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Rahardja R, Love H, Clatworthy MG, Young SW. Comparison of Knee Pain and Difficulty With Kneeling Between Patellar Tendon and Hamstring Tendon Autografts After Anterior Cruciate Ligament Reconstruction: A Study From the New Zealand ACL Registry. Am J Sports Med 2023; 51:3464-3472. [PMID: 37775983 PMCID: PMC10623603 DOI: 10.1177/03635465231198063] [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: 03/02/2023] [Accepted: 07/24/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND The bone-patellar tendon-bone (BTB) autograft is associated with difficulty with kneeling after anterior cruciate ligament (ACL) reconstruction; however, it is unclear whether it results in a more painful or symptomatic knee compared with the hamstring tendon autograft. PURPOSE To identify the rate and risk factors for knee pain and difficulty with kneeling after ACL reconstruction. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Primary ACL reconstruction procedures prospectively recorded in the New Zealand ACL Registry from April 2014 to May 2021 were analyzed. The Knee injury and Osteoarthritis Outcome Score (KOOS) was used to identify patients reporting consequential knee pain (CKP), defined as a KOOS Pain subscore of ≤72 points, and severe kneeling difficulty (SKD), defined as a self-report of "severe" or "extreme" difficulty with kneeling. Absolute values of the KOOS Pain and Symptoms subscales were also compared. RESULTS A total of 10,999 patients were analyzed. At 2-year follow-up, 9.3% (420/4492) reported CKP, and 12.0% (537/4471) reported SKD. The most important predictor of CKP at 2-year follow-up was having significant pain before surgery (adjusted odds ratio, 4.10; P < .001). The most important predictor of SKD at 2-year follow-up was the use of a BTB autograft rather than a hamstring tendon autograft (21.3% vs 9.4%, respectively; adjusted odds ratio, 3.12; P < .001). There was no difference between the BTB and hamstring tendon grafts in terms of CKP (9.9% vs 9.2%, respectively; P = .494) or in absolute values of the KOOS Pain (mean, 88.7 vs 89.0, respectively; P = .37) and KOOS Symptoms (mean, 82.5 vs 82.1, respectively; P = .49) subscales. CONCLUSION At 2-year follow-up after primary ACL reconstruction, 9.3% of patients reported CKP, and 12.0% reported SKD. The BTB autograft was associated with difficulty with kneeling, but it did not result in a more painful or symptomatic knee compared with the hamstring tendon autograft.
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Affiliation(s)
- Richard Rahardja
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | | | - Mark G. Clatworthy
- Department of Orthopaedic Surgery, Middlemore Hospital, Auckland, New Zealand
| | - Simon W. Young
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Department of Orthopaedic Surgery, North Shore Hospital, Auckland, New Zealand
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Spierings J, Van den Hengel M, Janssen RPA, Van Rietbergen B, Ito K, Foolen J. Knee instability caused by altered graft mechanical properties after anterior cruciate ligament reconstruction: the early onset of osteoarthritis? Front Bioeng Biotechnol 2023; 11:1244954. [PMID: 37691908 PMCID: PMC10484411 DOI: 10.3389/fbioe.2023.1244954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/15/2023] [Indexed: 09/12/2023] Open
Abstract
Anterior cruciate ligament (ACL) rupture is a very common knee joint injury. Torn ACLs are currently reconstructed using tendon autografts. However, half of the patients develop osteoarthritis (OA) within 10 to 14 years postoperatively. Proposedly, this is caused by altered knee kine(ma)tics originating from changes in graft mechanical properties during the in vivo remodeling response. Therefore, the main aim was to use subject-specific finite element knee models and investigate the influence of decreasing graft stiffness and/or increasing graft laxity on knee kine(ma)tics and cartilage loading. In this research, 4 subject-specific knee geometries were used, and the material properties of the ACL were altered to either match currently used grafts or mimic in vivo graft remodeling, i.e., decreasing graft stiffness and/or increasing graft laxity. The results confirm that the in vivo graft remodeling process increases the knee range of motion, up to >300 percent, and relocates the cartilage contact pressures, up to 4.3 mm. The effect of remodeling-induced graft mechanical properties on knee stability exceeded that of graft mechanical properties at the time of surgery. This indicates that altered mechanical properties of ACL grafts, caused by in vivo remodeling, can initiate the early onset of osteoarthritis, as observed in many patients clinically.
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Affiliation(s)
- Janne Spierings
- Department of Biomedical Engineering, Orthopaedic Biomechanics, Eindhoven University of Technology, Eindhoven, Netherlands
- Institute of Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Marloes Van den Hengel
- Department of Biomedical Engineering, Orthopaedic Biomechanics, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Rob P. A. Janssen
- Department of Biomedical Engineering, Orthopaedic Biomechanics, Eindhoven University of Technology, Eindhoven, Netherlands
- Department of Orthopaedic Surgery and Trauma, Máxima Medical Centre Eindhoven/Veldhoven, Eindhoven, Netherlands
- Department of Paramedical Sciences, Health Innovations and Technology, Fontys University of Applied Sciences, Eindhoven, Netherlands
| | - Bert Van Rietbergen
- Department of Biomedical Engineering, Orthopaedic Biomechanics, Eindhoven University of Technology, Eindhoven, Netherlands
- Institute of Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Keita Ito
- Department of Biomedical Engineering, Orthopaedic Biomechanics, Eindhoven University of Technology, Eindhoven, Netherlands
- Institute of Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Jasper Foolen
- Department of Biomedical Engineering, Orthopaedic Biomechanics, Eindhoven University of Technology, Eindhoven, Netherlands
- Institute of Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, Netherlands
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Grueva-Pancheva T, Stambolieva K. Effectiveness of early onset of rehabilitation on the postural stability after anterior cruciate ligament reconstruction. J Bodyw Mov Ther 2023; 35:43-48. [PMID: 37330801 DOI: 10.1016/j.jbmt.2023.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/16/2023] [Accepted: 04/11/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE The objective of this study was to evaluate the early onset of rehabilitation on restoring the postural stability of patients after anterior cruciate ligament reconstruction (ACLR) at the 3rd postoperative month. METHODS Forty patients after ACLR and twenty healthy controls took part in the investigation. The patients were divided into two groups, depending on the start of their proprioceptive rehabilitation program: an experimental group - on the 5th day after the surgery and a control group - on around the 30th postoperative day. Postural stability was investigated by static posturographic tests on stable and foam surfaces with open and closed eyes. RESULTS The patients from the experimental group showed lower amplitudes and velocities of the postural sways than the patients from the control group at the 3rd postoperative month. We found that the early start of the proprioceptive rehabilitation affects more the amplitude than the velocity of the postural sway which remains significantly high in both directions compared to the conventional rehabilitation. CONCLUSION The early start of the rehabilitation has a beneficial role in the recovery of the postural stability in the 3rd postoperative month, especially in more challenging conditions for keeping the equilibrium, which contributes to the minimizes the risk of a second anterior cruciate ligament injury after patients' return to their usual sport and daily activities routine.
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Affiliation(s)
- Tanya Grueva-Pancheva
- Department of Theory and Methods of Kinesitherapy, National Sports Academy, Sofia, Bulgaria
| | - Katerina Stambolieva
- Department of Cognitive Psychophysiology, Institute of Neurobiology, Bulgarian Academy of Sciences, Sofia, Bulgaria.
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Functional outcome of implant-free bone-patellar tendon autograft versus hamstring autograft in arthroscopic anterior cruciate ligament reconstruction: A prospective study. Ann Med Surg (Lond) 2021; 63:102184. [PMID: 33732450 PMCID: PMC7937666 DOI: 10.1016/j.amsu.2021.102184] [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: 01/11/2021] [Revised: 02/13/2021] [Accepted: 02/14/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction The use of implant in anterior cruciate ligament (ACL) reconstruction has been associated with several drawbacks including graft injury, implant osteolysis, implant migration and soft tissue irritation. Implant-free ACL reconstruction surgery offers additional benefits of cost-effective, improved graft incorporation and ease of revision surgery. Our study aimed to compare the functional outcome of ACL reconstruction by using bone-patellar tendon autograft with press-fit fixation technique and hamstring autografts with implant. Methods A prospective cohort study design was used. Between March 2013 and March 2014, 12 patients underwent patella tendon-bone graft fixated by press-fit fixation technique (implant-free), while 24 patients underwent ACL reconstruction using implant-fixated hamstring tendon graft. Objective functional outcome was measured by using rolimeter, and subjective functional outcome was measured according to the functional score of IKDC, Tegner-Lysholm and KOOS. Results Both techniques have shown no significant difference in terms of functional outcome, whether assessed by rolimeter measurement, IKDC score, Tegner-Lysholm, KOOS score between implant group and implant-free group, preoperatively and postoperatively. Discussion Our study results are in line with several other studies with various follow-up time and systematic review. With the right technique, graft harvesting of patella tendon-tibial tuberosity bone block can be successfully performed, and associated donor site morbidity can be avoided. Conclusion Patients who underwent ACL reconstruction using implant-free technique by press-fit fixation had comparable outcome with ACL reconstruction with implant, objectively and subjectively. This technique should be further revisited and reevaluated.
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Rahardja R, Zhu M, Love H, Clatworthy MG, Monk AP, Young SW. Effect of Graft Choice on Revision and Contralateral Anterior Cruciate Ligament Reconstruction: Results From the New Zealand ACL Registry. Am J Sports Med 2020; 48:63-69. [PMID: 31730379 DOI: 10.1177/0363546519885148] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The patellar tendon is often considered the "gold standard" graft for reducing the risk of graft rupture after anterior cruciate ligament (ACL) reconstruction. However, its use may also be associated with an increased risk of injury to the contralateral ACL. PURPOSE To clarify the association between graft choice and the risk of revision and contralateral ACL reconstruction. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Prospective data captured by the New Zealand ACL Registry between April 2014 and December 2018 were reviewed. All primary ACL reconstructions performed using either a hamstring tendon or patellar tendon autograft were included. Cox regression survival analysis adjusting for patient factors was performed to compare the risk of revision and contralateral ACL reconstruction between the hamstring tendon graft and the patellar tendon graft. RESULTS A total of 7155 primary ACL reconstructions were reviewed, of which 5563 (77.7%) were performed using a hamstring tendon graft and 1592 (22.3%) were performed using a patellar tendon graft. Patients with a hamstring tendon graft had a revision rate of 2.7% compared with 1.3% in patients with a patellar tendon graft (adjusted hazard ratio [HR], 2.51; 95% CI, 1.55-4.06; P < .001). The patellar tendon graft was associated with an increased risk of contralateral ACL reconstruction compared with the hamstring tendon graft (adjusted HR, 1.91; 95% CI, 1.15-3.16; P = .012). The number needed to treat (NNT) with a patellar tendon graft to prevent 1 revision was 73.6. However, the NNT with a hamstring tendon graft to prevent 1 contralateral reconstruction was 116.3. CONCLUSION Use of a patellar tendon graft reduced the risk of graft rupture but was associated with an increased risk of injury to the contralateral ACL. Adequate rehabilitation and informed decision making on return to activity and injury prevention measures may be important in preventing subsequent injury to the healthy knee.
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Affiliation(s)
| | - Mark Zhu
- University of Auckland, Auckland, New Zealand
| | | | - Mark G Clatworthy
- Department of Orthopaedic Surgery, Middlemore Hospital, Auckland, New Zealand
| | - Andrew Paul Monk
- University of Auckland, Auckland, New Zealand.,Department of Orthopaedic Surgery, Auckland Hospital, Auckland, New Zealand
| | - Simon W Young
- University of Auckland, Auckland, New Zealand.,Department of Orthopaedic Surgery, North Shore Hospital, Auckland, New Zealand
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Salem HS, Varzhapetyan V, Patel N, Dodson CC, Tjoumakaris FP, Freedman KB. Anterior Cruciate Ligament Reconstruction in Young Female Athletes: Patellar Versus Hamstring Tendon Autografts. Am J Sports Med 2019; 47:2086-2092. [PMID: 31233335 DOI: 10.1177/0363546519854762] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Female athletes are 2 to 8 times more prone to anterior cruciate ligament (ACL) rupture than males. Furthermore, reinjury to the ipsilateral or contralateral knee can occur in >20% of athletes. Female sex and younger age are known risk factors for graft failure. The optimal graft choice for young females remains unknown and poorly studied. PURPOSE/HYPOTHESIS The authors aimed to compare clinical outcomes in young females who underwent ACL reconstruction (ACLR) with bone-patellar tendon-bone (BTB) and quadrupled hamstring (HS) autografts. It was hypothesized that no significant differences in outcomes exist between graft choices. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Female patients aged 15 to 25 years who underwent primary ACLR with BTB or HS autograft were included for review. Patients were subdivided into 2 age groups: 15 to 20 years and 21 to 25 years. The occurrence of chondral, meniscal, or ligamentous injury to either knee was recorded for comparison. RESULTS A total of 256 females were included (BTB, n = 175; HS, n = 81). The majority of patients were between the ages of 15 and 20 years (BTB, 80%; HS, 77.8%). Overall, graft rupture occurred in 23 patients (9%) and contralateral ACL tear occurred in 18 (7%). Subgroup analysis showed that 75% of BTB and 100% of HS graft retears occurred in females aged 15 to 20 years. Within this age group, there was a significantly lower rate of graft ruptures in the BTB group (6.4%) as compared with the HS group (17.5%, P = .02). Allograft augmentation was used in 4 of the 11 HS grafts that retore. When allograft-augmented grafts were excluded, there was no significant difference in graft failure rate between graft choices. Fifteen patients in the BTB group (12%) as opposed to 1 in the HS group (2%) reported extreme difficulty or the inability to kneel on the front of the knee (P = .04). CONCLUSION In females aged 15 to 20 years undergoing ACLR, BTB autograft may lead to fewer graft ruptures than HS autograft. While this difference was not observed in females aged 21 to 25 years, a larger sample may be required to accept the null hypothesis in this age group. BTB autograft significantly increased the risk of kneeling pain as compared with HS regardless of age.
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Affiliation(s)
| | | | - Nimit Patel
- Rothman Institute, Philadelphia, Pennsylvania, USA
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Janssen RPA, van Melick N, van Mourik JBA, Reijman M, van Rhijn LW. ACL reconstruction with hamstring tendon autograft and accelerated brace-free rehabilitation: a systematic review of clinical outcomes. BMJ Open Sport Exerc Med 2018; 4:e000301. [PMID: 29682311 PMCID: PMC5905729 DOI: 10.1136/bmjsem-2017-000301] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 01/05/2018] [Accepted: 02/19/2018] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To investigate the clinical outcomes after hamstring tendon autograft ACL reconstruction (ACLR) with accelerated, brace-free rehabilitation. DESIGN Systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. DATA SOURCES Embase, MEDLINE Ovid, Web of Science, Cochrane CENTRAL and Google scholar from 1 January 1974 to 31 January 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Study designs reporting outcomes in adults after arthroscopic, primary ACLR with hamstring autograft and accelerated, brace-free rehabilitation. RESULTS Twenty-four studies were included in the review. The clinical outcomes after hamstring tendon autograft ACLR with accelerated brace-free rehabilitation were the following: (1) early start of open kinetic exercises at 4 weeks in a limited range of motion (ROM, 90°-45°) and progressive concentric and eccentric exercises from 12 weeks did not alter outcomes, (2) gender and age did not influence clinical outcomes, (3) anatomical reconstructions showed better results than non-anatomical reconstructions, (4) there was no difference between single-bundle and double-bundle reconstructions, (5) femoral and tibial tunnel widening occurred, (6) hamstring tendons regenerated after harvest and (7) biological knowledge did not support return to sports at 4-6 months. CONCLUSIONS After hamstring tendon autograft ACLR with accelerated brace-free rehabilitation, clinical outcome is similar after single-bundle and double-bundle ACLR. Early start of open kinetic exercises at 4 weeks in a limited ROM (90°-45°) and progressive concentric and eccentric exercises from 12 weeks postsurgery do not alter clinical outcome. Further research should focus on achievement of best balance between graft loading and graft healing in the various rehabilitation phases after ACLR as well as on validated, criterion-based assessments for safe return to sports. LEVEL OF EVIDENCE Level 2b; therapeutic outcome studies.
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Affiliation(s)
- Rob P A Janssen
- Orthopaedic Center Máxima, Máxima Medical Center, Eindhoven, The Netherlands
| | | | - Jan B A van Mourik
- Orthopaedic Center Máxima, Máxima Medical Center, Eindhoven, The Netherlands
| | - Max Reijman
- Orthopaedic Center Máxima, Máxima Medical Center, Eindhoven, The Netherlands
- Department of Orthopaedic Surgery, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Lodewijk W van Rhijn
- Orthopaedic Surgery & Traumatology, Maastricht University Medical Center, Maastricht, The Netherlands
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