Complications and Adverse Events of a Randomized Clinical Trial Comparing 3 Graft Types for ACL Reconstruction

Incidence, Common Pathogens, and Risk Factors for Infection after Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review

We sought to assess the current literature to present a comprehensive summary of the incidence, common pathogens, and risk factors for infection after anterior cruciate ligament (ACL) reconstruction. PubMed, CINAHL, EMBASE, and Scopus databases were searched for relevant studies reporting on infection after ACL reconstruction. Two reviewers independently screened the extracted studies for adherence to inclusion and exclusion criteria. Studies were selected if they reported on the incidence of infection, pathogens cultured from infected knees, or risk factors for infection after primary ACL reconstruction. Exclusion criteria consisted of studies with fewer than 100 patients or studies that included revision ACL reconstruction. Fifty studies met the inclusion and exclusion criteria, reporting on a total of 316,214 ACL reconstructions. Included studies evaluated between 123 and 104,255 patients. The overall incidence of infection was 0.60% (0.15-2.44%). The most common pathogens were Staphylococcus aureus, S. epidermidis, and coagulase-negative Staphylococci. Five studies reported that the use of hamstring autograft was a statistically significant risk factor for infection after ACL reconstruction, thus making hamstring autograft the most commonly reported risk factor. Other reported risk factors included male sex, use of immuno-suppressive medications or intraarticular steroid injections, prior knee surgery, and diabetes. Systematic review of the literature revealed that infection after ACL reconstruction remains an infrequent event with an incidence of 0.60% (0.15-2.44%). Furthermore, the most common pathogens are from the Staphylococcus genus of bacteria, comprising 84% of all culture-positive infections. Multiple risk factors have been reported for ACL reconstruction; however, statistical significance varied across studies. Together, these findings may help guide physicians in the prevention and treatment of infection after ACL reconstruction.

Morphology of the quadriceps tendon and its patella insertion site on three-dimensional computed tomography and magnetic resonance imaging: A cadaveric study

AIM

This study was conducted to clarify the morphological properties of the quadriceps tendon (QT) and its patella insertion site using three-dimensional computed tomography and magnetic resonance imaging.

METHODS

Twenty-one right knees from human cadavers were evaluated using three-dimensional computed tomography and magnetic resonance imaging. The morphologies of the QT and its patella insertion site were evaluated, along with intra-tendon differences in length, width, and thickness.

RESULTS

The QT insertion site on the patella was dome-shaped without characteristic bony features. The mean surface area of the insertion site was 502.5 ± 68.5 mm2 (range, 336.0-610.7). The QT was longest 2.0 mm lateral to the central width of the insertion and gradually became shorter toward both edges (mean length, 59.7 ± 8.3 mm). The QT was widest at the insertion site (mean width, 39.1 ± 5.3 mm) and gradually became narrower toward the proximal side. The QT was thickest 2.0 mm medial to the center (mean thickness, 11.4 ± 1.9 mm).

CONCLUSION

The morphological properties of the QT and its insertion site were consistent. The characteristics of the QT graft depend on the harvested region.

Knee Extensor Mechanism Complications After Autograft Harvest in ACL Reconstruction: A Systematic Review and Meta-analysis

Background

Existing systematic reviews have sought to characterize the relative donor-site morbidity of bone-patellar tendon-bone (BTB) and quadriceps tendon (QT) grafts after anterior cruciate ligament reconstruction (ACLR). However, no studies have reported the pooled proportions of patellar fractures and donor tendon ruptures across the body of literature.

Purpose

To estimate the proportion of patellar fractures, patellar tendon ruptures, and QT ruptures associated with BTB or QT autograft harvest during ACLR using published data.

Study Design

Systematic review; Level of evidence, 4.

Methods

A meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using 3 online databases (PubMed, Scopus, and Web of Science). A total of 800 manuscripts were included in the initial research of peer-reviewed articles in English that reported extensor mechanism complications associated with graft harvest in patients after ACLR. Pooled proportions of patellar fractures, patellar tendon ruptures, and QT ruptures were calculated for each graft type (BTB, QT) using a random-effects model for meta-analysis.

Results

A total of 28 studies were analyzed. The pooled proportion of patellar fractures was 0.57% (95% CI, 0.34%-0.91%) for the BTB harvest and 2.03% (95% CI, 0.78%-3.89%) for the QT harvest. The proportion of patellar tendon ruptures was 0.22% (95% CI, 0.14%-0.33%) after the BTB harvest, and the proportion of QT ruptures was 0.52% (95% CI, 0.06%-1.91%) after the QT harvest. The majority of included studies (16/28 [57.1%]) had an evidence level of 4.

Conclusion

Based on the current literature, the proportion of extensor mechanism complications after ACLR using either a BTB or a QT autograft is low, indicating that the extensor mechanism harvest remains a safe option. A higher proportion of patellar fractures was noted for QT grafts and a higher proportion of donor tendon ruptures was noted for QT grafts compared with BTB grafts.

Lower donor site morbidity with hamstring and quadriceps tendon autograft compared with bone-patellar tendon-bone autograft after anterior cruciate ligament reconstruction: a systematic review and network meta-analysis of randomized controlled trials

PURPOSE

To perform a meta-analysis of RCTs evaluating donor site morbidity after bone-patellar tendon-bone (BTB), hamstring tendon (HT) and quadriceps tendon (QT) autograft harvest for anterior cruciate ligament reconstruction (ACLR).

METHODS

PubMed, OVID/Medline and Cochrane databases were queried in July 2022. All level one articles reporting the frequency of specific donor-site morbidity were included. Frequentist model network meta-analyses with P-scores were conducted to compare the prevalence of donor-site morbidity, complications, all-cause reoperations and revision ACLR among the three treatment groups.

RESULTS

Twenty-one RCTs comprising the outcomes of 1726 patients were included. The overall pooled rate of donor-site morbidity (defined as anterior knee pain, difficulty/impossibility kneeling, or combination) was 47.3% (range, 3.8-86.7%). A 69% (95% confidence interval [95% CI]: 0.18-0.56) and 88% (95% CI: 0.04-0.33) lower odds of incurring donor-site morbidity was observed with HT and QT autografts, respectively (p < 0.0001, both), when compared to BTB autograft. QT autograft was associated with a non-statistically significant reduction in donor-site morbidity compared with HT autograft (OR: 0.37, 95% CI: 0.14-1.03, n.s.). Treatment rankings (ordered from best-to-worst autograft choice with respect to donor-site morbidity) were as follows: (1) QT (P-score = 0.99), (2) HT (P-score = 0.51) and (3) BTB (P-score = 0.00). No statistically significant associations were observed between autograft and complications (n.s.), reoperations (n.s.) or revision ACLR (n.s.).

CONCLUSION

ACLR using HT and QT autograft tissue was associated with a significant reduction in donor-site morbidity compared to BTB autograft. Autograft selection was not associated with complications, all-cause reoperations, or revision ACLR. Based on the current data, there is sufficient evidence to recommend that autograft selection should be personalized through considering differential rates of donor-site morbidity in the context of patient expectations and activity level without concern for a clinically important change in the rate of adverse events.

LEVEL OF EVIDENCE

Level I.

Sex-Specific Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Background:

Despite the significant difference between men and women in incidence of anterior cruciate ligament (ACL) injuries, there is a paucity of consistent information on the influence of patient sex on outcomes after ACL reconstruction. A previous meta-analysis has demonstrated that female patients have worse outcomes with regard to laxity, revision rate, Lysholm score, and Tegner activity score and are less likely to return to sports (RTS).

Purpose:

To conduct a systematic review and meta-analysis to evaluate and compare sex-specific outcomes after ACL reconstruction.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review was performed using PubMed, PubMed Central, Embase, OVID, and Cochrane databases per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The following search terms were used: “anterior cruciate ligament reconstruction” OR “ACL reconstruction” OR “anterior cruciate ligament” OR “ACL” AND “gender” OR “sex” OR “male” OR “female” AND “outcome” AND “2015-Present” to gather all relevant articles between 2015 and 2020. A risk-of-bias assessment and quality assessment was conducted on included studies.

Results:

Of 9594 studies initially identified, 20 studies with 35,935 male and 21,455 female patients were included for analysis. The 7 studies reporting International Knee Documentation Committee (IKDC) scores showed that male patients had statistically significantly higher postoperative scores (mean difference, 3.02 [95% CI, 1.19-4.84]; P< .01; I² = 66%), and 7 studies that reported the rate of ACL revision showed there was no significant difference between male and female patients (odds ratio, 0.85 [95% CI, 0.45-1.60]; P = .61; I² = 94%). The 7 studies that reported rates of rerupture showed that males were significantly more likely than females to have a graft rerupture (odds ratio, 1.35 [95% CI, 1.22-1.50]; P < .01; I² = 0%). Male patients reported a higher RTS rate than did their female counterparts (59.82% compared with 42.89%); however, no formal statistical analysis could be done because of the variability in reporting techniques.

Conclusion:

Male and female patients with ACL injuries demonstrated similar outcomes regarding their rates of revision; however, male patients were found to have statistically significantly higher postoperative IKDC scores but at the same time higher rerupture rates. Our findings suggest that sex-based differences in outcomes after ACL reconstruction vary based on which metric is used. These results must be considered when counseling patients with ACL injuries.

Bone Grafting the Patellar Defect After Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction Decreases Anterior Knee Morbidity: A Systematic Review

PURPOSE

The aim of this systematic review was to evaluate the impact of bone grafting of patellar defects on reported anterior knee morbidity and subjective outcomes after bone-patellar tendon-bone autograft reconstruction of the anterior cruciate ligament.

METHODS

A systematic electronic search of MEDLINE, Embase, Web of Science, and the Cochrane Library was carried out. All English-language prospective randomized clinical trials published from January 1, 2000, to July 24, 2020, were eligible for inclusion. All studies addressing patellar defect grafting were eligible for inclusion regardless of the timing of surgery, graft type, surgical technique, or rehabilitation protocol.

RESULTS

A total of 39 studies with 1,955 patients were included for analysis. There were 796 patients in the no patellar grafting (NPG) group, with a mean age range of 22.7 to 33.0 years, and 1,159 patients in the patellar grafting (PG) group, with a mean age range of 17.8 to 34.7 years. The visual analog scale pain score ranged from 1.2 to 5.1 in the NPG group compared with 0.3 to 3.7 in the PG group. The proportion of patients with anterior knee pain ranged from 19% to 81% in the NPG group and from 15% to 32% in the PG group. Moderate to severe kneeling pain was reported in 22% to 57% of patients in the NPG group and 10% of those in the PG group. The percentage of patients with at least 3° of extension loss ranged from 4% to 43% in the NPG group and from 2% to 11% in the PG group.

CONCLUSIONS

PG favors decreased anterior knee pain, kneeling pain, and extension loss compared with non-grafted defects; however, the functional outcomes are comparable. Owing to the heterogeneity in reporting, statistical conclusions could not be drawn.

LEVEL OF EVIDENCE

Level II, systematic review of Level I and II studies.

Trauma and femoral tunnel position are the most common failure modes of anterior cruciate ligament reconstruction: a systematic review

PURPOSE

To improve outcomes of anterior cruciate ligament reconstruction (ACLR), it is important to understand the reasons for failure of this procedure. This systematic review was performed to identify current failure modes of ACLR.

METHODS

A systematic search was performed using PubMed, EMBASE, Cochrane, and annual registries for ACLR failures. Studies were included when failure modes were reported (I) of ≥ 10 patients and (II) at a minimum of two-year follow-up. Modes of failure were also compared between different graft types and in femoral tunnel positions.

RESULTS

This review included 24 cohort studies and 4 registry-based studies (1 level I, 1 level II, 10 level III, and 16 level IV studies). Overall, a total of 3657 failures were identified. The most common single failure mode of ACLR was new trauma (38%), followed by technical errors (22%), combined causes (i.e. multiple failure mechanisms; 19%), and biological failures (i.e. failure due to infection or laxity without traumatic or technical considerations; 8%). Technical causes also played a contributing role in 17% of all failures. Femoral tunnel malposition was the most common cause of technical failure (63%). When specifically looking at the bone-patellar tendon-bone (BPTB) or hamstring (HT) autografts, trauma was the most common failure mode in both, whereas biological failure was more pronounced in the HT group (4% vs. 22%, respectively). Technical errors were more common following transtibial as compared to anteromedial portal techniques (49% vs. 26%).

CONCLUSION

Trauma is the single leading cause of ACLR failure, followed by technical errors, and combined causes. Technical errors seemed to play a major or contributing role in large part of reported failures, with femoral tunnel malposition being the leading cause of failure. Trauma was also the most common failure mode in both BPTB and HT grafts. Technical errors were a more common failure mode following transtibial than anteromedial portal technique.

LEVEL OF EVIDENCE

IV.

Conventional Follow-up Versus Mobile Application Home Monitoring for Postoperative Anterior Cruciate Ligament Reconstruction Patients: A Randomized Controlled Trial

PURPOSE

To determine whether a mobile app can reduce the need for in-person visits and examine the resulting societal cost differences between mobile and conventional follow-up for postoperative anterior cruciate ligament (ACL) reconstruction patients.

METHODS

Study design was a single-center, 2-arm parallel group randomized controlled trial. All patients undergoing ACL reconstruction aged 16 to 70 years were screened for inclusion in the study. Competent use of a mobile device and ability to communicate in English was required. Patients were randomly assigned to receive follow-up via a mobile app or conventional appointments. Analysis was intention-to-treat. The primary outcome was the number of in-person visits to any health care professional during the first 6 postoperative weeks. Secondary outcomes included analysis of costs incurred by the health care system and personal patient costs related to both methods of follow-up. Patient-reported satisfaction and convenience scores, rates of complications, and clinical outcomes were also analyzed.

RESULTS

Sixty patients were analyzed. Participants in the app group attended a mean of 0.36 in-person visits versus 2.44 in-person visits in the conventional group (95% confidence interval 0.08-0.28; P < .0001). On average, patients in the app group spent $211 (Canadian dollars) less than the conventional group over 6 weeks (P < .0001) on personal costs related to follow-up. Health care system costs were also significantly less in the app group ($157.5 vs CAD $202.2; P < .0001). There was no difference between groups in patient satisfaction, convenience, complication rates, or clinical outcome measures.

CONCLUSIONS

Mobile follow-up can eliminate a significant number of in-person visits during the first 6 postoperative weeks in patients undergoing ACL reconstruction with cost savings to both the patient and health care system. This method should be considered for dissemination among similar orthopaedic procedures during early postoperative care.

LEVEL OF EVIDENCE

I: Prospective randomized controlled trial.

Complications After Anterior Cruciate Ligament Reconstruction and Their Relation to the Type of Graft: A Prospective Study of 958 Cases

BACKGROUND

Complications and adverse events after anterior cruciate ligament (ACL) reconstruction are well known, but they have been underestimated in previous studies.

PURPOSE

To describe the complications and adverse events after ACL reconstruction within a 2-year follow-up and analyze them in relation to the type of graft.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

From 2000 to 2012, 958 patients with an isolated ACL injury underwent surgery by a single knee surgeon. ACL reconstruction was performed with the medial portal technique for the femoral tunnel and the use of bone-patellar tendon-bone (BPTB) or hamstring tendon graft. Patients were reviewed at 6 weeks and 3, 6, 12, and 24 months after surgery with the International Knee Documentation Committee score, plain radiographs, and the KT-1000 arthrometer.

RESULTS

Of 958 patients enrolled, 147 (15%) were lost at last follow-up. The 2 groups (bone-patellar tendon-bone [n = 257] and hamstring [n = 554]) were similar regarding the mean age at the time of surgery and preoperative anterior laxity. The main complications were as follows: anterior knee pain (n = 130 of 811, 16%), stiffness (n = 72, 8.8%), secondary meniscal lesions (n = 59, 7.2%), pain attributed to fixation (n = 79, 9.7%), ACL rerupture (n = 47, 5.7%), contralateral ACL ruptures (n = 24, 3%), patellar fractures (n = 3, 0.3%), infections (n = 9, 1%), and thromboembolic complications (n = 5, 0.6%). There was no significant difference between the grafts with respect to the frequency of joint stiffness, secondary meniscal lesions, or anterior knee pain. During the first 2 postoperative years, the percentage of patients with anterior knee pain was higher in the patellar tendon group (23.3% vs 12.6%, P < .001); however, this difference was not significant after the 2-year interval (3.1% vs 2.5%, P = .63). The percentage of patients with a rerupture of the graft was significantly lower in the patellar tendon group than in the hamstring group (25 of 811 [3.1%] vs 57 of 811 [7%], P = .023). Similar results were recorded regarding the pain related to the hardware material (7 of 811 [0.8%] in the BPTB group vs 113 of 811 [13.9%] in the hamstring group, P = .001). The percentage of ACL ruptures contralateral to the repair was higher in the patellar tendon group (41 of 811 [5%] vs 17 of 811 [2%], P = .016).

CONCLUSION

The total rate of complications after an ACL reconstruction was 39%, and the surgical revision rate for any reason was 28%. Problems with the hardware material were more frequent in the hamstring group, leading to an increased rate of surgical revision. Anterior knee pain was initially higher in the patellar tendon group, but there was no significant difference in a 2-year interval. The rerupture rate was statistically higher in the hamstring group.

A Randomized Clinical Trial Comparing Patellar Tendon, Hamstring Tendon, and Double-Bundle ACL Reconstructions: Patient-Reported and Clinical Outcomes at 5-Year Follow-up

BACKGROUND

This randomized clinical trial evaluated the 5-year, disease-specific quality-of-life outcomes of patients treated for anterior cruciate ligament (ACL) deficiency with use of a patellar tendon, single-bundle quadruple-stranded hamstring, or double-bundle hamstring reconstruction.

METHODS

Patients (n = 110 per group; 183 male; 14 to 50 years of age) were randomly allocated to anatomically positioned ACL reconstruction with use of a patellar tendon graft (patellar tendon group; mean age, 28.7 years), quadruple-stranded hamstring tendon construct (hamstring tendon group; mean age, 28.5 years), or double-bundle hamstring tendon construct (double-bundle group; mean age, 28.3 years). Computer-generated allocation with varied block randomization was performed intraoperatively. The 5-year primary outcome measure was the Anterior Cruciate Ligament-Quality of Life (ACL-QOL) score, and secondary outcome measures included the International Knee Documentation Committee (IKDC) subjective score and objective grades, pivot shift assessment, range of motion, kneeling pain, Tegner activity scale, Cincinnati Occupational Rating Scale, complete traumatic reruptures, partial traumatic tears, total traumatic reinjuries, and atraumatic graft failures.

RESULTS

Three hundred and fifteen patients (95%) completed the 5-year follow-up (4 withdrawals, and 11 lost to follow-up). ACL-QOL scores increased significantly from baseline for all groups (p < 0.0001), but mean scores at 5 years did not differ among the groups (p = 0.548): mean (and standard deviation) of 82.5 ± 17.9 (95% confidence interval [CI], 79.0 to 86.0) for patellar tendon, 83.9 ± 18.2 (95% CI, 80.3 to 87.4) for hamstring tendon, and 81.1 ± 19.3 (95% CI, 77.4 to 84.8) for double-bundle. The proportions of patients at 5 years with a pivot shift grade of ≥2 (12% for patellar tendon, 16% for hamstring tendon, and 22% for double-bundle; p = 0.149) and with normal and nearly normal knees per IKDC grade (87%, 82%, and 75% for the 3 groups, respectively; p = 0.093) trended in favor of patellar tendon reconstruction. No differences were seen for the IKDC subjective scores, knee range of motion including passive extension deficits, the single leg hop test, Cincinnati Occupational Rating scores, and Tegner activity levels. Kneeling pain was more common with patellar tendon reconstruction (10% of patients compared with 4% for hamstring tendon and 2% for double-bundle; p = 0.029). For hamstring tendon and double-bundle reconstructions, there were trends toward more complete traumatic reruptures (4% for patellar tendon, 10% for hamstring tendon, and 10% for double-bundle; p = 0.145) and partial traumatic tears (0%, 5%, and 6%, respectively; p = 0.059), with significantly fewer combined traumatic reinjuries in the patellar tendon group (4 patients compared with 16 for hamstring tendon and 17 for double-bundle; p = 0.010). Atraumatic graft failure (pivot shift grade of ≥2) was found for 10% of the patients.

CONCLUSIONS

At 5 years, we found no significant difference in the quality-of-life outcome among the patellar tendon, hamstring tendon, and double-bundle techniques for ACL reconstruction. Significantly more patients in the hamstring tendon and double-bundle groups experienced traumatic graft reinjury compared with the patellar tendon group. There was a trend toward a higher percentage with normal and nearly normal IKDC grades in the patellar tendon group compared with hamstring tendon and double-bundle groups.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Hamstring Injuries in Major League Baseball Pitchers: Implications in Graft Selection for Ulnar Collateral Ligament Reconstruction

BACKGROUND

Hamstring tendons are commonly harvested as autograft for ulnar collateral ligament reconstruction. There is no consensus in the literature whether the hamstring tendon should be harvested from the ipsilateral (drive) leg or contralateral (landing) leg of baseball pitchers undergoing ulnar collateral ligament reconstruction. Hamstring injuries commonly occur in baseball players, but there are no reports on their incidence specifically among Major League Baseball (MLB) pitchers, nor are there reports on whether they occur more commonly in the drive leg or the landing leg.

HYPOTHESIS

Hamstring injuries occur more commonly in the landing legs of MLB pitchers.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

MLB pitchers who sustained hamstring injuries requiring time spent on the disabled list were identified from publicly available sources over 10 seasons. Demographics of the pitchers and injury and return-to-sport data were collected. Hamstring injuries to the drive leg were compared with injuries to the landing leg.

RESULTS

Sixty-five pitchers had 78 disabled list stints due to hamstring injuries over 10 seasons. The landing leg was injured in 67.9% of cases, and the most common mechanism of injury was pitching. There were no significant differences in demographics between pitchers who sustained drive leg and landing leg injuries. There was no significant difference in mechanism of injury or time to return to sport between pitchers who sustained drive leg and landing leg injuries.

CONCLUSION

The landing leg is more commonly injured than the drive leg among MLB pitchers who sustain hamstring injuries. There is no difference in time to return to sport between pitchers who sustain drive leg and landing leg injuries. More research is required to determine whether there is a difference in performance or future injury between hamstring tendons harvested from the drive leg and the landing leg for ulnar collateral ligament reconstruction among pitchers.

Reinterventions after dynamic intraligamentary stabilization in primary anterior cruciate ligament repair

BACKGROUND

The goal of this study was to perform an in-depth analysis of the frequency and cause of secondary interventions subsequent to primary anterior cruciate ligament (ACL) repair with dynamic intraligamentary stabilization (DIS).

METHODS

Between July 2009 and June 2014, 455 patients underwent DIS treatment. The minimum follow-up was 21months (mean 28months, range 21-64months).

RESULTS

A total of 215 (48.2%) reinterventions were performed in 190 (42.6%) patients. One-hundred and seventy-six (39.4%) were non-revision reinterventions, and 39 (8.7%) were revision ACL reconstructions. Re-arthroscopies included 26 (5.8%) scar tissue debridements with hardware removal due to range of motion deficits, 14 (3.1%) partial meniscectomies, four (0.9%) meniscal sutures, and four (0.9%) arthroscopies due to crepitation or knee pain. Minor non-revision reinterventions performed under analgosedation consisted of 97 (21.7%) hardware removals, 20 (4.5%) hardware removals with manipulations under anesthesia, and four manipulations under anesthesia alone (0.9%).

CONCLUSIONS

In our study, the revision rate was within the range of published results after ACL reconstructions. In over 90% of patients, the native ACL was preserved with no need for a secondary reconstruction. Most of the non-revision reinterventions were minor and included hardware removals and manipulations under anesthesia. The re-arthroscopy rate was lower than that after ACL reconstruction with fewer secondary meniscal sutures and partial meniscectomies. Early treatment of meniscal tears may be one crucial benefit of ACL repair with DIS.

Do Major League Baseball Team Physicians Harvest the Semitendinosus From the Drive Leg or Landing Leg When Performing Ulnar Collateral Ligament Reconstruction on Elite Baseball Pitchers?

Background:

Hamstring autograft is a common graft choice when performing ulnar collateral ligament reconstruction (UCLR).

Purpose/Hypothesis:

The purpose of this study was to survey Major League Baseball (MLB) team physicians and determine whether these physicians harvest the hamstring (semitendinosus or gracilis) from the drive leg (ipsilateral to surgical site) or landing leg (contralateral to surgical site) when performing UCLR on elite-level pitchers. The hypothesis was that the majority of surgeons harvest the hamstring from the drive leg when performing a UCLR.

Study Design:

Descriptive epidemiology study.

Methods:

Overall, 52 MLB team orthopaedic surgeons were sent the 5-question online survey. The survey assessed surgeon UCLR volume, surgical technique, which leg the hamstring graft was harvested from, the reasoning for choosing that particular leg, and whether the surgeon would change their practice if evidence showed the hamstring from one of the legs was more important than the other. The survey was sent out 5 separate times to maximize the response rate.

Results:

Forty (77%) MLB team physicians completed the survey. The largest number of surgeons (n = 16; 40%) performed between 5 and 14 UCLRs annually, while 6 (15%) performed more than 50 UCLRs annually. Most surgeons (n = 23; 57.5%) used the docking technique. Significantly more surgeons harvested the hamstring from the landing leg (n = 29; 72.5%) compared with the drive leg (n = 11; 27.5%) (P = .007). More surgeons cited the reason for their choice of leg as a belief that the hamstring they harvested plays less of a role in the ability of a pitcher to generate a forceful pitch (n = 25; 62.5%) than for logistical reasons in the operating room (n = 15; 37.5%); this difference was not statistically significant. Significantly more surgeons would change their practice (n = 35; 87.5%) if evidence showed the hamstrings from a specific (drive or landing) leg to be more active in the throwing motion compared with those who would not (P < .001).

Conclusion:

When performing a UCLR using hamstring autograft, the majority of MLB team physicians harvest the hamstring from the landing leg as opposed to the drive leg, as they believe the hamstring from the landing leg plays less of a role in generating a forceful pitch than that from the drive leg.