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Prentice HA, Chan PH, Paxton EW, Felson DT, Funahashi TT, Maletis GB. Patient and Operative Risk Factors for Osteoarthritis After Primary Anterior Cruciate Ligament Reconstruction: A Cohort Study of 41,976 Patients. Am J Sports Med 2024; 52:2482-2492. [PMID: 39097770 DOI: 10.1177/03635465241261357] [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] [Indexed: 08/05/2024]
Abstract
BACKGROUND The reported incidence of posttraumatic knee osteoarthritis (PTOA) after primary anterior cruciate ligament reconstruction (ACLR) varies considerably. Further, there are gaps in identifying which patients are at risk for PTOA after ACLR and whether there are modifiable factors. PURPOSE To (1) determine the incidence of PTOA in a primary ACLR cohort and (2) identify patient and perioperative factors associated with the development of PTOA after primary ACLR. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Data from the Kaiser Permanente ACLR Registry were used to conduct a cohort study. Patients who had undergone primary ACLR without a previous diagnosis of osteoarthritis were identified (2009-2020). The crude incidence of PTOA was calculated using the Aalen-Johansen estimator with a multistate model. The association of patient and operative factors with the development of PTOA after primary ACLR was modeled as a time to event using multistate Cox proportional hazards regression. Models stratified by age (<22 and ≥22 years) were also conducted because of the effect modification of age. RESULTS The study sample included 41,976 cases of primary ACLR. The incidence of PTOA was 1.7%, 5.1%, and 13.6% at 2, 5, and 10 year follow-ups, respectively. Risk factors for PTOA that were consistently identified in the overall cohort and age-stratified groups included a body mass index ≥30 versus <30 and an allograft or quadriceps tendon autograft versus a hamstring tendon autograft. Patients presenting with knee pain after ACLR were further identified when considering postoperative factors. Other risk factors for PTOA in the overall cohort included age ≥22 versus <22 years, bone-patellar tendon-bone autograft versus hamstring tendon autograft, hypertension, cartilage injury, meniscal injury, revision after primary ACLR with concomitant meniscal/cartilage surgery, multiligament injury, other activity at the time of injury compared with sport, and tibial tunnel drilling technique rather than the anteromedial portal. CONCLUSION Knee pain after ACLR may be an early sign of PTOA. Surgeons should consider the adverse associations of a higher body mass index and an allograft or quadriceps tendon autograft with the development of PTOA, as these were factors identified with a higher risk, regardless of a patient's age at the time of primary ACLR.
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Affiliation(s)
- Heather A Prentice
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California, USA
| | - Priscilla H Chan
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California, USA
| | - Elizabeth W Paxton
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California, USA
| | - David T Felson
- Section of Rheumatology, Chobanian & Avedisian School of Medicine, Boston University, Boston, Massachusetts, USA
| | - Tadashi T Funahashi
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Irvine, California, USA
| | - Gregory B Maletis
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Baldwin Park, California, USA
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Petit CB, Slone HS, Diekfuss JA, Barber Foss KD, Warren SM, Montalvo AM, Lamplot JD, Myer GD, Xerogeanes JW. Sex-Specific Outcomes After Anterior Cruciate Ligament Reconstruction Using an All-Soft Tissue Quadriceps Tendon Autograft in a Young Active Population. Am J Sports Med 2024; 52:2450-2455. [PMID: 39097771 DOI: 10.1177/03635465241262018] [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] [Indexed: 08/05/2024]
Abstract
BACKGROUND The ideal graft for anterior cruciate ligament (ACL) reconstruction (ACLR) in young athletes has a high return-to-sport (RTS) rate and a low reinjury rate. Quadriceps tendon autografts are being used with increasing frequency for ACLR in this population, despite a paucity of evidence to support their use. PURPOSE To report the RTS rate, ipsilateral reinjury rate, and contralateral ACL injury rate in a young athletic population undergoing primary ACLR using an all-soft tissue quadriceps tendon (ASTQT) autograft. STUDY DESIGN Cases series; Level of evidence, 4. METHODS Patients aged 14 to 22 years who underwent primary ACLR using an ASTQT autograft by a single surgeon between January 1, 2005, and April 30, 2020, were identified via electronic medical records and contacted ≥24 months after ACLR to complete a survey regarding subsequent ipsilateral or contralateral ACL injuries and RTS. Patients who had undergone previous ACLR (ipsilateral or contralateral) were excluded. RESULTS A total of 656 patients (330 male, 326 female; mean age, 17.9 years) were identified, and 395 patients completed the survey (60.2%; 174 male, 221 female; mean age, 17.8 years) with a mean follow-up of 73 ± 29 months (range, 24-139 months). The RTS rate was high (male: 87.7%; female: 82.8%; P = .19). Male and female patients had similar rates of revision ACLR (male: 12.6%; female: 10.0%; P = .40) and contralateral ACL injuries (male: 13.8%; female: 11.3%; P = .46). CONCLUSION A high RTS rate and similar rates of ipsilateral and contralateral ACL injuries were found for male and female patients in a young athletic population undergoing primary ACLR using an ASTQT autograft. These results help one to better understand the utility of ASTQT grafts to support successful ACLR in young athletic populations, for which ASTQT grafts appear to yield favorable outcomes.
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Affiliation(s)
- Camryn B Petit
- Emory Sports Performance And Research Center, Flowery Branch, Georgia, USA
- Emory Sports Medicine Center, Atlanta, Georgia, USA
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia, USA
- Medical College of Georgia, Augusta, Georgia, USA
| | - Harris S Slone
- Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jed A Diekfuss
- Emory Sports Performance And Research Center, Flowery Branch, Georgia, USA
- Emory Sports Medicine Center, Atlanta, Georgia, USA
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kim D Barber Foss
- Emory Sports Performance And Research Center, Flowery Branch, Georgia, USA
- Emory Sports Medicine Center, Atlanta, Georgia, USA
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Shayla M Warren
- Emory Sports Performance And Research Center, Flowery Branch, Georgia, USA
- Emory Sports Medicine Center, Atlanta, Georgia, USA
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Alicia M Montalvo
- Emory Sports Performance And Research Center, Flowery Branch, Georgia, USA
- College of Health Solutions, Arizona State University, Phoenix, Arizona, USA
| | - Joseph D Lamplot
- Emory Sports Performance And Research Center, Flowery Branch, Georgia, USA
- Campbell Clinic Orthopaedics, Germantown, Tennessee, USA
| | - Gregory D Myer
- Emory Sports Performance And Research Center, Flowery Branch, Georgia, USA
- Emory Sports Medicine Center, Atlanta, Georgia, USA
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia, USA
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, USA
- Youth Physical Development Centre, Cardiff Metropolitan University, Cardiff, UK
| | - John W Xerogeanes
- Emory Sports Performance And Research Center, Flowery Branch, Georgia, USA
- Emory Sports Medicine Center, Atlanta, Georgia, USA
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia, USA
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Tan Y, Kaldau NC, Lumban-Gaol I, Budhiparama NC, Peers K. Anterior cruciate ligament injuries in elite badminton athletes: 84% Return to sport, half return to performance. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38984858 DOI: 10.1002/ksa.12347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 06/03/2024] [Accepted: 06/17/2024] [Indexed: 07/11/2024]
Abstract
PURPOSE Badminton requires fast and pivoting movements, putting athletes at risk of sustaining an anterior cruciate ligament (ACL) injury. The primary purpose is to investigate the return to sport (RTS) and the return to performance (RTP) after an ACL injury in elite badminton athletes. The secondary purpose is to describe ACL injury mechanisms in elite badminton players. METHODS Athletes within the top 200 of the Badminton World Federation World Ranking who sustained an ACL injury between January 2001 and December 2021 were retrospectively included. An anonymous online survey was created in eight languages. RTS, RTP and contributing factors were analysed among athletes aiming to RTP. The injury mechanism was analysed in all participants. RESULTS Sixty-six athletes from 32 countries were included. Fifty-seven athletes (86.4%) aimed to RTP. Forty-eight out of 57 (84.2%) did RTS. Twenty-nine (50.9%) managed to successfully RTP. Forty-nine (74.2%) of ACL injuries occurred during a competition, 14 (21.2%) occured during training. Thirty-one (49.2%) occurred in the rear court backhand side and 47 (74.6%) occurred during landing after a jump. CONCLUSION Forty-eight out of 57 (84.2%) athletes managed to RTS. Half of the athletes managed to successfully RTP. Most of the ACL injuries occurred during competition, in the rear court backhand side and during landing after a jump. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Yuhan Tan
- Department of Orthopaedics, Noorderhart Ziekenhuis, Pelt, Belgium
- Department of Orthopaedics, University Hospital Brussels, Brussels, Belgium
- Department of Physical Medicine & Rehabilitation, University Hospitals Leuven, Leuven, Belgium
| | - Niels Christian Kaldau
- Department of Orthopaedic Surgery, Sports Orthopaedic Research Center Copenhagen (SORC-C), Copenhagen University Hospital, Amager-Hvidovre Hospital, Copenhagen, Denmark
| | - Imelda Lumban-Gaol
- Nicolaas Institute of Constructive Orthopaedic Research and Education Foundation for Arthroplasty and Sports Medicine, Department of Orthopaedics, Medistra Hospital, Jakarta, Indonesia
| | - Nicolaas C Budhiparama
- Nicolaas Institute of Constructive Orthopaedic Research and Education Foundation for Arthroplasty and Sports Medicine, Department of Orthopaedics, Medistra Hospital, Jakarta, Indonesia
| | - Koenraad Peers
- Department of Physical Medicine & Rehabilitation, University Hospitals Leuven, Leuven, Belgium
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Solie BS, Tollefson LV, Doney CP, O'Keefe JMJ, Thompson WC, LaPrade RF. Return to the Pre-Injury Level of Sport after Anterior Cruciate Ligament Reconstruction: A Practical Review with Medical Recommendations. Int J Sports Med 2024; 45:572-588. [PMID: 38527465 DOI: 10.1055/a-2270-3233] [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: 03/27/2024]
Abstract
Returning to sport after anterior cruciate ligament reconstruction (ACLR) can be a challenging and complex process for the athlete, with the rate of return to the pre-injury level of sport observed to be less than athlete expectations. Of the athletes that do return to sport (RTS), knee re-injury rates remain high, and multiple studies have observed impaired athletic performance upon RTS after ACLR as well as reduced playing time, productivity, and career lengths. To mitigate re-injury and improve RTS outcomes, multiple RTS after ACLR consensus statements/clinical practice guidelines have recommended objective RTS testing criteria to be met prior to medical clearance for unrestricted sports participation. While the achievement of RTS testing criteria can improve RTS rates after ACLR, current criteria do not appear valid for predicting safe RTS. Therefore, there is a need to review the various factors related to the successful return to the pre-injury level of sport after ACLR, clarify the utility of objective performance testing and RTS criteria, further discuss safe RTS decision-making as well as present strategies to reduce the risk of ACL injury/re-injury upon RTS. This article provides a practical review of the current RTS after ACLR literature, as well as makes medical recommendations for rehabilitation and RTS decision-making after ACLR.
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Affiliation(s)
- Braidy S Solie
- Physical Therapy, Training HAUS, Twin Cities Orthopedics, Eagan, MN, United States
- Research, Twin Cities Orthopedics, Edina, MN, United States
| | | | - Christopher P Doney
- Physical Therapy, Training HAUS, Twin Cities Orthopedics, Eagan, MN, United States
| | - Jeremy M J O'Keefe
- Physical Therapy, Training HAUS, Twin Cities Orthopedics, Eagan, MN, United States
| | - Will C Thompson
- Sports Science, Training HAUS, Twin Cities Orthopedics, Eagan, MN, United States
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Cognault J, Chaillot PF, Norgate J, Murgier J, Ponsot A, Pailhe R, Horteur C, Agu C, van Rooij F. High rates of donor site healing using quadriceps tendon for anterior cruciate ligament reconstruction: A case series. J Exp Orthop 2024; 11:e12033. [PMID: 38887660 PMCID: PMC11180971 DOI: 10.1002/jeo2.12033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/18/2024] [Accepted: 04/19/2024] [Indexed: 06/20/2024] Open
Abstract
Purpose To investigate the healing of the quadriceps tendon donor site after partial thickness graft harvesting through ultrasound imaging at a short-term follow-up of 6-month following anterior cruciate ligament reconstruction (ACLR) and to investigate the clinical outcomes. Methods Between March 2019 and August 2020, 61 knees were retrospectively included in this study. Intraoperatively, the length, width and thickness of the harvested QT graft were measured. At a 6-month follow-up, patients were assessed by one of five radiologists, following the same protocol to calculate the defect volume, and patients performed a self-evaluation of pain on the Visual Analogue Scale, International Knee Documentation Committee (IKDC) and the Knee injury and Osteoarthritis Outcome Scores (KOOS). Results Intraoperatively, the QT grafts had a volume of 4635.4 ± 912.5 mm3. Postoperatively, ultrasound was performed at 6.5 ± 0.7 months, and the defect volume was 323.3 ± 389.2 mm3, representing a healing rate of 93% ± 9% of the donor site. At a minimum 6-month follow-up, IKDC was 61.6 ± 16 and KOOS was 70.2 ± 16.6. Age was significantly associated with the healing rate (β: -0.005; p = 0.032). Conclusion At 6 months follow-up, the defect size of the QT donor site had healed by 93 ± 9% leaving a mean defect volume of 323.3 mm3 according to ultrasound measurements. This suggests that the QT has a high capacity for healing after graft harvesting, with 10 patients reaching full defect closure 6 months after surgery. The clinical relevance of these findings is that the quadriceps tendon donor site has high rates of healing, but surgeons should be aware of lower healing rates in older patients. Level of Evidence Level IV, retrospective case series.
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Rupp MC, Winkler PW, Willinger L, Runer A. Editorial Commentary: Early Outcomes of Suture Tape Augmentation in Quadriceps Tendon Autograft Anterior Cruciate Ligament Reconstruction Are Promising but Require Long-term Proof. Arthroscopy 2024:S0749-8063(24)00328-1. [PMID: 38705543 DOI: 10.1016/j.arthro.2024.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Accepted: 04/29/2024] [Indexed: 05/07/2024]
Abstract
The management of anterior cruciate ligament (ACL) injuries continually evolves, with new interest in all-soft tissue quadriceps tendon autograft, as well as new interest in suture tape augmentation of the graft, particularly in high-risk patients with young age; female sex; lower-limb alignment, tibial, or femoral abnormalities; hyperlaxity; concomitant meniscal and/or additional ligamentous injuries; or participation in high-risk sports. Load-sharing suture tape enhances the biomechanical stability of the reconstructed ACL, especially during the initial ingrowth and ligamentization phase, and biomechanical evidence highlights a reduced risk of graft elongation and failure under the loads encountered during daily physical activities and sport. Optimal tape tensioning could be achieved in knee hyperextension, when the ACL is at maximal length, to avoid overconstraint. The published 2-year outcomes of this technique are excellent. Current comparative studies, however, have not shown superiority. Additional controlled studies and studies with longer-term follow-up are needed, as well as comparison to extra-articular tenodesis augmentation.
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Affiliation(s)
| | | | | | - Armin Runer
- Technical University of Munich (P.W.W., L.W., A.R.)
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Daniel AV, Smith PA. Primary All-Soft Tissue Quadriceps Tendon Autograft Anterior Cruciate Ligament Reconstruction With Suture Tape Augmentation Resulted in Satisfactory Patient Outcomes and a Low Graft Failure Rate in High School and Collegiate Athletes. Arthroscopy 2024:S0749-8063(24)00234-2. [PMID: 38518869 DOI: 10.1016/j.arthro.2024.02.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 03/24/2024]
Abstract
PURPOSE To evaluate ≥2-year patient outcomes after primary all-soft tissue quadriceps tendon autograft (ASTQ) anterior cruciate ligament reconstruction (ACLR) with suture tape augmentation (STA) in skeletally mature high school and collegiate athletes. METHODS All high school and collegiate athletes who underwent primary ASTQ ACLR with STA with a minimum of 2-year follow-up were analyzed retrospectively. Patients were administered validated patient-reported outcome measures (PROMs) pre- and postoperatively. The minimal clinically important difference was calculated for each PROM based on this study population and applied to the individual patient. Return to sport, subsequent surgical intervention including contralateral ACLR, and KT-1000 arthrometer measurements for knee laxity were collected. Complications were assessed by physical examination, radiologic studies, or obtained via telephone. RESULTS In total, 60 patients were included in the final data analysis, with a mean age of 16.8 years (95% confidence interval 13-23) and mean final follow-up of 37.1 months (95% confidence interval 33.1-41.1). Twelve patients (20%) required subsequent surgery on the ipsilateral knee, which included 7 patients having a subsequent meniscal procedure and 3 patients who underwent arthrolysis. None sustained a graft failure, and 6 patients sustained a contralateral ACL injury necessitating surgery. All PROMs improved at the final follow-up (P < .001). In addition, KT-1000 arthrometer measurements significantly improved postoperatively at 1-year clinical follow-up (P < .001). Most patients obtained the minimal clinically important difference thresholds for each PROM at the final follow-up. There were 48 patients (80%) who participated in pivoting sports. The return-to-sport rate at same level was 54 patients (90%), with 6 patients (10%) not returning to the same level because of graduation. CONCLUSIONS ASTQ ACLR with STA in a young athletic patient population may result in a low graft failure rate while maintaining satisfactory patient outcomes at short-term follow-up, including a return to sport at the same level of 90%. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Adam V Daniel
- Columbia Orthopaedic Group, Columbia, Missouri, 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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Inoue J, Dadoo S, Nukuto K, Özbek EA, Lesniak BP, Sprague AL, Irrgang JJ, Musahl V. Near complete quadriceps tendon healing 2 years following harvest in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2023; 31:5747-5754. [PMID: 37930438 PMCID: PMC11181339 DOI: 10.1007/s00167-023-07638-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/11/2023] [Indexed: 11/07/2023]
Abstract
PURPOSE Despite the recent increase in the use of quadriceps tendon (QT) autograft in anterior cruciate ligament reconstruction (ACLR); however, there remains a paucity of literature evaluating the postoperative morphology of the QT. The present study aimed to determine the postoperative morphologic change of the QT at a minimum of 2 years following harvesting during ACLR. METHODS Patients who underwent ACLR with QT autograft and underwent magnetic resonance imaging (MRI) at a minimum of 2 years following harvesting were retrospectively included in the study. The anterior-to-posterior (A-P) thickness, medial-to-lateral (M-L) width, cross-sectional area (CSA), and signal/noise quotient (SNQ) of the QT were assessed at 5 mm, 15 mm, and 30 mm proximal to the superior pole of the patella on MRI. The CSA was adjusted by the angle between the QT and the plane of the axial cut based on a cosine function (adjusted CSA). The A-P thickness, M-L width, adjusted CSA, and SNQ were compared pre- and postoperatively. In addition, defects or scar tissue formation in the harvest site were investigated on postoperative MRI. RESULTS Thirty patients were recruited for the study. The mean duration between postoperative MRI and surgery was 2.8 ± 1.1 years. The mean A-P thickness was 10.3% and 11.9% larger postoperatively at 5 mm and 15 mm, respectively. The mean M-L width was 7.3% and 6.5% smaller postoperatively at 5 mm and 15 mm, respectively. There were no significant differences in the adjusted CSA between pre- and post-operative states (275.7 ± 71.6 mm2 vs. 286.7 ± 91.8 mm2, n.s.). There was no significant difference in the postoperative change in the SNQ of the QT at all assessment locations. Defect or scar tissue formation at the harvest site was observed in 4 cases (13.3%), and 5 cases (16.6%), respectively. CONCLUSION At a minimum of 2 years following QT harvest during ACLR, the QT became slightly thicker and narrower (approximately 11% and 7%, respectively). While the current study demonstrates that QT re-harvesting can be considered due to nearly normalized tendon morphology, future histological and biomechanical studies are required to determine the re-harvesting potential of the QT. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Jumpei Inoue
- Department of Orthopaedic Surgery, University of Pittsburgh, 3200 S Water St, Pittsburgh, PA, 15203, USA.
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Science, Nagoya, Japan.
| | - Sahil Dadoo
- Department of Orthopaedic Surgery, University of Pittsburgh, 3200 S Water St, Pittsburgh, PA, 15203, USA
| | - Koji Nukuto
- Department of Orthopaedic Surgery, University of Pittsburgh, 3200 S Water St, Pittsburgh, PA, 15203, USA
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Emre Anil Özbek
- Department of Orthopaedic Surgery, University of Pittsburgh, 3200 S Water St, Pittsburgh, PA, 15203, USA
- Department of Orthopaedic Surgery, Ankara University, Ankara, Turkey
| | - Bryson P Lesniak
- Department of Orthopaedic Surgery, University of Pittsburgh, 3200 S Water St, Pittsburgh, PA, 15203, USA
| | - Andrew L Sprague
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - James J Irrgang
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh, 3200 S Water St, Pittsburgh, PA, 15203, USA
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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: 4] [Impact Index Per Article: 4.0] [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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Verhagen S, Dietvorst M, Delvaux E, van der Steen MC, Janssen R. Clinical outcomes of different autografts used for all-epiphyseal, partial epiphyseal or transphyseal anterior cruciate ligament reconstruction in skeletally immature patients - a systematic review. BMC Musculoskelet Disord 2023; 24:630. [PMID: 37537529 PMCID: PMC10401849 DOI: 10.1186/s12891-023-06749-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 07/24/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Different types of grafts can be used for anterior cruciate ligament reconstruction (ACLR). There is little published data regarding skeletally immature patients. The purpose of this systematic review was to assess the clinical outcomes and complications for different autograft types used in all-epiphyseal, transphyseal and partial epiphyseal/hybrid ACLR in skeletally immature children and adolescents. METHODS PubMed, Embase and Cochrane databases were systematically searched for literature regarding ACLR using hamstrings, quadriceps or bone-patellar-tendon-bone (BPTB) autografts in skeletally immature patients. Studies were included if they examined at least one of the following outcomes: graft failure, return to sport(s), growth disturbance, arthrofibrosis or patient reported outcomes and had a minimum follow-up of 1 year. Case reports, conference abstracts and studies examining allografts and extra-articular or over-the-top ACL reconstruction techniques were excluded. Graft failure rates were pooled for each graft type using the quality effects model of MetaXL. A qualitative synthesis of secondary outcomes was performed. RESULTS The database search identified 242 studies. In total 31 studies were included in this review, comprising of 1358 patients. Most patients (81%) were treated using hamstring autograft. The most common used surgical technique was transphyseal. The weighted, pooled failure rate for each graft type was 12% for hamstring tendon autografts, 8% for quadriceps tendon autografts and 6% for BPTB autografts. Confidence intervals were overlapping. The variability in time to graft failure was high. The qualitative analysis of the secondary outcomes showed similar results with good clinical outcomes and low complication rates across all graft types. CONCLUSIONS Based on this review it is not possible to determine a superior graft type for ACLR in skeletally immature. Of the included studies, the most common graft type used was the hamstring tendon. Overall, graft failure rates are low, and most studies show good clinical outcomes with high return to sports rates.
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Affiliation(s)
- S Verhagen
- Department of Orthopaedic Surgery & Trauma, PO box, Máxima, Eindhoven, 5600 PD, MC, The Netherlands.
| | - M Dietvorst
- Department of Orthopaedic Surgery & Trauma, PO box, Máxima, Eindhoven, 5600 PD, MC, The Netherlands
| | - Ejlg Delvaux
- MMC Academy, Máxima, Veldhoven, MC, The Netherlands
| | - M C van der Steen
- Department of Orthopaedic Surgery & Trauma, PO box, Máxima, Eindhoven, 5600 PD, MC, The Netherlands
- Department of Orthopaedic Surgery & Trauma, Catharina Hospital Eindhoven, PO box 1350, Eindhoven, 5602 ZA, The Netherlands
| | - Rpa Janssen
- Department of Orthopaedic Surgery & Trauma, PO box, Máxima, Eindhoven, 5600 PD, MC, The Netherlands
- Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Chair Value‑Based Health Care, Department of Paramedical Sciences, Fontys University of Applied Sciences, Eindhoven, The Netherlands
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12
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Runer A, Keeling L, Wagala N, Nugraha H, Özbek EA, Hughes JD, Musahl V. Current trends in graft choice for anterior cruciate ligament reconstruction - part I: anatomy, biomechanics, graft incorporation and fixation. J Exp Orthop 2023; 10:37. [PMID: 37005974 PMCID: PMC10067784 DOI: 10.1186/s40634-023-00600-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/22/2023] [Indexed: 04/04/2023] Open
Abstract
Graft selection in anterior cruciate ligament (ACL) reconstruction is critical, as it remains one of the most easily adjustable factors affecting graft rupture and reoperation rates. Commonly used autografts, including hamstring tendon, quadriceps tendon and bone-patellar-tendon-bone, are reported to be biomechanically equivalent or superior compared to the native ACL. Despite this, such grafts are unable to perfectly replicate the complex anatomical and histological characteristics of the native ACL. While there remains inconclusive evidence as to the superiority of one autograft in terms of graft incorporation and maturity, allografts appear to demonstrate slower incorporation and maturity compared to autografts. Graft fixation also affects graft properties and subsequent outcomes, with each technique having unique advantages and disadvantages that should be carefully considered during graft selection.
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Affiliation(s)
- Armin Runer
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA.
- Department for Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Laura Keeling
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nyaluma Wagala
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hans Nugraha
- Department of Orthopaedic and Traumatology, Faculty of Medicine, University of Udayana, / Prof. Dr. I.G.N.G. Ngoerah General Hospital, Denpasar, Bali, Indonesia
| | - Emre Anil Özbek
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopedics and Traumatology, Ankara University, Ankara, Turkey
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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