Revision Anterior Cruciate Ligament Reconstruction. JBJS Rev 2023; 11:01874474-202310000-00002. [PMID: 37812667 PMCID: PMC10558152 DOI: 10.2106/jbjs.rvw.23.00057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
» The quadriceps tendon (QT) autograft is becoming increasingly popular in both primary and revision anterior cruciate ligament reconstruction (ACLR).» The biomechanical properties of the QT are similar to those of the native ACL, the hamstring tendon (HT), and bone-patellar tendon-bone (BTB) autografts.» QT autograft allows surgeons to be flexible with their graft size and reconstruction technique.» The QT autograft performs in a similar fashion to the BTB and HT autografts, with excellent patient-reported outcomes, consistent postoperative knee stability, and low rates of postoperative complications including graft failure and donor site morbidity.» There are emerging data that the QT autograft is a viable option in revision ACLR.
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Affiliation(s)
- Stephen E. Marcaccio
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Patrick J. Morrissey
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Edward J. Testa
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Paul D. Fadale
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Meena A, Farinelli L, Hoser C, Abermann E, Raj A, Hepperger C, Herbort M, Fink C. Revision ACL reconstruction using quadriceps, hamstring and patellar tendon autografts leads to similar functional outcomes but hamstring graft has a higher tendency of graft failure. Knee Surg Sports Traumatol Arthrosc 2023; 31:2461-2468. [PMID: 36266369 PMCID: PMC10183416 DOI: 10.1007/s00167-022-07200-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/10/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the differences in the patient-reported functional outcomes, and graft failure in revision ACL reconstruction using quadriceps tendon (QT), Hamstring tendon (HT) and bone-patellar tendon-bone (BPTB) autografts. METHODS Between 2010 and 2020, 97 patients who underwent revision ACL reconstruction (40 patients received a QT, 26 an HT and 31 a BPTB graft) met the inclusion criteria. Pre-injury and at 2-year postoperatively patients were evaluated for patient-reported functional outcomes; Lysholm knee score, Tegner activity level and VAS (visual analogue scale) for pain; and graft failure. Patient-reported outcomes and graft failure were compared between the QT, HT and BPTB groups. The patients with graft failure were not included for outcome analysis at 2-years of follow-up. RESULTS All three revision groups with QT, HT and BPTB autograft did not differ significantly in terms of age, sex, time from injury to surgery, concomitant injuries and single-stage or double-stage procedures (n.s.). No significant difference was found in the pre-injury patient-reported outcome; Lysholm knee score, Tegner activity and VAS for pain (n.s.) between the three groups. At the 2-year follow-up functional outcomes improved in all three groups and all the patients returned to pre-injury activity level; however, no significant difference was found in functional outcomes at the 2-year follow-up between the three groups (n.s.). Graft failure occurred in 4 (10%), 5 (19%) and 3 (10%) patients of QT, HT and BPTB groups, respectively. However, the rate of failure did not differ significantly between groups. CONCLUSION All three autografts (QT, HT and BPTB) demonstrated satisfactory patient-reported outcomes in revision ACL reconstruction. Compared with QT and BPTB grafts, HT graft showed a higher tendency for failure rates. With the increasing incidence of revision ACL reconstruction, surgeons should be aware of all the available graft options. The findings of this study will assist the surgeons in the graft selection for revision ACL reconstruction. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Amit Meena
- Gelenkpunkt-Sports and Joint Surgery, FIFA Medical Centre of Excellence, Olympiastraße 39, 6020 Innsbruck, Austria
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Medical Informatics and Technology, Private University for Health Sciences, Innsbruck, Austria
| | - Luca Farinelli
- Clinical Orthopaedics, Department of Clinical and Molecular Sciences, Università Politecnica Delle Marche, Ancona, Italy
| | - Christian Hoser
- Gelenkpunkt-Sports and Joint Surgery, FIFA Medical Centre of Excellence, Olympiastraße 39, 6020 Innsbruck, Austria
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Medical Informatics and Technology, Private University for Health Sciences, Innsbruck, Austria
| | - Elisabeth Abermann
- Gelenkpunkt-Sports and Joint Surgery, FIFA Medical Centre of Excellence, Olympiastraße 39, 6020 Innsbruck, Austria
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Medical Informatics and Technology, Private University for Health Sciences, Innsbruck, Austria
| | - Akshya Raj
- Central Institute of Orthopaedics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029 India
| | - Caroline Hepperger
- Gelenkpunkt-Sports and Joint Surgery, FIFA Medical Centre of Excellence, Olympiastraße 39, 6020 Innsbruck, Austria
| | - Mirco Herbort
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Medical Informatics and Technology, Private University for Health Sciences, Innsbruck, Austria
- OCM Clinic, Munich, Germany
| | - Christian Fink
- Gelenkpunkt-Sports and Joint Surgery, FIFA Medical Centre of Excellence, Olympiastraße 39, 6020 Innsbruck, Austria
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Medical Informatics and Technology, Private University for Health Sciences, Innsbruck, Austria
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Hetsroni I, Fuchs Y, Mann G, Ohana N. Ipsilateral Quadriceps Tendon-Bone ACL Revision Reconstruction to Address Failed Primary Bone-Patellar Tendon-Bone ACL Reconstruction with Persistent Patellar Bone Defect. Arthrosc Tech 2023; 12:e491-e501. [PMID: 37138693 PMCID: PMC10150001 DOI: 10.1016/j.eats.2022.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/25/2022] [Indexed: 05/05/2023] Open
Abstract
Bone-patellar tendon-bone (BPTB) autograft is a popular graft choice for anterior cruciate ligament reconstruction (ACLR) in active young adults. In case of BPTB ACLR failure, the 3 most popular autograft choices for a revision surgery include contralateral BPTB, contralateral or ipsilateral hamstrings autograft, and contralateral or ipsilateral quadriceps tendon autograft. Quadriceps tendon autograft has been gaining increasing popularity in recent years in this respect, but using quadriceps tendon-bone autograft in the setup of a previous use of ipsilateral BPTB autograft deserves special technical considerations, with emphasis on preserving patellar bone integrity. We describe a technique for performing revision ACLR after failed primary BPTB ACLR by using ipsilateral quadriceps tendon-bone autograft in the setup of persistent distal patellar bone defect. Using this autograft benefits the advantages of highly resilient graft tissue in addition to fast bone-to-bone healing on the femoral side, and it can be an excellent choice in revision reconstruction for surgeons who prefer tendon-bone autograft for highly active young adults and specifically when the patients underwent bilateral primary autologous BPTB ACLRs.
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Affiliation(s)
- Iftach Hetsroni
- Address correspondence to Iftach Hetsroni, M.D., Sports Medicine Injuries Service, Department of Orthopedic Surgery, Meir General Hospital, Tsharnichovski Street 59, Kfar Saba 44281, Israel.
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Meena A, Di Paolo S, Grassi A, Raj A, Farinelli L, Hoser C, Tapasvi S, Zaffagnini S, Fink C. No difference in patient reported outcomes, laxity, and failure rate after revision ACL reconstruction with quadriceps tendon compared to hamstring tendon graft: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2023:10.1007/s00167-023-07380-5. [PMID: 36961538 DOI: 10.1007/s00167-023-07380-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/01/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE The purpose of this study was to synthesize and quantitatively assess the outcomes of ACL Revision using a quadriceps tendon (QT) graft and to compare them with those of ACL Revisions performed with hamstring tendons (HT) graft. METHODS A comprehensive search based on the PRISMA protocol was performed across PubMed, Scopus, Embase, and Cochrane Library from inception until February 2022. Clinical studies reporting the outcomes of ACL Revision with QT autograft were included. Subjective and Objective IKDC, Tegner activity level, Lysholm knee score, KOOS score, VAS for pain, knee laxity (KT-1000/2000 arthrometer, Lachman test, and pivot-shift test), and graft failure were assessed. A systematic review and meta-analysis were performed and a quality assessment of the included studies was carried out with the MINORS score. RESULTS Seven studies met the selection criteria and were included in the systematic review for the qualitative synthesis of data. A pooled mean of all the variables was provided for the 7 studies, while 3 studies included a control group of ACL Revision with HT and were included in a meta-analysis. A total of 420 participants with a mean age of 28.9 ± 10.5 years and a mean postoperative follow-up of 39.3 ± 16.4 months were assessed. Of these, 277 patients underwent ACL Revision with QT and 143 patients underwent ACL Revision with HT. In the QT group, average graft failure was 9.8% compared to 17.4% in the HT group. KOOS Sport and pivot-shift test showed better postoperative outcomes in QT than HT, although it was not statistically significant (p = 0.052). CONCLUSION The QT autograft was associated with an improved trend of rotatory laxity, PROMs and failure rate compared to HT autograft after revision ACL reconstruction. The QT autograft for revision ACL reconstruction is supported by the current literature. It is a viable graft that should be considered for both primary and revision ACL reconstruction. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Amit Meena
- Gelenkpunkt-Sports and Joint Surgery, FIFA Medical Centre of Excellence, Olympiastraße 39, 6020, Innsbruck, Austria
- Research Unit for Orthopedic Sports Medicine and Injury Prevention (OSMI), Medical Informatics and Technology, Private University for Health Sciences, Innsbruck, Austria
- Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, ON, Canada
| | - Stefano Di Paolo
- Department for Life Quality Studies, University of Bologna, Bologna, Italy
| | - Alberto Grassi
- IIa Clinica Ortopedica E Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Akshya Raj
- Central Institute of Orthopedics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029, India
| | - Luca Farinelli
- Clinical Orthopedics, Department of Clinical and Molecular Sciences, Università Politecnica Delle Marche, Ancona, Italy
| | - Christian Hoser
- Gelenkpunkt-Sports and Joint Surgery, FIFA Medical Centre of Excellence, Olympiastraße 39, 6020, Innsbruck, Austria
- Research Unit for Orthopedic Sports Medicine and Injury Prevention (OSMI), Medical Informatics and Technology, Private University for Health Sciences, Innsbruck, Austria
| | | | - Stefano Zaffagnini
- IIa Clinica Ortopedica E Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Christian Fink
- Gelenkpunkt-Sports and Joint Surgery, FIFA Medical Centre of Excellence, Olympiastraße 39, 6020, Innsbruck, Austria.
- Research Unit for Orthopedic Sports Medicine and Injury Prevention (OSMI), Medical Informatics and Technology, Private University for Health Sciences, Innsbruck, Austria.
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10
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Wolfson TS, Mannino B, Owens BD, Waterman BR, Alaia MJ. Tunnel Management in Revision Anterior Cruciate Ligament Reconstruction: Current Concepts. Am J Sports Med 2023; 51:545-556. [PMID: 34766840 DOI: 10.1177/03635465211045705] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Bone tunnel-related complications are frequently encountered during revision anterior cruciate ligament reconstruction (ACLR). Issues with tunnel positioning, enlargement, containment, and hardware interference may complicate surgery and compromise outcomes. As a result, several strategies have emerged to address these issues and optimize results. However, a systematic, unified approach to tunnel pathology in revision ACLR is lacking. The purpose of this review is to highlight the current state of the literature on bone tunnel complications and, although extensive literature on the subject is lacking, present an updated approach to the evaluation and management of tunnel-related issues in revision ACLR.
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Affiliation(s)
| | | | - Brett D Owens
- Brown University Alpert Medical School, East Providence, Rhode Island, USA
| | - Brian R Waterman
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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11
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ANDREZ TÁSSIONAVAJAS, CHAGAS JÚLIABEZERRAMARTINS, D’OLIVEIRA LÍVIABAPTISTA. GRAFTS FOR ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: SYSTEMATIC REVIEW AND META-ANALYSIS. ACTA ORTOPEDICA BRASILEIRA 2022; 30:e256048. [PMID: 36561474 PMCID: PMC9757723 DOI: 10.1590/1413-785220223006e256048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 11/01/2021] [Indexed: 12/23/2022]
Abstract
Objective This study proposes to systematically review the literature and compare data on (1) function, (2) pain, (3) return to sport, and (4) complications after anterior cruciate ligament (ACL) reconstruction with quadriceps tendon autograft (QT) and hamstring tendon autograft (HT). Methods In June 2021, a systematic review of the EMBASE, MEDLINE/PubMed, Cochrane Central Register of Controlled Trials, and LILACS databases was performed, based on PRISMA guidelines. The search strategy included the keywords: "Previous Cruciate Ligament Reconstruction," "ACL reconstruction," "quadriceps tendon autograft," "quadriceps graft," "Hamstring-Tendon Autografts." Meta-analyses were performed using Review Manager software (RevMan Web). Results There were no significant differences between the two groups regarding function according to Lysholm score (MD 3.01; CI-0.30, 6.33, p = 0.08), the presence of pain (RR 0.89; CI-0.57, 1.39, p = 0.60), and re-rupture (RR 0.60; IC-0.19, 1.88, p = 0.38). Conclusion QT and HT autografts show comparatively good results in ACL reconstruction without significant differences regarding function, pain, and rupture after surgical intervention. Level of Evidence II, Systematic Review of Level II Studies.
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12
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Petersen W, Ohde J, Karpinski K, Bierke S, Häner M. Technique of ACL Reconstruction With Autologous Quadriceps Tendon Bone Graft and Femoral Press Fit Fixation. VIDEO JOURNAL OF SPORTS MEDICINE 2022. [DOI: 10.1177/26350254221122506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background: Recently, there has been an increase in interest in the quadriceps tendon (QT) as an alternative autologous graft option for primary anterior cruciate ligament (ACL) reconstruction. Indication: Anterior cruciate ligament reconstruction in skeletally mature patients (high-risk patients for re-rupture and patients with medial instability). Technique Description: The QT graft is harvested with a 4-cm skin incision over the superior pole of the patella. A double knife and an oscillating saw are used to obtain the QT graft with a bone block from the patella (65 mm x 10 mm graft and 15 mm bone block). Then an arthroscopy is carried out with assessment of the ACL tear and treatment of further intraarticular injuries. ACL reconstruction begins with debridement of the femoral insertion to expose the land marks. The medial portal is used for femoral tunnel drilling with the knee in more than 110° of flexion. A special portal aiming device is introduced via the anteromedial portal and a guide wire is placed in the area of the femoral anteromedial insertion. This guide wire is gradually overdrilled with various drills and dilators of increasing size. The final diameter should be 0.5 mm smaller than the diameter of the bone block of the graft to allow for press-fit fixation. Then, the tibial tunnel is drilled using a tibial drill guide leaving the tibial stump of the original ACL intact. The graft is pulled into the joint through the tibial tunnel until the bone block stops at the femoral tunnel entrance. The bone block is then pushed through the medial portal into the femoral tunnel (press-fit fixation). The tibial fixation is performed with an interference screw and optionally with an extracortical button. Results: Prior studies with 2 years follow-up have shown that the clinical outcomes in primary and revision ACL reconstruction were not significantly different between the use of QT grafts with femoral press-fit fixation and the use of hamstring grafts with femoral suspension fixation. Discussion/Conclusion: Quadriceps tendon bone autograft and femoral press-fit fixation provides an excellent alternative as a graft choice in ACL reconstruction. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
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Baker HP, Bhattacharjee S, Poff C, Bartolotta C, Athiviraham A. Postoperative Anterior Cruciate Ligament Reconstruction Quadricep and Patella Tendon Rupture, Infection, and Lysis of Adhesions Decreased Despite Changing Graft Trends Over the Past Decade. Arthrosc Sports Med Rehabil 2022; 4:e1437-e1443. [PMID: 36033204 PMCID: PMC9402459 DOI: 10.1016/j.asmr.2022.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/27/2022] [Indexed: 11/17/2022] Open
Abstract
Purpose To investigate recent trends in postoperative complications following anterior cruciate ligament (ACL) reconstruction. Methods Patients who underwent ACL reconstruction surgery were identified in a national insurance database and separated into 2 cohorts based on the date of their initial surgery comprising the years 2010 to 2012 and 2016 to 2018, respectively. Patients were matched 1:1 based on comorbidities and Elixhauser Comorbidity Index. All patients were assessed for postoperative complications within 18 months of surgery. Rate of complication was compared between cohorts. Results Overall, the all-cause complication rate was 2%. There were significantly more quadriceps tendon rupture, patella tendon rupture, lysis of adhesion, and infection in the early cohort. There were significantly more instances of deep vein thrombosis in the late cohort. We found no significant difference in manipulations under anesthesia between the 2 cohorts. Conclusions Patients who underwent surgery in the late cohort had lower rates of postoperative complications, except for deep vein thrombosis. The rate of postoperative quadriceps tendon rupture decreased despite considerable increase in the use of quadriceps tendon autograft. Clinical Relevance As there has been an increased use of quadriceps tendon autografts, but little is known about the postoperative complications after ACL reconstruction with these grafts. This information has the potential to improve patient outcomes.
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Affiliation(s)
- Hayden P. Baker
- Address correspondence to Hayden P. Baker, M.D., 5758 S. Maryland Ave., Dept. 4B, Chicago, IL 60637.
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14
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Direct suturing quadriceps tendon to a continuous loop with a suspensory button provides biomechanically superior fixation in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2022; 30:2307-2313. [PMID: 34807305 DOI: 10.1007/s00167-021-06805-3] [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: 08/25/2021] [Accepted: 11/11/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To compare the biomechanical strength of different fixation configurations using suspensory buttons in a soft-tissue quadriceps tendon (QT) grafts in anterior cruciate ligament (ACL) reconstruction. METHODS Forty bovine QTs, 6-cm long and 10-mm wide, were allocated into four groups with different suture configurations using suspensory buttons (n = 10 in each group): Group A, a baseball suture with a knot tied to the continuous loop with a suspensory button; Group B, same configuration as in Group A but with the knot tied at the opposite end of the baseball suture; Group C, a continuous loop with a suspensory button stitched directly to the QT with simple sutures, and Group D, a baseball suture tied directly to a suspensory button. Biomechanical testing was performed by preloading followed by cyclic loading for 500 cycles between 10 and 100 N. The length of elongation (mm) and maximum load to failure (N) were recorded, and compared among the four groups. RESULTS Group C showed significantly smaller elongation (4.1 mm [95% CI 3.1-5.2]) than Group A (8.2 mm [95% CI 7.0-9.4]), Group B (10.5 mm [95% CI 7.7-13.3]), and Group D (8.5 mm [95% CI 7.0-9.9]) (A-C; P = 0.004, B-C; P = 0.0001, C-D; P = 0.0018). The maximum load to failure in Group C (386 N [95%CI 306-466]) was significantly higher than that in Group A (196 N [95% CI 141-251]), Group B (226 N [95% CI 164-289]), and Group D (212 N [95%CI 171-253]) (A-C; P = 0.0001, B-C; P = 0.0009, C-D; P = 0.0002). No significant differences were observed between Group A, B, and D in terms of elongation and maximum load to failure. CONCLUSION The soft-tissue QT graft fixation configuration stitched directly to a continuous loop with suspensory button using simple sutures exhibits small elongation and high maximum load to failure among the four configurations. Regarding clinical relevance, direct suturing of the soft-tissue QT to a continuous loop with a suspensory button may be advantageous for femoral fixation in ACL reconstruction from a biomechanical perspective, and warrant future development of a novel fixation device using this principle.
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15
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de Souza Borges JH, Oliveira M, Junior PL, de Souza Machado R, Lima R, Ramos LA, Cohen M. Is contralateral autogenous patellar tendon graft a better choice than ipsilateral for anterior cruciate ligament reconstruction in young sportsmen? A randomized controlled trial. Knee 2022; 36:33-43. [PMID: 35468330 DOI: 10.1016/j.knee.2022.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 02/09/2022] [Accepted: 03/29/2022] [Indexed: 02/02/2023]
Abstract
AIM The aim of this study was to compare the peak extensor torque (primary outcome), sensory-motor capacity and Lysholm questionnaire score up to the fourth postoperative month post-primary anterior cruciate ligament reconstruction (ACLR) with bone-patellar-tendon-bone (BPTB) graft using either ipsilateral or contralateral technique in young sportsmen. METHODS We performed a randomized controlled trial from 2018 to 2019. The same preoperative protocol, surgical technique and postoperative protocol were used in both groups. Eighty-eight young adult male patients were randomized, and 44 of each group completed the trial. RESULTS After the follow up analysis, the contralateral receptor and donor limb demonstrated a statistically significant increase in peak extension torque compared with the ipsilateral operated limb (effect size (ES) = 0.99, power = 0.99, P < 0.0001; ES = 0.46, power = 0.56, P < 0.04). The symmetry between limbs was compared between groups. In the contralateral group, there was a significant decrease in the recipient limb (after surgery), compared with the donor limb (before surgery) (ES = 0.87, power = 0.99, P < 0.0001). In the ipsilateral group, the operated limb demonstrated a significant decrease in peak extension torque compared with the non-operated limb after surgery (ES = 1.88, power = 0.99, P < 0.0001). The comparison between groups in sensory-motor capacity and Lysholm score demonstrated a non-significant group effect postoperatively. CONCLUSION The use of contralateral BPTB is more effective in increasing peak extension torque when compared with ipsilateral technique in young sportsmen. Furthermore, patients achieved greater symmetry (side to side) in quadriceps muscle performance after the 4-month follow up with a contralateral graft.
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Affiliation(s)
- Jose Humberto de Souza Borges
- Institute of Research and Teaching, Orthopedic Hospital and Specialized Medicine (IPE - H O M E), Brasília, Distrito Federal, Brazil; Department of Orthopedics, Traumatology and Sports Medicine, Federal University of São Paulo (UNIFESP), São Paulo, Brazil.
| | - Marcio Oliveira
- Institute of Research and Teaching, Orthopedic Hospital and Specialized Medicine (IPE - H O M E), Brasília, Distrito Federal, Brazil; University Center of Brasília (UniCEUB), Brasília, Distrito Federal, Brazil
| | - Paulo Lobo Junior
- Institute of Research and Teaching, Orthopedic Hospital and Specialized Medicine (IPE - H O M E), Brasília, Distrito Federal, Brazil
| | - Ronny de Souza Machado
- Institute of Research and Teaching, Orthopedic Hospital and Specialized Medicine (IPE - H O M E), Brasília, Distrito Federal, Brazil
| | - Révia Lima
- Institute of Research and Teaching, Orthopedic Hospital and Specialized Medicine (IPE - H O M E), Brasília, Distrito Federal, Brazil
| | - Leonardo Addêo Ramos
- Department of Orthopedics, Traumatology and Sports Medicine, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Moises Cohen
- Department of Orthopedics, Traumatology and Sports Medicine, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
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Zhang K, Beshay T, Murphy B, Sheean A, de Sa D. Quadriceps Tendon Anterior Cruciate Ligament Reconstruction: A Systematic Review of Postoperative Rehabilitation and Complication Profiles. Arthroscopy 2022; 38:2062-2072.e1. [PMID: 34942315 DOI: 10.1016/j.arthro.2021.12.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 12/09/2021] [Accepted: 12/12/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purposes of this study are to explore current elements for postoperative rehabilitation protocol after quadriceps tendon-anterior cruciate ligament reconstruction (QT-ACLR), outline general timelines for progression of those elements, and explore their associated complication rates and profiles. METHODS In accordance with PRISMA guidelines, 5 online databases (EMBASE, MEDLINE, CINAHL, Cochrane, and PubMed) were searched and screened in duplicate using predetermined criteria for studies on the aforementioned patient population. Descriptive statistics are presented. RESULTS A total of 56 studies were included, with 31 studies using quadriceps tendon with bone block (B-QT) and 26 studies using all-soft tissue quadriceps tendon (S-QT). The majority of studies permitted full weightbearing and range of motion (ROM) within the first 12 postoperative weeks, and motion-controlled braces within 6 weeks. Isometric exercises were initiated within 1 week after surgery, closed-chain exercises within 12 weeks, and open-chain and sports-specific exercises within 36 weeks. Complication profiles were similar between graft types and included graft failure (1.2%-1.6%), cyclops syndrome (0.4%-0.7%), and persistent stiffness (0.9%). CONCLUSIONS Current postoperative rehabilitation strategies in ACLR with QT offer a complication profile comparable to those reported with other graft types. Based on the included rehabilitation regimen, these protocols should focus on early ROM, specifically on achieving full extension, alongside isometric quadriceps strengthening. Progression to closed- and open-chain exercises should follow in a progressive manner, similar to existing protocols in ACLR. Adjuncts such as motion-controlled bracing and continuous passive motion machines may be used if graft protection is prioritized. This review highlights the need for comparison of defined protocols against one another in the setting of QT-ACLR. LEVEL OF EVIDENCE IV, systematic review of Level I-IV studies.
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Affiliation(s)
- Kailai Zhang
- Department of Physical Medicine and Rehabilitation, McMaster University, Hamilton, Ontario, Canada.
| | - Tony Beshay
- Faculty of Science, McMaster University, Hamilton, Ontario, Canada
| | - Ben Murphy
- Niagara Orthopedic Institute Hamilton, Hamilton, Ontario, Canada
| | - Andrew Sheean
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas, U.S.A
| | - Darren de Sa
- Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario, Canada
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Winkler PW, Wagala NN, Hughes JD, Lesniak BP, Musahl V. A high tibial slope, allograft use, and poor patient-reported outcome scores are associated with multiple ACL graft failures. Knee Surg Sports Traumatol Arthrosc 2022; 30:139-148. [PMID: 33517476 PMCID: PMC8800919 DOI: 10.1007/s00167-021-06460-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/18/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE To compare clinical outcomes, radiographic characteristics, and surgical factors between patients with single and multiple anterior cruciate ligament (ACL) graft failures. It was hypothesized that patients experiencing multiple ACL graft failures exhibit lower patient-reported outcome scores (PROs) and a higher (steeper) posterior tibial slope (PTS) than patients with single ACL graft failure. METHODS Patients undergoing revision ACL reconstruction with a minimum follow-up of 12 months were included in this retrospective cohort study. Based on the number of ACL graft failures, patients were assigned either to the group "single ACL graft failure "or" multiple ACL graft failures ". The PTS was measured on strict lateral radiographs. Validated PROs including the International Knee Documentation Committee (IKDC) subjective knee form, Knee Injury and Osteoarthritis Outcome Score, Lysholm Score, Tegner Activity Scale, ACL-Return to Sport after Injury Scale, and Visual Analogue Scale for pain were collected. RESULTS Overall, 102 patients were included with 58 patients assigned to the single ACL graft failure group and 44 patients to the multiple ACL graft failures group. Quadriceps tendon autograft was used significantly more often (55% vs. 11%, p < 0.001) and allografts were used significantly less often (31% vs. 66%, p < 0.001) as the graft for first revision ACL reconstruction in patients with single versus multiple ACL graft failures. Patients with multiple ACL graft failures were associated with statistically significantly worse PROs (IKDC: 61.7 ± 19.3 vs. 77.4 ± 16.8, p < 0.05; Tegner Activity Scale: 4 (range, 0-7) vs. 6 (range 2-10), p < 0.05), higher PTS (12 ± 3° vs. 9 ± 3°, p < 0.001), and higher rates of subsequent surgery (73% vs. 14%, p < 0.001) and complications (45% vs. 17%, p < 0.05) than patients with single ACL graft failure. CONCLUSION Compared to single ACL graft failure in this study multiple ACL graft failures were associated with worse PROs, higher PTS, and allograft use. During the first revision ACL reconstruction, it is recommended to avoid the use of allografts and to consider slope-reducing osteotomies to avoid multiple ACL graft failures and improve PROs. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Philipp W. Winkler
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA 15203 USA ,Department for Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Nyaluma N. Wagala
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA 15203 USA
| | - Jonathan D. Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA 15203 USA
| | - Bryson P. Lesniak
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA 15203 USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA, 15203, USA.
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18
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Worley JR, Brimmo O, Nuelle CW, Zitsch BP, Leary EV, Cook JL, Stannard JP. Revision Anterior Cruciate Ligament Reconstruction after Surgical Management of Multiligament Knee Injury. J Knee Surg 2022; 35:72-77. [PMID: 32544974 DOI: 10.1055/s-0040-1712969] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this study is to determine factors associated with the need for revision anterior cruciate ligament reconstruction (ACLR) after multiligament knee injury (MLKI) and to report outcomes for patients undergoing revision ACLR after MLKI. This involves a retrospective review of 231 MLKIs in 225 patients treated over a 12-year period, with institutional review board approval. Patients with two or more injured knee ligaments requiring surgical reconstruction, including the ACL, were included for analyses. Overall, 231 knees with MLKIs underwent ACLR, with 10% (n = 24) requiring revision ACLR. There were no significant differences in age, sex, tobacco use, diabetes, or body mass index between cohorts requiring or not requiring revision ACLR. However, patients requiring revision ACLR had significantly longer follow-up duration (55.1 vs. 37.4 months, p = 0.004), more ligament reconstructions/repairs (mean 3.0 vs. 1.7, p < 0.001), more nonligament surgeries (mean 2.2 vs. 0.7, p = 0.002), more total surgeries (mean 5.3 vs. 2.4, p < 0.001), and more graft reconstructions (mean 4.7 vs. 2.7, p < 0.001). Patients in both groups had similar return to work (p = 0.12) and activity (p = 0.91) levels at final follow-up. Patients who had revision ACLR took significantly longer to return to work at their highest level (18 vs. 12 months, p = 0.036), but similar time to return to their highest level of activity (p = 0.33). Range of motion (134 vs. 127 degrees, p = 0.14), pain severity (2.2 vs. 1.7, p = 0.24), and Lysholm's scores (86.3 vs. 90.0, p = 0.24) at final follow-up were similar between groups. Patients requiring revision ACLR in the setting of a MLKI had more overall concurrent surgeries and other ligament reconstructions, but had similar final outcome scores to those who did not require revision surgery. Revision ligament surgery can be associated with increased pain, stiffness, and decrease patient outcomes. Revision surgery is often necessary after multiligament knee reconstructions, but patients requiring ACLR in the setting of a MLKI have good overall outcomes, with patients requiring revision ACLR at a rate of 10%.
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Affiliation(s)
- John R Worley
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Olubusola Brimmo
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Clayton W Nuelle
- Department of Orthopaedics, TSAOG Orthopaedics, San Antonio, Texas.,Department of Orthopaedics, Burkhart Research Institute for Orthopaedics, San Antonio, Texas
| | | | - Emily V Leary
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
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19
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Cohen D, Slawaska-Eng D, Almasri M, Sheean A, de Sa D. Quadricep ACL Reconstruction Techniques and Outcomes: an Updated Scoping Review of the Quadricep Tendon. Curr Rev Musculoskelet Med 2021; 14:462-474. [PMID: 34755275 DOI: 10.1007/s12178-021-09726-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an up-to-date summary on the most recent literature examining techniques and outcomes in anterior cruciate ligament (ACL) reconstruction using quadriceps tendon (QT) which will enable surgeons to make well informed evidence-based decisions when choosing a particular graft option and technique in ACL reconstruction. RECENT FINDINGS Several RCTs and systematic reviews have been published recently on this topic, and overall, there were no differences found between the QT, HT, and BPTB groups in patient-reported outcomes, stability testing, or graft re-rupture rates. In terms of strength testing, the QT group did have inferior knee extensor strength on isokinetic testing when compared to the HT group, whereas the HT group had inferior knee flexor strength compared to the QT group. No differences were found on strength testing between the QT and BPTB groups. Currently, two large RCTs, the Stability2 and SQuASH trials, are ongoing examining the effectiveness of the QT vs BPTB with or without LET and QT vs HT in the pediatric population which will help shed further light on the effectiveness of the QT as a graft choice in ACL reconstruction. The findings of this scoping review demonstrate that the QT is an excellent graft option in ACL reconstruction both in the primary and revision settings, among adult and pediatric populations. This review provides surgeons with further assurance when selecting QT autograft in ACL reconstruction.
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Affiliation(s)
- Dan Cohen
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - David Slawaska-Eng
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Mahmoud Almasri
- Mercy Health - Cincinnati Sports Medicine and Orthopaedic Center, Cincinnati, OH, USA
| | - Andrew Sheean
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada. .,McMaster University Medical Centre, 1200 Main St West, 4E, Hamilton, Ontario, L8N 3Z5, Canada.
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20
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Quadriceps tendon has a lower re-rupture rate than hamstring tendon autograft for anterior cruciate ligament reconstruction – A meta-analysis. J ISAKOS 2021; 7:87-93. [DOI: 10.1016/j.jisako.2021.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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21
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Hunnicutt JL, Haynes WB, Slone HS, Prince JA, Boden SA, Xerogeanes JW. Revision Anterior Cruciate Ligament Reconstruction with the All-Soft Tissue Quadriceps Tendon Autograft Has Acceptable Early and Intermediate-Term Outcomes. Arthroscopy 2021; 37:2848-2857. [PMID: 33774061 DOI: 10.1016/j.arthro.2021.03.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 03/13/2021] [Accepted: 03/14/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purposes were to (1) examine early to intermediate-term clinical outcomes and complications of revision anterior cruciate ligament reconstruction (ACLR) using all-soft tissue quadriceps tendon (QT) autografts, and (2) compare quadriceps strength between patients who had hamstring versus patella tendon autografts in their previous reconstruction. METHODS One hundred patients (52 males/48 females; 22.6 ± 8.0 years) undergoing revision ACLR with all-soft tissue QT autografts were prospectively followed. All revision procedures were performed by a single surgeon, using a minimally invasive graft harvest technique and suspensory fixation. Subjective assessment of knee function was obtained before and after surgery with the International Knee Documentation Committee (IKDC) survey. Postoperative knee laxity and isokinetic quadriceps strength were collected at regular intervals. Strength was reported as limb symmetry index (LSI; surgical side divided by nonsurgical side). Complications including hematomas, postoperative loss of knee extension, and graft failures were recorded. To determine clinical significance (P ≤ .05), outcomes were compared using analysis of variance or paired samples t-tests. RESULTS The mean IKDC scores significantly improved (54.3 ± 13.0 vs 82.8 ± 13.8), with an average follow-up of 42.2 ± 21.2 months. There were no significant changes in knee laxity side-to-side differences: 6 weeks (1.2 ± 1.5 mm), 3 months (1.2 ± 1.8 mm), 6 months (1.4 ± 1.6 mm). Quadriceps LSIs significantly improved from 71.6% ± 19.3% at 6 months to 81.5% ± 19.3% at 12 months for 60°/s isokinetic testing and 76.6% ± 16.4% at 6 months to 83.9% ± 16.9% at 12 months for 180°/s testing. Graft harvest site hematomas developed in 2 patients, postoperative loss of knee extension in 4 patients, and graft failure in 11 patients. No significant differences in quadriceps or hamstrings LSIs were noted between patients with previous hamstring versus patella tendon autografts (P > .050). CONCLUSION Revision ACLR with all-soft tissue QT autografts has acceptable early and intermediate-term outcomes with reasonable complication rates (11/80 patients with follow-up). Secondary insult to the extensor mechanism via QT autograft harvest does not adversely affect strength after prior patellar tendon versus hamstring autograft. LEVEL OF EVIDENCE Level IV, cases series subgroup analysis.
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Affiliation(s)
- Jennifer L Hunnicutt
- Department of Orthopaedics, School of Medicine, Emory University, Atlanta, Georgia, U.S.A..
| | | | - Harris S Slone
- Department of Orthopaedics and Physical Medicine, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Janelle A Prince
- Department of Orthopaedics, School of Medicine, Emory University, Atlanta, Georgia, U.S.A
| | - Stephanie A Boden
- Department of Orthopaedic Surgery, University of Pittsburg Medical Center, Pittsburg, Pennsylvania, U.S.A
| | - John W Xerogeanes
- Department of Orthopaedics, School of Medicine, Emory University, Atlanta, Georgia, U.S.A
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22
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Karpinski K, Häner M, Bierke S, Diermeier T, Petersen W. Comparing Knee Laxity After Anatomic Anterior Cruciate Ligament Reconstruction Using Quadriceps Tendon Versus Semitendinosus Tendon Graft. Orthop J Sports Med 2021; 9:23259671211014849. [PMID: 34368380 PMCID: PMC8312171 DOI: 10.1177/23259671211014849] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 01/12/2021] [Indexed: 01/08/2023] Open
Abstract
Background: The choice of graft in anterior cruciate ligament (ACL) reconstruction is still under discussion. The hamstrings are currently the most used grafts for primary ACL reconstruction in Europe. However, increased interest has arisen in the quadriceps tendon (QT) as an alternative autologous graft option for primary ACL reconstruction. Purpose: To evaluate knee stability and the subjective outcome after ACL reconstruction using either autologous QT graft in implant-free femoral press-fit fixation technique or semitendinosus tendon (ST) graft. Study Design: Cohort study; Level of evidence, 2. Methods: We evaluated 50 patients who underwent ACL reconstruction, including 25 patients who received autologous ipsilateral QT graft (QT group) and 25 patients who received the ipsilateral ST graft (ST group). The follow-up for this prospective comparative study was at least 2 years after surgery, comprising KT-1000 arthrometer testing, pivot-shift test, Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm score, and rerupture rate. Results: The mean patient age was 31.72 years (9 women, 16 men) in the QT group and 32.08 years (13 women, 12 men) in the ST group. The mean ± standard deviation postoperative side-to-side difference assessed using KT-1000 arthrometer was 1.56 ± 1.56 mm for the QT group and 1.64 ± 1.41 mm for the ST group, with no significant difference. No significant difference was found on any of the KOOS subscale scores (P = .694) or the Lysholm score (P = .682). No rerupture or positive pivot-shift test occurred during follow-up. No difference was found in donor-site morbidity between the study groups. Conclusion: Clinical outcomes were not significantly different between QT and ST grafts in the current study. Thus, the QT may serve as a good alternative graft for primary ACL reconstruction.
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23
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Lubis AM, Dasril DF. Comparison of functional outcome between bone quadriceps tendon (BQT) and single-bundle hamstring tendon (SBHT) autograft in arthroscopic-assisted anterior cruciate ligament reconstruction cases: a prospective cohort study. Ann Med Surg (Lond) 2020; 60:509-514. [PMID: 33294183 PMCID: PMC7695890 DOI: 10.1016/j.amsu.2020.11.023] [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] [Received: 09/03/2020] [Revised: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 12/03/2022] Open
Abstract
Background ACL rupture has a high morbidity in productive-age population. The increasing incidence and proper management has become a point of interest in the musculoskeletal sport injury. Choosing the best graft has become the main focus in searching for a better outcome regarding ACL reconstruction in these patient population. Currently, single bundle hamstring tendon (SBHT) autograft was preferred in Asian population compared to bone quadriceps tendon (BQT) autograft. However, there are some problems such as short and small in diameter of SBHT. This study is focused on evaluation of the clinical outcome between BQT and SBHT in arthroscopic-assisted ACL reconstruction patients. Materials and methods In this prospective cohort study, 30 subjects were divided into 2 groups (BQT and SBHT). Sampling was taken between February 2017–2018 (1 year) in one orthopaedic center. The instruments used for evaluation are rolimeter and patient-reported outcome (PRO) questionnaires (IKDC, Tegner-Lysholm, and KOOS) with data mining between 3 months, 6 months, and 1 year post operation. This study has been reported in line with the STROCSS criteria. Results Mean difference of quadriceps (3.12 ± 0.94) and hamstring (3.87 ± 0.61) in rolimeter measurement 1 year post operation is statistically significant (p = 0.015). Side-to-side difference shows better result in quadriceps (0.34 ± 0.70) compared to hamstring (0.84 ± 0.60) with p value 0.04. IKDC scores in one month (p = 0.002; CI95% [8.81–31.79]) and three months (p = 0.004; CI95% [4.85–20.39]) post operative is better in quadriceps group. Tegner-Lysholm assessment 1 month post operative showed consistent results between numeric (p = 0.004) and categoric data (p = 0.050) in quadriceps group. There was an improvement during six months and one year post operative KOOS sub-item scales; pain (p = 0.034) and symptoms (p = 0.001). Conclusion Functional outcome of patient undergoing arthroscopic-assisted ACL reconstruction is better in BQT group compared to SBHT group, both in subjective and objective parameters given. Bone quadriceps tendon autograft. Arthroscopic-assisted ACL reconstruction. Functional outcome (subjective, objective). Faster return to sport. Pilot study.
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Affiliation(s)
- Andri Mt Lubis
- Department of Orthopaedic & Traumatology, Faculty of Medicine Universitas Indonesia - Ciptomangunkusumo Hospital, Indonesia
| | - Demy Faheem Dasril
- Department of Orthopaedic & Traumatology, Faculty of Medicine Universitas Indonesia - Ciptomangunkusumo Hospital, Indonesia
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24
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Hunnicutt JL, Slone HS, Xerogeanes JW. Implications for Early Postoperative Care After Quadriceps Tendon Autograft for Anterior Cruciate Ligament Reconstruction: A Technical Note. J Athl Train 2020; 55:623-627. [PMID: 32396469 DOI: 10.4085/1062-6050-172-19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The quadriceps tendon (QT) has become increasingly used by orthopaedic surgeons as an alternative autograft choice in anterior cruciate ligament reconstruction. As its use increases, athletic trainers and other rehabilitation clinicians will treat a greater number of patients with this autograft type. The recently developed, minimally invasive technique for harvest of the all-soft tissue autograft has many benefits, including versatility, decreased donor-site morbidity, and enhanced cosmesis. Early clinical trials revealed that the QT autograft resulted in decreased anterior knee pain and similar strength and functional outcomes to those of more common autograft types. From a rehabilitation perspective, many characteristics should be considered, such as the importance of early knee extension and quadriceps activation. Therefore, the purpose of this technical note is to expose athletic trainers to the QT autograft so that they may provide the best care for patients after anterior cruciate ligament reconstruction.
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Affiliation(s)
| | - Harris S Slone
- Department of Orthopaedics and Physical Medicine, College of Medicine, Medical University of South Carolina, Charleston
| | - John W Xerogeanes
- Department of Orthopaedics, School of Medicine, Emory University, Atlanta, GA.,Emory Health Care, Atlanta, GA
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25
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Mouarbes D, Dagneaux L, Olivier M, Lavoue V, Peque E, Berard E, Cavaignac E. Lower donor-site morbidity using QT autografts for ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2020; 28:2558-2566. [PMID: 32020251 DOI: 10.1007/s00167-020-05873-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 01/21/2020] [Indexed: 01/10/2023]
Abstract
PURPOSE Comparing scar cosmesis and regional hypoesthesia at the incision site between quadriceps tendon (QT), bone-patellar tendon-bone (BPTB), and hamstring tendon (HT) for anterior cruciate ligament (ACL) reconstruction. METHODS Ninety patients undergoing ACL reconstruction with QT, HT or BPTB were evaluated at 1-year post-op. Scar cosmesis was assessed using the patient and observer scar assessment scale (POSAS) and length of the incision. Sensory outcome was analyzed by calculating the area of hypoesthesia around the scar. The classical ACL reconstruction functional follow-up was measured using the Lysholm score and KOOS. RESULTS Concerning QT versus BPTB group, QT patients have a significantly lower mean POSAS (24.8 ± 6.3 vs. 39.6 ± 5.8; p < 0.0001), shorter mean incision (2.8 ± 0.4 cm vs. 6.4 ± 1.3 cm; p < 0.0001), lower extent of hypoesthesia (8.7 ± 5.1 cm2 vs. 88.2 ± 57 cm2; p < 0.0001), and better Lysholm score (90.1 ± 10.1 vs. 82.6 ± 13.5; n.s.). No significant difference was seen in KOOS (90.7 ± 7.2 vs. 88.4 ± 7.0; n.s.). Concerning QT versus HT group, no significant difference was found regarding mean POSAS score (24.8 ± 6.3 vs. 31.8 ± 6.2; n.s.), mean length of the incision (2.8 ± 0.4 cm vs. 2.5 ± 0.6 cm; n.s.), KOOS (90.7 ± 7.2 vs. 89.8 ± 8.2; n.s.) and mean Lysholm score (90.1 ± 10.1 vs. 87.8 ± 0.6; n.s.). The mean measured area of hypoesthesia was significantly higher in the HT group (70.3 ± 77.1 cm2 vs. 8.7 ± 5.1 cm2; p < 0.0001). CONCLUSION Quadriceps tendon harvesting technique has the safest incision by causing less sensory loss compared to BPTB and HT. It also has the advantage of a short incision with more cosmetic scar compared to BPTB, with no difference compared to HT. However, no significant difference in terms of functional outcome was shown between the three autografts. These findings provide surgeons evidence about their clinical practice and help with graft choice decisions. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Dany Mouarbes
- Department of Orthopedic Surgery and Trauma, Pierre Paul Riquet University Hospital, Toulouse, France
| | - Louis Dagneaux
- Department of Orthopedic Surgery, Lower Limb Surgery Unit, Lapeyronie University Hospital, Montpellier, France
| | - Matthieu Olivier
- Department of Orthopedic Surgery and Traumatology, Saint Marguerite University Hospital, Marseille, France
| | - Vincent Lavoue
- Department of Orthopaedic Surgery, University Hospital of Nice, Nice, France
| | - Enrique Peque
- Department of Orthopedic Surgery and Trauma, Pierre Paul Riquet University Hospital, Toulouse, France
| | - Emilie Berard
- Department of Epidemiology, Health Economics and Public Health, UMR1027 INSERM-University of Toulouse III, Toulouse University Hospital, Toulouse, France
| | - Etienne Cavaignac
- Department of Orthopedic Surgery and Trauma, Pierre Paul Riquet University Hospital, Toulouse, France. .,Department of Orthopedic Surgery, Hopital Pierre Paul Riquet, CHU Toulouse, Rue Jean Dausset, 3105, Toulouse, France.
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26
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Diermeier T, Tisherman R, Hughes J, Tulman M, Baum Coffey E, Fink C, Lynch A, Fu FH, Musahl V. Quadriceps tendon anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2020; 28:2644-2656. [PMID: 32072203 DOI: 10.1007/s00167-020-05902-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/03/2020] [Indexed: 12/17/2022]
Abstract
Quadriceps tendon is a promising alternative graft option for anterior cruciate ligament (ACL) reconstruction, which can be harvested with or without a bone block as well as a full or partial thickness graft. Therefore, quadriceps tendon graft could be used in primary and revision ACL reconstruction based on the requirements (tunnel size, tunnel position, etc.). The all soft tissue, partial thickness quadriceps tendon graft in detail and pitfalls of the harvest are described in the present review. After quadriceps tendon harvest, especially in soccer players, who need a strong quadriceps to strike a ball with power, the postoperative rehabilitation may need to be adapted. LEVEL OF EVIDENCE: V.
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Affiliation(s)
- Theresa Diermeier
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, UPMC Rooney Sports Complex, 3200 South Water Street, Pittsburgh, PA, 15203, USA.,Department of Orthopaedic Sport Medicine, Technical University Munich, Munich, Germany
| | - Rob Tisherman
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, UPMC Rooney Sports Complex, 3200 South Water Street, Pittsburgh, PA, 15203, USA.,Department of Orthopaedic Sport Medicine, Technical University Munich, Munich, Germany
| | - Jonathan Hughes
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, UPMC Rooney Sports Complex, 3200 South Water Street, Pittsburgh, PA, 15203, USA
| | - Michael Tulman
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Christian Fink
- Gelenkpunkt-Sports and Joint Surgery, Innsbruck, Austria.,Research Unit for Orthopedic Sports Medicine and Injury Prevention, UMIT Hall, Hall, Austria
| | - Andrew Lynch
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA.,UPMC Centers for Rehab Services, Pittsburgh, PA, USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, UPMC Rooney Sports Complex, 3200 South Water Street, Pittsburgh, PA, 15203, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, UPMC Rooney Sports Complex, 3200 South Water Street, Pittsburgh, PA, 15203, USA.
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27
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Migliorini F, Eschweiler J, Mansy YE, Quack V, Tingart M, Driessen A. Quadriceps tendon autograft for primary ACL reconstruction: a Bayesian network meta-analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:1129-1138. [PMID: 32367221 PMCID: PMC8215032 DOI: 10.1007/s00590-020-02680-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/22/2020] [Indexed: 01/09/2023]
Abstract
Background The purpose of the current study was to clarify the role of the quadriceps tendon (QT) autograft for primary ACL reconstruction. Thus, a Bayesian network meta-analysis comparing patients undergoing a primary ACL reconstruction with QT versus patellar tendon (PT) and hamstring tendon (HT) autografts was conducted. Material and methods This Bayesian network meta-analysis was conducted according to the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of health care interventions. In January 2020, the main databases were accessed. Articles comparing the outcomes of the QT autograft versus HT autograft and/or PT autograft for primary ACL reconstruction were included in the present study. The statistical analysis was performed with STATA Software/MP, through a Bayesian hierarchical random-effect model analysis. Results Data from a total of 2603 knees were analysed. The overall mean follow-up was 35.0 months. Among the different grafts were evidenced comparable values of IKDC, Tegner and Lysholm score. The QT autograft detected comparable rate of Lachman test > 3 mm, Pivot shift test > 3 m and instrumental laxity > 3 mm. The QT autograft showed a lower rate of autograft failure above all. The QT autograft detected the reduced rate of AKP than the PT. Conclusion Quadriceps tendon autograft may represent a feasible option for primary ACL reconstruction. These results must be interpret within the limitations of the present network meta-anlaysis.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedics, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Jörg Eschweiler
- Department of Orthopaedics, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Yasser El Mansy
- Department of Orthopaedics, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.,Department of Orthopaedics, University Clinic of Alexandria, Alexandria, Egypt
| | - Valentin Quack
- Department of Orthopaedics, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Markus Tingart
- Department of Orthopaedics, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Arne Driessen
- Department of Orthopaedics, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
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28
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Ugwuoke A, Syed F, El-Kawy S. Predicting adequacy of free quadriceps tendon autograft, for primary and revision ACL reconstruction, from patients' physical parameters. Knee Surg Sports Traumatol Arthrosc 2020; 28:448-453. [PMID: 31363806 DOI: 10.1007/s00167-019-05640-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 07/10/2019] [Accepted: 07/19/2019] [Indexed: 01/11/2023]
Abstract
PURPOSE Free quadriceps tendon autograft (QTA) has gained popularity for both primary and revision ACL reconstruction. The aim of this study is to measure the dimensions of quadriceps tendon and determine its correlation with patient's height, weight and BMI. This is to provide a guide for patients and surgeons in predicting the suitability of QTA for ACL reconstructions. METHODS A cross-sectional study in which the length and thickness of the quadriceps tendon was measured in 51 Caucasian patients who underwent primary total knee arthroplasty. Exclusion criteria include non-Caucasians and previous tendon pathology. Patients were selected from routine elective total knee arthroplasty list. Tendon length is taken from musculotendinous junction to its insertion. Thickness was measured at midpoint and at distal insertion. Patients' height, weight and BMI were recorded. The correlation between patient physical parameters and tendon dimensions were determined. RESULTS Subjects' median age was 65 years (range 44-87), with 34 females and 17 males. Median length of the tendon was 9 mm (range 70-110), and median insertional thickness was 9 mm (7-10 mm). Median thickness at midpoint was 7 mm (range 4-10 mm). There was moderately positive correlation between subjects' height and tendon length (correlation coefficient 0.50), and also between weight and tendon length (correlation coefficient 0.47). There was no significant correlation between subjects' BMI and the tendon length. There was also no significant correlation between tendon thickness and subject's physical parameters. CONCLUSION This study has shown that most patients could provide adequate QTA for ACL reconstruction. It also points to the fact that no investigation is required to predict the adequacy of QTA. Though further studies with larger sample size are required to confirm this, clinician can rely on analysing patients' physical parameter in predicting the adequacy of QTA for ACL reconstruction. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Anthony Ugwuoke
- Department of Orthopaedics, Warwick Hospital, Lakin Road, Warwick, CV34 5BW, UK.
| | - Farhan Syed
- Trauma and Orthopaedics, Warwick Hospital, Warwick, UK
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29
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Mouarbes D, Menetrey J, Marot V, Courtot L, Berard E, Cavaignac E. Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Outcomes for Quadriceps Tendon Autograft Versus Bone-Patellar Tendon-Bone and Hamstring-Tendon Autografts. Am J Sports Med 2019; 47:3531-3540. [PMID: 30790526 DOI: 10.1177/0363546518825340] [Citation(s) in RCA: 207] [Impact Index Per Article: 41.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Comprehensive studies evaluating quadriceps tendon (QT) autograft for anterior cruciate ligament (ACL) reconstruction are lacking. The optimal choice of graft between bone-patellar tendon-bone (BPTB), hamstring tendon (HT), and QT is still debatable. HYPOTHESIS The current literature supports the use of QT as a strong autograft with good outcomes when used in ACL reconstruction. STUDY DESIGN Meta-analysis; Level of evidence, 2. METHODS A systematic search of the literature was performed in PubMed, MEDLINE, Cochrane, and Ovid databases to identify published articles on clinical studies relevant to ACL reconstruction with QT autograft and studies comparing QT autograft versus BPTB and HT autografts. The results of the eligible studies were analyzed in terms of instrumented laxity measurements, Lachman test, pivot-shift test, Lysholm score, objective and subjective International Knee Documentation committee (IKDC) scores, donor-site pain, and graft failure. RESULTS Twenty-seven clinical studies including 2856 patients with ACL reconstruction met the inclusion criteria. Comparison of 581 QT versus 514 BPTB autografts showed no significant differences in terms of instrumented mean side-to-side difference (P = .45), Lachman test (P = .76), pivot-shift test grade 0 (P = .23), pivot-shift test grade 0 or 1 (P = .85), mean Lysholm score (P = .1), mean subjective IKDC score (P = .36), or graft failure (P = .50). However, outcomes in favor of QT were found in terms of less donor-site pain (risk ratio for QT vs BPTB groups, 0.25; 95% CI, 0.18-0.36; P < .00001). Comparison of 181 QT versus 176 HT autografts showed no significant differences in terms of instrumented mean side-to-side difference (P = .75), Lachman test (P = .41), pivot-shift test grade 0 (P = .53), Lysholm score less than 84 (P = .53), mean subjective IKDC score (P = .13), donor-site pain (P = .40), or graft failure (P = .46). However, outcomes in favor of QT were found in terms of mean Lysholm score (mean difference between QT and HT groups, 3.81; 95% CI, 0.45-7.17; P = .03). CONCLUSION QT autograft had comparable clinical and functional outcomes and graft survival rate compared with BPTB and HT autografts. However, QT autograft showed significantly less harvest site pain compared with BPTB autograft and better functional outcome scores compared with HT autograft.
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Affiliation(s)
- Dany Mouarbes
- Department of Orthopedic Surgery and Trauma, Pierre-Paul Riquet Hospital, Toulouse, France
| | - Jacques Menetrey
- Center for Sports Medicine, Hirslanden Clinique La Colline, Geneva, Switzerland.,Orthopaedic Surgery Service, University Hospital of Geneva, Geneva, Switzerland
| | - Vincent Marot
- Department of Orthopedic Surgery and Trauma, Pierre-Paul Riquet Hospital, Toulouse, France
| | - Louis Courtot
- Department of Orthopedic Surgery and Trauma, Pierre-Paul Riquet Hospital, Toulouse, France
| | - Emilie Berard
- Department of Epidemiology, Health Economics and Public Health, UMR 1027 INSERM-University of Toulouse III, Toulouse University Hospital (CHU), Toulouse, France
| | - Etienne Cavaignac
- Department of Orthopedic Surgery and Trauma, Pierre-Paul Riquet Hospital, Toulouse, France
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30
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Horvath A, Senorski EH, Westin O, Karlsson J, Samuelsson K, Svantesson E. Outcome After Anterior Cruciate Ligament Revision. Curr Rev Musculoskelet Med 2019; 12:397-405. [PMID: 31286413 PMCID: PMC6684825 DOI: 10.1007/s12178-019-09571-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW To describe the current literature related to anterior cruciate ligament (ACL) revision in terms of surgical aspects, graft choices, concomitant injuries, patient-reported outcome, return to sport, and objective measurement outcome. RECENT FINDINGS An ACL rupture is a common knee injury, and the number of primary ACL reconstructions is increasing, implying a subsequent increase of ACL revisions in the future. It is widely accepted that an ACL revision is surgically challenging with a myriad of graft options to choose from. In many cases, simultaneous injuries to the index limb including meniscal and chondral lesions, respectively, are observed in the setting of a secondary ACL injury. Furthermore, the general understanding is that an ACL revision results in inferior outcome compared with a primary ACL reconstruction. Surgical treatment of an ACL revision can be performed as one-stage or two-stage procedure depending on, for example, the presence of limb malalignments, concomitant injuries, and tunnel widening. Nonirradiated allografts and autologous patella tendon, hamstring tendon, and quadriceps tendon are feasible options for ACL revision. Concomitant injuries to the affected knee such as intraarticular chondral lesions are more common in the setting of an ACL revision compared with primary ACL reconstruction while a lower presence of concomitant meniscal pathology is reported at ACL revision. Patients undergoing ACL revision have lower clinical and patient-reported outcome and lower rates of return to sport when compared with primary ACL surgery cases. However, long-term follow-ups with large study cohorts evaluating outcome of ACL revision are limited. Further research is needed to confirm the present findings of this review.
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Affiliation(s)
- Alexandra Horvath
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, PO Göteborgsvägen 31, SE-431 80 Mölndal, Gothenburg Sweden
| | - Eric Hamrin Senorski
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Olof Westin
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, PO Göteborgsvägen 31, SE-431 80 Mölndal, Gothenburg Sweden
| | - Jón Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, PO Göteborgsvägen 31, SE-431 80 Mölndal, Gothenburg Sweden
| | - Kristian Samuelsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, PO Göteborgsvägen 31, SE-431 80 Mölndal, Gothenburg Sweden
| | - Eleonor Svantesson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, PO Göteborgsvägen 31, SE-431 80 Mölndal, Gothenburg Sweden
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Petersen W, Karpinski K, Bierke S, Hees T, Häner M. [Primary revision with replasty of the anterior cruciate ligament]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2019; 31:221-247. [PMID: 31172213 DOI: 10.1007/s00064-019-0606-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/27/2019] [Accepted: 01/28/2019] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Restoration of knee stability after rerupture of an anterior cruciate ligament (ACL) graft. INDICATION Acute and chronic functional instability with rerupture of an ACL graft with subjective instability with anatomical or non-anatomical bone tunnel without tunnel widening. CONTRAINDICATIONS Partial anatomical bone tunnels of the previous operation, significant tunnel widening of anatomical bone tunnels, local infection of the knee joint, local soft tissue damage. SURGICAL TECHNIQUE Graft choices are hamstring tendons (semitendinosus muscle, gracilis muscle), the quadriceps tendon, patellar tendon and a peroneus tendon split graft. In cases with anatomical tunnels, careful debridement is performed down to the tunnel wall. In non-anatomical tunnels, a new femoral tunnel is drilled over a deep anteromedial portal with the knee flexed more than 110° in the insertion area of the ACL. Using drills and dilators, a tunnel is prepared. At the tibia, the anterior horn of the lateral meniscus serves as a landmark in the absence of an ACL stump. The cortical tibial tunnel aperture is probed with a guide wire and the tunnel is drilled stepwise until the tunnel wall is reached, which is debrided with a spoon or synovial resector to remove graft residues and implants from the tunnel. The femoral fixation can either be done with a flip button, an interference screw or in the case of a bone block graft implant-free. At the tibial side, the graft is fixed with a resorbable interference screw and fixation button. POSTOPERATIVE MANAGEMENT The rehabilitation program comprises 4-5 phases. Inflammatory phase (weeks 1-2): control of pain and swelling (cooling, isometric tension exercises, 20 kg partial load). Phase 2 (weeks 2-6): increasing load and range of motion with closed chain exercises (target: extension/flexion 0-0-120°). Phase 3 (from week 6): strength and coordination exercises. Phase 4: balance, strength and jump exercises. Return to competitive sport not before postoperative month 6-10. RESULTS Included were 51 patients with recurrent instability after ACL surgery where primary ACL replacement was performed with ipsilateral bone quadriceps tendon graft or contralateral semitendinosus-gracilis graft. All patients had anatomical or non-anatomical tunnel locations without significant widening (>11 mm). After 2 years, the side-to-side difference for anterior tibial translation measured with the KT 1000 arthrometer was 2.0 ± 1.2 mm for the quadriceps group and 3.0 ± 2.9 mm for the semitendinosus-gracilis group (P = 0.461). No difference in the rate of positive pivot shift tests (P = 0.661); no significant difference in the individual Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores or in the frequency of anterior knee pain.
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Affiliation(s)
- W Petersen
- Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus, Caspar Theysstraße 27-31, 14193, Berlin, Deutschland.
| | - K Karpinski
- Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus, Caspar Theysstraße 27-31, 14193, Berlin, Deutschland
| | - S Bierke
- Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus, Caspar Theysstraße 27-31, 14193, Berlin, Deutschland
| | - T Hees
- Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus, Caspar Theysstraße 27-31, 14193, Berlin, Deutschland
| | - M Häner
- Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus, Caspar Theysstraße 27-31, 14193, Berlin, Deutschland
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Vorderes Kreuzband – Neue Operationstechniken. ARTHROSKOPIE 2018. [DOI: 10.1007/s00142-018-0218-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Hurley ET, Calvo-Gurry M, Withers D, Farrington SK, Moran R, Moran CJ. Quadriceps Tendon Autograft in Anterior Cruciate Ligament Reconstruction: A Systematic Review. Arthroscopy 2018; 34:1690-1698. [PMID: 29628380 DOI: 10.1016/j.arthro.2018.01.046] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 01/06/2018] [Accepted: 01/15/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically review the current evidence to ascertain whether quadriceps tendon autograft (QT) is a viable option in anterior cruciate ligament reconstruction. METHODS A literature review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Cohort studies comparing QT with bone-patellar tendon-bone autograft (BPTB) or hamstring tendon autograft (HT) were included. Clinical outcomes were compared, with all statistical analyses performed using IBM SPSS Statistics for Windows, version 22.0, with P < .05 being considered statistically significant. RESULTS We identified 15 clinical trials with 1,910 patients. In all included studies, QT resulted in lower rates of anterior knee pain than BPTB. There was no difference in the rate of graft rupture between QT and BPTB or HT in any of the studies reporting this. One study found that QT resulted in greater knee stability than BPTB, and another study found increased stability compared with HT. One study found that QT resulted in improved functional outcomes compared with BPTB, and another found improved outcomes compared with HT, but one study found worse outcomes compared with BPTB. CONCLUSIONS Current literature suggests QT is a viable option in anterior cruciate ligament reconstruction, with published literature showing comparable knee stability, functional outcomes, donor-site morbidity, and rerupture rates compared with BPTB and HT. LEVEL OF EVIDENCE Level III, systematic review of Level I, II, and III studies.
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Affiliation(s)
- Eoghan T Hurley
- Sports Surgery Clinic, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Manuel Calvo-Gurry
- Sports Surgery Clinic, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Shane K Farrington
- Sports Surgery Clinic, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ray Moran
- Sports Surgery Clinic, Dublin, Ireland
| | - Cathal J Moran
- Sports Surgery Clinic, Dublin, Ireland; Trinity College Dublin, Dublin, Ireland
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Sheean AJ, Musahl V, Slone HS, Xerogeanes JW, Milinkovic D, Fink C, Hoser C. Quadriceps tendon autograft for arthroscopic knee ligament reconstruction: use it now, use it often. Br J Sports Med 2018; 52:698-701. [PMID: 29705749 DOI: 10.1136/bjsports-2017-098769] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2018] [Indexed: 01/14/2023]
Abstract
Traditional bone-patellar tendon-bone and hamstring tendon ACL grafts are not without limitations. A growing body of anatomic, biomechanical and clinical data has demonstrated the utility of quadriceps tendon autograft in arthroscopic knee ligament reconstruction. The quadriceps tendon autograft provides a robust volume of tissue that can be reliably harvested, mitigating the likelihood of variably sized grafts and obviating the necessity of allograft augmentation. Modern, minimally invasive harvest techniques offer the advantages of low rates of donor site morbidity and residual extensor mechanism strength deficits. New data suggest that quadriceps tendon autograft may possess superior biomechanical characteristics when compared with bone-patella tendon-bone (BPTB) autograft. However, there have been very few direct, prospective comparisons between the clinical outcomes associated with quadriceps tendon autograft and other autograft options (eg, hamstring tendon and bone-patellar tendon-bone). Nevertheless, quadriceps tendon autograft should be one of the primary options in any knee surgeon's armamentarium.
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Affiliation(s)
- Andrew J Sheean
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Harris S Slone
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Danko Milinkovic
- Universitatsklinikum Munster, Klinik fur Unfall-Hand-und Wiederherstellungschirurgie Munster, Munster, Nordrhein-Westfalen, Germany
| | - Christian Fink
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Private University UMIT, Innsbruck, Austria
| | - Christian Hoser
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Private University UMIT, Innsbruck, Austria
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Petersen W, Häner M, Karpinski K. Einzeitige Revision nach vorderer Kreuzbandplastik mit autologer Quadrizepssehne. ARTHROSKOPIE 2018. [DOI: 10.1007/s00142-018-0208-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Clinical Outcomes in Revision Anterior Cruciate Ligament Reconstruction: A Meta-analysis. Arthroscopy 2018; 34:289-300. [PMID: 28866344 DOI: 10.1016/j.arthro.2017.06.029] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 05/08/2017] [Accepted: 06/20/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE The purpose of this meta-analysis was to determine overall objective graft failure rate, failure rate by graft type (allograft vs autograft reconstruction), instrumented laxity, and patient outcome scores following revision anterior cruciate ligament (ACL) reconstruction. Outcomes of interest were collected for all studies meeting the study inclusion criteria, but lower-level studies (level III/IV) were not pooled for quantitative synthesis due to high levels of heterogeneity in these study populations. METHODS A comprehensive search strategy was performed to identify studies reporting outcomes of revision ACL reconstruction. The primary outcome reported was graft failure. A meta-analysis comparing rate of failure by graft type was conducted using a random effects model. Studies also reported patient clinical outcome scores, including International Knee Documentation Committee (IKDC), Lysholm, and knee injury and osteoarthritis outcome scores (KOOS) and graft laxity. RESULTS Eight studies with 3,021 patients (56% male, 44% female) with an average age of 30 ± 4 years and mean follow-up time of 57 months were included. The overall objective failure rate was 6% (95% confidence interval [CI], 1.8%-12.3%). Mean instrumented laxity as side-to-side difference was 2.5 mm (95% CI, 1.9-3.1 mm). Mean IKDC subjective score was 76.99 (95% CI, 76.64-77.34), mean KOOS symptoms score was 76.73 (95% CI, 75.85-77.61), and mean Lysholm score was 86.18 (95% CI, 79.08-93.28). The proportion of patients with IKDC grade A or B was 85% (95% CI, 77%-91%). When the available data for failure rate were analyzed by graft type, autograft reconstruction had a failure rate of 4.1% (95% CI, 2.0%-6.9%), similar to allograft reconstruction at 3.6% (95% CI, 1.4%-6.7%). CONCLUSIONS In this meta-analysis, revision ACL reconstruction had failure rates similar to autograft or allograft reconstruction. Overall outcome scores for revision reconstruction have improved but appear modest when compared with primary ACL reconstruction surgery. LEVEL OF EVIDENCE Meta-analysis of Level II studies, Level II.
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Louis ML, D'ingrado P, Ehkirch FP, Bertiaux S, Colombet P, Sonnery-Cottet B, Schlatterer B, Pailhé R, Panisset JC, Steltzlen C, Lustig S, Lutz C, Dalmay F, Imbert P, Saragaglia D. Combined intra- and extra-articular grafting for revision ACL reconstruction: A multicentre study by the French Arthroscopy Society (SFA). Orthop Traumatol Surg Res 2017; 103:S223-S229. [PMID: 28889985 DOI: 10.1016/j.otsr.2017.08.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 08/23/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND A careful analysis of the reasons for ACL reconstruction failure is essential to selection of the optimal surgical revision technique designed to ensure good rotational stability and to minimise the risk of re-rupture. OBJECTIVE To evaluate anterolateral ligament (ALL) stabilisation during revision ACL reconstruction. HYPOTHESIS ALL stabilisation during revision ACL reconstruction provides good rotational stability without increasing the risk of complications. MATERIAL AND METHODS This multicentre study included 349 patients, 151 retrospectively and 198 prospectively. There were 283 males and 66 females. Inclusion criteria were an indication for revision ACL reconstruction surgery with combined intra-articular reconstruction and ALL stabilisation after failed autograft ACL reconstruction, and intact PCL. Exclusion criteria were primary ACL reconstruction and concomitant peripheral medial and/or lateral lesions. Each patient underwent a clinical and radiographic evaluation before and after revision surgery. Before revision surgery, the mean IKDC score was 56.5±15.5 and 96% of patients were IKDC C or D. RESULTS Rates were 5.0% for early and 10.5% for late postoperative complications. Lachmann's test had a hard stop at last follow-up in 97% of patients. The pivot-shift test was positive in 1% of patients. The mean subjective IKDC score was 84.5±13.0 and 86.5% of patients were IKDC A or B. The proportions of patients with radiographic knee osteoarthritis at last follow-up was unchanged for the lateral tibio-femoral and patello-femoral compartments but increased by 9.7% to 21.2% for the medial tibio-femoral compartment. The re-rupture rate was 1.2% and the further surgical revision rate was 5.4%. CONCLUSION Anterior laxity at last follow-up was consistent with previous studies of revision ACL reconstruction. However, rotational stability and the re-rupture risk were improved. ALL stabilisation is among the techniques that deserve consideration as part of the therapeutic options for revision ACL reconstruction. LEVEL OF EVIDENCE IV, retrospective and prospective cohort study.
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Affiliation(s)
- M-L Louis
- Institut de chirurgie orthopédique et sportive, clinique Juge, 463, rue Paradis, 13008 Marseille, France.
| | - P D'ingrado
- Clinique du Parc, 155, boulevard de Stalingrad, 69006 Lyon, France
| | - F P Ehkirch
- Clinique Maussins-Nollet, 67, rue de Romainville, 75019 Paris, France
| | - S Bertiaux
- Hôpital privé de l'Estuaire, 505, rue Irène-Joliot-Curie, 76620 le Havre, France
| | - P Colombet
- Centre de chirurgie orthopédique et sportive, 2, rue Negrevergne, 33700 Mérignac, France
| | - B Sonnery-Cottet
- Centre orthopédique Santy, 24, avenue Paul-Santy, 69008 Lyon, France
| | - B Schlatterer
- Institut Monégasque de médecine du sport, 11, avenue d'Ostende, 98000, Monaco
| | - R Pailhé
- Clinique universitaire, hôpital Sud, CHU de Grenoble, avenue de Kimberley, 38130 Échirolles, France
| | - J C Panisset
- Clinique des cèdres, 21, rue Albert-Londres, 38432 Échirolles, France
| | - C Steltzlen
- Centre hospitalier de Versailles André-Mignot, 177, rue de Versailles, 78150 Le Chesnay, France
| | - S Lustig
- Centre Albert-Trillat, hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69004 Lyon, France
| | - C Lutz
- ICOSS, 50, avenue des Vosges, 67000 Strasbourg, France
| | - F Dalmay
- CEBIMER, faculté de médecine de Limoges, 2, rue du Docteur-Marcland, 87042 Limoges cedex, France
| | - P Imbert
- Institut de chirurgie articulaire et des pathologies du sport, 87, avenue Archimède, 83700 St-Raphael, France
| | - D Saragaglia
- Clinique universitaire, hôpital Sud, CHU de Grenoble, avenue de Kimberley, 38130 Échirolles, France
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Lowe WR. Editorial Commentary: "There, It Fits!"-Justifying Nonsignificant P Values. Arthroscopy 2016; 32:2318-2321. [PMID: 27816097 DOI: 10.1016/j.arthro.2016.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 08/04/2016] [Indexed: 02/02/2023]
Abstract
The increasing emphasis placed on value-based medicine has become a powerful motivating factor that has driven the performance and publication of more comparative clinical outcome studies. Although these endeavors are well intentioned and significant progress has been made in our field over the past few decades, I believe that we need both to re-emphasize the importance of results derived from meaningful study designs and to avoid the notion that nonsignificant P values represent study failure.
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