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Hanna AJ, Johns WL, Perez AR, Kemler B, Onor GI, Freedman KB, Dodson CC, Ciccotti MG. Patients' under 25 subjective readiness to return to sport after ACL reconstruction with bone-patellar-bone grafts: Autograft vs. allograft. J Orthop 2024; 55:149-156. [PMID: 38694957 PMCID: PMC11059441 DOI: 10.1016/j.jor.2024.04.010] [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: 04/05/2024] [Accepted: 04/14/2024] [Indexed: 05/04/2024] Open
Abstract
Purpose To assess the difference in perceived readiness to return to sport (RTS) within the first year postoperative period between individuals undergoing anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BTB) autografts or allografts. Methods This was a prospective cohort study of patients undergoing primary ACL reconstruction done either with BTB autograft or allograft from 2010 to 2018. Skeletally mature patients aged 14 to 25 were eligible for inclusion. Patients completed the Marx Activity Rating Scale (MARS) questionnaire postoperatively evaluating perceived ability to perform various activities to compare subjective ability to RTS. Those patients who were outside outlined cohort age, failed to complete a single post-operative survey, underwent revision procedures, or underwent simultaneous or staged additional ligament surgery were excluded. Results Fifty-nine patients (20.1 ± 3.19 years, 57.6 % Male) were included in the study. Sixteen patients underwent ACL reconstruction with allograft (19.8 ± 3.43 years) while 43 patients received autograft (20.2 ± 3.13). At 3 months autograft recipients reported higher perceived ability to cut (P = .003). At 6-months, allograft recipients reported higher perceived ability to run (P = .033), cut (P = .048), and decelerate (P = .008) as well as a higher overall perceived ability to RTS (P = .032). At all other times, there was no significant difference between cohorts' subjective readiness to perform activities. Conclusion The results of this study indicate that at times within the first year of recovery following ACL reconstruction, patients who receive allografts and autografts may have significantly different perceived ability to perform activities or RTS. However, while present at various times throughout the first year of recovery, any difference in perceived ability to perform activities or in overall RTS is no longer present at 12 months. Level of evidence Level II, Prospective cohort study.
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Affiliation(s)
- Adeeb J Hanna
- Rothman Orthopaedics Institute, Philadelphia, PA, USA
| | | | | | - Bryson Kemler
- Rothman Orthopaedics Institute, Philadelphia, PA, USA
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2
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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 2024:3635465241262018. [PMID: 39097771 DOI: 10.1177/03635465241262018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [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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3
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Dadoo S, Herman ZJ, Nazzal EM, Drain NP, Finger L, Reddy RP, Miller L, Lesniak BP, Musahl V, Hughes JD. Outcomes After Anterior Cruciate Ligament Reconstruction With Quadriceps Tendon in Adolescent Athletes at Mean Follow-up of 4 Years. Orthop J Sports Med 2024; 12:23259671241254795. [PMID: 39100218 PMCID: PMC11295237 DOI: 10.1177/23259671241254795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 12/06/2023] [Indexed: 08/06/2024] Open
Abstract
Background Despite increasing use of quadriceps tendon (QT) autograft in anterior cruciate ligament (ACL) reconstruction (ACLR), limited data exist regarding its outcomes in high-risk adolescent athletes. Purpose To (1) report the outcomes after QT ACLR in adolescent athletes and (2) identify patient-related and surgery-related factors that may influence failure rates after QT ACLR. Study Design Case series; Level of evidence, 4. Methods All patients aged 14 to 17 years who underwent primary anatomic, transphyseal, single-bundle QT ACLR between 2010 and 2021 with a minimum 2-year follow-up were included for analysis. Demographic and surgical data as well as preoperative International Knee Documentation Committee (IKDC) and Marx activity scores were collected retrospectively. All patients were also contacted to assess postoperative patient-reported outcomes (PROs), including IKDC and Marx activity scores, and return-to-sports (RTS) data. Outcomes of interest included rates of revision ACLR and ipsilateral complications, contralateral ACL tears, difference in pre- and postoperative PROs, and rates of RTS. Patient and surgical characteristics were compared between groups who required revision ACLR versus those who did not. Results A total of 162 patients met inclusion criteria, of which 89 adolescent athletes (mean age 16.2 ± 1.1 years, 64% female) were included for analysis at mean follow-up of 4.0 years. Postoperative IKDC scores were significantly higher than preoperative scores (88.5 vs 37.5; P < .001), whereas Marx activity scores decreased postoperatively (14.3 vs 12.2; P = .011). Successful RTS occurred in 80% of patients at a mean time of 9.7 ± 6.9 months, and 85% of these patients returned to the same or higher level of sports. The most common reasons for failure to RTS included lack of time (n = 7, 70%) and fearing reinjury in the operative knee (n = 5, 50%). The overall revision ACLR rate was 10% (n = 9), and contralateral ACL tears occurred in 14% (n = 12) of patients. The overall ipsilateral knee reoperation rate was 22.5% (n = 20). No statistically significant differences in patient or surgical characteristics were observed between patients who underwent revision ACLR and those who did not. Conclusion At a minimum 2-year follow-up after QT ACLR, adolescent athletes experienced significantly improved postoperative IKDC scores, high rates of RTS, and low rates of graft failure, despite a relatively high ipsilateral reoperation rate. Surgeons may utilize this information when identifying the optimal graft choice for adolescent athletes who have sustained an ACL injury and wish to return to high level of sporting activities.
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Affiliation(s)
- Sahil Dadoo
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Zachary J. Herman
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ehab M. Nazzal
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nicholas P. Drain
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Logan Finger
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rajiv P. Reddy
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Liane Miller
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Bryson P. Lesniak
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jonathan D. Hughes
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Rangasamy K, Baburaj V, Gopinathan NR, Dhillon MS, Parikh SN. Quadriceps tendon autograft is promising with lower graft rupture rates and better functional Lysholm scores than hamstring tendon autograft in pediatric ACL reconstruction. A systematic review and meta-analysis. J Orthop 2024; 49:156-166. [PMID: 38223427 PMCID: PMC10787221 DOI: 10.1016/j.jor.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 12/17/2023] [Indexed: 01/16/2024] Open
Abstract
Purpose Graft rupture is the most prevalent complication following pediatric anterior cruciate ligament reconstruction (ACLR). The hamstring tendon (HT) autograft is frequently employed, while the quadriceps tendon (QT) autograft has garnered increased attention recently. This study aims to perform a systematic review to assess the complication rates and functional outcomes associated with these two widely used autografts in skeletally immature patients - comparing HT versus QT autografts. Research question Is QT autograft better than HT autograft for ACLR in skeletally immature cohorts? Methodology Three electronic databases (PubMed/Medline, Scopus, and Ovid) were comprehensively searched to identify pertinent articles reporting the outcomes of HT and QT autografts in pediatric ACLR with a minimum 2-year follow-up. Data on the outcome parameters, such as graft rupture rates, contralateral ACL injury rates, functional outcomes, and growth disturbances rates, were extracted. Meta-analysis was performed using OpenMeta Analyst software. Results Twelve studies were included for meta-analysis (pooled analysis) with 659 patients (QT: 205; HT: 454). The analysis showed that QT autografts had a significantly lesser graft rupture rate than HT autografts (3.5 % [95 % CI 0.2, 6.8] and 12.4 % [95 % CI 6.1, 18.7] respectively, p < 0.001). The graft rupture rates between QT with bone and without bone block showed no statistically significant difference (4.6 % [95 % CI 0.8, 1.0] and 3.5 % [95 % CI 2.0, 8.9] respectively, p = 0.181). The overall contralateral ACL injury rate was 10.2 %, and the subgroup analysis revealed no statistically significant difference between the QT and HT groups (p = 0.7). Regarding functional outcome scores at the final follow-up, the mean Lysholm score demonstrated a significant increase in the QT group compared to the HT group (p < 0.001). There were no significant differences between the two groups concerning growth disturbances at the final follow-up. Return to sports (RTS) varied between 6 and 13.5 months after surgery. Conclusion QT autografts demonstrate encouraging outcomes, showcasing lower graft rupture rates, better functional outcomes, and comparable contralateral ACL injury rates and growth disturbances relative to the commonly used HT autograft in skeletally immature patients undergoing ACLR.
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Affiliation(s)
- Karthick Rangasamy
- Clinical Fellow, Paediatric Orthopaedic Division, Children's Hospital, London Health Science Centre, London, Ontario, Canada
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vishnu Baburaj
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Nirmal Raj Gopinathan
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Mandeep Singh Dhillon
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Shital N. Parikh
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, USA
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Monaco E, Cantagalli MR, Daggett M, Carrozzo A, Annibaldi A, Criseo N, Labianca L, Ferretti A. Arthroscopic Physeal Sparing Anterior Cruciate Ligament Reconstruction and Lateral Extra-articular Tenodesis With Semitendinosus and Gracilis Tendons. Arthrosc Tech 2024; 13:102843. [PMID: 38435246 PMCID: PMC10907894 DOI: 10.1016/j.eats.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/20/2023] [Indexed: 03/05/2024] Open
Abstract
Anterior cruciate ligament (ACL) injuries among young patients have increased in recent years. The purpose of this study was to present a physeal-sparing intra- and extra-articular reconstruction using semitendinosus and gracilis tendons autograft. In recent years, the management of these injuries in the pediatric population has become increasingly surgical to restore knee function and reduce the risk of meniscal and chondral injury due to persistent knee instability. However, this is a population at high risk for ACL graft rupture, but it can be lowered by an addition of lateral extra-articular tenodesis (LET). This study shows the pearls and pitfalls of an arthroscopic physeal-sparing ACL reconstruction combined with a concomitant LET using hamstrings autograft.
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Affiliation(s)
- Edoardo Monaco
- Sant’Andrea University Hospital, La Sapienza University of Rome, Rome, Italy
| | | | - Matt Daggett
- Sant’Andrea University Hospital, La Sapienza University of Rome, Rome, Italy
| | - Alessandro Carrozzo
- Sant’Andrea University Hospital, La Sapienza University of Rome, Rome, Italy
| | | | - Natale Criseo
- Sant’Andrea University Hospital, La Sapienza University of Rome, Rome, Italy
| | - Luca Labianca
- Sant’Andrea University Hospital, La Sapienza University of Rome, Rome, Italy
| | - Andrea Ferretti
- Sant’Andrea University Hospital, La Sapienza University of Rome, Rome, Italy
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6
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Lee SS, Kwon KB, Lee J, Ryu DJ, Jang S, Wang JH. Single Bundle Anterior Cruciate Ligament With Anterolateral Ligament Reconstruction Yields Similar Clinical and Radiographic Results at Minimum 2-Year Follow-Up Versus Double Bundle Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Controlled Trial. Arthroscopy 2023; 39:2502-2512. [PMID: 37207917 DOI: 10.1016/j.arthro.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/27/2023] [Accepted: 04/27/2023] [Indexed: 05/21/2023]
Abstract
PURPOSE To compare the clinical, radiographic, and second-look arthroscopic outcomes between double-bundle (DB) anterior cruciate ligament (ACL) reconstruction (DB group) and combined single-bundle (SB) ACL and anterolateral ligament (ALL) reconstruction (SB + ALL group) by a prospective randomized controlled trial. METHODS From May 2019 to June 2020, 84 patients were enrolled in this study. Among them, 10 were lost to follow-up. Thirty-six and 38 patients were successfully allocated to the DB (mean follow up 27.3 ± 4.2 months) and SB + ALL groups (27.2 ± 4.5 months), respectively. The preoperative and postoperative Lachman test, pivot shift test, anterior translation on stress radiographs, KT-2000 arthrometer, Lysholm score, International Knee Documentation Committee score, and Tegner activity score were evaluated and compared. Graft continuity was evaluated using postoperative magnetic resonance imaging (MRI) (32 and 36 patients underwent MRI in the DB and SB + ALL groups at 7.4 ± 3.2 and 7.5 ± 2.9 months after surgery, respectively), and second-look examinations (second-look examination and tibial screw removal were performed concomitantly when patients (1) had tibial screw-related irritation or (2) needed the screws removed, 28 and 23 patients underwent examinations in the DB and SB + ALL groups at 24.0 ± 6.8 and 24.9 ± 8.1 months after surgery, respectively). All measurements were compared between the groups. RESULTS Postoperative clinical outcomes significantly improved in both groups. (All variables showed P < .001) No statistically different outcomes were found between the 2 groups. Additionally, postoperative graft continuity on MRI and second-look examinations were not different between the 2 groups. CONCLUSIONS The DB and SB + ALL groups showed similar postoperative clinical, radiographic, and second-look arthroscopic outcomes. Both groups showed excellent postoperative stability and clinical outcomes compared with the preoperative measurements. LEVEL OF EVIDENCE Level II, randomized controlled trial.
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Affiliation(s)
- Sung-Sahn Lee
- Department of Orthopaedic Surgery, Ilsan Paik Hospital, Inje University School of Medicine, Goyangsi, Gyeonggido, Korea
| | - Kyeu Baek Kwon
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeounghun Lee
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Jin Ryu
- Department of Orthopaedic Surgery, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Seungpil Jang
- Department of Orthopaedic Surgery, Bupyeong Himchan Hospital, Incheon, Korea
| | - Joon Ho Wang
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; Department of Health Sciences and Technology and Department of Medical Device Management and Research, SAIHST, Sungkyunkwan University, Seoul, Korea.
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7
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Engler ID, Chang AY, Kaarre J, Shannon MF, Curley AJ, Smith CN, Hughes JD, Lesniak BP, Musahl V. Revision Rates After Primary Allograft ACL Reconstruction by Allograft Tissue Type in Older Patients. Orthop J Sports Med 2023; 11:23259671231198538. [PMID: 37731958 PMCID: PMC10508052 DOI: 10.1177/23259671231198538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/19/2023] [Indexed: 09/22/2023] Open
Abstract
Background While there is extensive literature on the use of allograft versus autograft in anterior cruciate ligament (ACL) reconstruction, there is limited clinical evidence to guide the surgeon in choice of allograft tissue type. Purpose To assess the revision rate after primary ACL reconstruction with allograft and to compare revision rates based on allograft tissue type and characteristics. Study Design Cohort study; Level of evidence, 3. Methods Patients who underwent primary allograft ACL reconstructions at a single academic institution between 2015 and 2019 and who had minimum 2-year follow-up were included. Exclusion criteria were missing surgical or allograft tissue type data. Demographics, operative details, and subsequent surgical procedures were collected. Allograft details included graft tissue type (Achilles, bone-patellar tendon-bone [BTB], tibialis anterior or posterior, semitendinosus, unspecified soft tissue), allograft category (all-soft tissue vs bone block), donor age, irradiation duration and intensity, and chemical cleansing process. Revision rates were calculated and compared by allograft characteristics. Results Included were 418 patients (age, 39 ± 12 years; body mass index, 30 ± 9 kg/m2). The revision rate was 3% (11/418) at a mean follow-up of 4.9 ± 1.4 years. There were no differences in revision rate according to allograft tissue type across Achilles tendon (3%; 3/95), BTB (5%; 3/58), tibialis anterior or posterior (3%; 5/162), semitendinosus (0%; 0/46), or unspecified soft tissue (0%; 0/57) (P = .35). There was no difference in revision rate between all-soft tissue versus bone block allograft (6/283 [2%] vs 5/135 [4%], respectively; P = .34). Of the 51% of grafts with irradiation data, all grafts were irradiated, with levels varying from 1.5 to 2.7 Mrad and 82% of grafts having levels of <2.0 Mrad. There was no difference in revision rate between the low-dose and medium-to high-dose irradiation cohorts (4% vs 6%, respectively; P = .64). Conclusion Similarly low (0%-6%) revision rates after primary ACL reconstruction were seen regardless of allograft tissue type, bone block versus all-soft tissue allograft, and sterilization technique in 418 patients with mean age of 39 years. Surgeons may consider appropriately processed allograft tissue with or without bone block when indicating ACL reconstruction in older patients.
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Affiliation(s)
- Ian D. Engler
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Central Maine Healthcare Orthopedics, Central Maine Medical Center, Lewiston, Maine, USA
| | - Audrey Y. Chang
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Janina Kaarre
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Michael F. Shannon
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andrew J. Curley
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Clair N. Smith
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jonathan D. Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bryson P. Lesniak
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Kimura M, Nakase J, Ishikawa T, Asai K, Yoshimizu R, Kanayama T, Yanatori Y, Ozaki N, Tsuchiya H. Growth-related changes in the ultrastructure of the quadriceps tendon. Knee 2023; 42:357-363. [PMID: 37150023 DOI: 10.1016/j.knee.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/16/2023] [Accepted: 04/12/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND The purpose of this study was to investigate the effect of growth on the ultrastructural characteristics of the quadriceps tendon (QT). METHODS Eighteen included patients were classified into three groups based on age and epiphyseal plate condition: the 'immature group' consisted of patients with open epiphyseal plates (11.5 ± 1.6 years old; mean ± standard deviation), the 'young group' consisted of patients aged <20 years with closed epiphyseal plates (15.8 ± 1.0 years), and the 'adult group' consisted of all patients aged >20 years (29.8 ± 11.3 years) irrespective of epiphyseal plate condition. Tendon tissue samples were used for ultrastructural analysis by transmission electron microscopy. Minimum collagen fibril diameters were measured from the cross sections of collagen fibril images using Image J software. The average number of collagen fibers per sample was 797 ± 109, and the average collagen fibril diameter of each sample was compared using one-way analysis of variance. RESULTS The mean collagen fibril diameter was 89.7 ± 14.4 nm in the immature group, 94.8 ± 16.4 nm in the young group, and 107.2 ± 12.1 nm in the adult group, with significant differences between the immature and adult groups, and between the young and adult groups (P = 0.001 and P = 0.021, respectively); however, no significant differences were observed between the immature and young adult groups (P = 0.49). CONCLUSIONS The collagen fibril diameter of the QT was found to have increased with growth. The study provided insights into graft selection.
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Affiliation(s)
- Mitsuhiro Kimura
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan; Department of Orthopedic Surgery, National Hospital Organization, Kanazawa Medical Center, Kanazawa, Japan
| | - Junsuke Nakase
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan.
| | - Tatsuya Ishikawa
- Department of Functional Anatomy, Graduate School of Medical Science Kanazawa University, Kanazawa, Japan
| | - Kazuki Asai
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan; Department of Orthopedic Surgery, National Hospital Organization Hokuriku Hospital, Kanazawa, Japan
| | - Rikuto Yoshimizu
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Tomoyuki Kanayama
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Yusuke Yanatori
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Noriyuki Ozaki
- Department of Functional Anatomy, Graduate School of Medical Science Kanazawa University, Kanazawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
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9
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Raja BS, Arora M, Gowda AKS, Maheshwari VK, Regmi A. Augmentation with Fibertape Leads to Biomechanically Superior but Similar Clinical Outcomes in ACL Surgeries: Systematic Review and Meta-analysis. Indian J Orthop 2023; 57:722-747. [PMID: 37128558 PMCID: PMC10147891 DOI: 10.1007/s43465-022-00805-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 12/15/2022] [Indexed: 01/09/2023]
Abstract
Purpose The current generation has witnessed significant progress in the field of knee arthroscopy. Suture tapes have gained immense popularity due to perceived improved biomechanical support to the graft while it heals. The purpose of the present systematic review is to analyze the biomechanical construct of suture tapes in ACL repairs and reconstructions along with clinical outcomes. Methods Cochrane Library, PubMed, and Embase were searched until December 2021. All Biomechanical Studies on animal or cadaver knees that compared construct characteristics of suture tape in ACL repair or reconstruction and clinical studies in English focusing on outcomes following suture tape augmentation in ACL repair or reconstruction were included. The quality of clinical studies using the Modified Coleman Methodology Score (MCMS). Results A total of 16 studies biomechanical and 23 clinical studies were included in qualitative synthesis, leaving nine biomechanical studies for final quantitative analyses. Suture tape revealed biomechanical superiority in terms of ultimate strength, stiffness, cyclic displacement, and elongation of graft, while comparing ACLR with internal brace to standard ACLR. No significant difference in retear rates was seen in clinical studies. Clinical score(IKDC score) was found similar in both augmented and non-augmented construct. Similar results were obtained in biomechanical studies. Conclusion The use of suture tape as a ligament augmentation in both ACL reconstruction and ACL repair offers more strength, less elongation or displacement, and is biomechanically stable and sound. There is a lack of data to comprehensively comment upon the clinical superiority of the use of internal augmentation. However, a meta-analysis of the retear rates and clinical outcome score revealed similar outcomes between suture tape augmented and nonaugmented groups.
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Affiliation(s)
- Balgovind S. Raja
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Manit Arora
- Department of Orthopaedics, Fortis Hospital, Mohali, Punjab India
| | - Aditya K. S. Gowda
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Vikas K. Maheshwari
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Anil Regmi
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
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10
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Brophy RH, Silverman RM, Lowry KJ. American Academy of Orthopaedic Surgeons Clinical Practice Guideline Case Study: Management of Anterior Cruciate Ligament Injuries. J Am Acad Orthop Surg 2023; 31:538-548. [PMID: 36952667 DOI: 10.5435/jaaos-d-23-00088] [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: 01/25/2023] [Accepted: 02/05/2023] [Indexed: 03/25/2023] Open
Abstract
Considering the frequency of anterior cruciate ligament (ACL) tears, optimal management of these injuries was the subject of a 2022 clinical practice guideline update from The American Academy of Orthopaedic Surgeons (AAOS) with input from representatives from the American Orthopaedic Society for Sports Medicine, the Pediatric Orthopaedic Society of North America, the American Orthopaedic Society for Sports Medicine, the American Medical Society for Sports Medicine, the American Academy of Physical Medicine and Rehabilitation, and the American College of Emergency Physicians. The eight recommendations and seven options to guide orthopaedic surgeons and other physicians managing patients with these anterior cruciate ligament injuries are based on the best current available evidence. The cases presented in this article are examples designed to demonstrate the clinical application of these guidelines.
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Affiliation(s)
- Robert H Brophy
- From the Washington University Orthopedics, Chesterfield, MO (Brophy), the Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO (Silverman), and the Aspirus Rhinelander Hospital, Rhinelander, WI (Lowry)
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11
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Cronström A, Tengman E, Häger CK. Return to Sports: A Risky Business? A Systematic Review with Meta-Analysis of Risk Factors for Graft Rupture Following ACL Reconstruction. Sports Med 2023; 53:91-110. [PMID: 36001289 PMCID: PMC9807539 DOI: 10.1007/s40279-022-01747-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND The risk of sustaining a graft rupture after anterior cruciate ligament reconstruction (ACLR) is high. Contributing risk factors are, however, still not clearly identified. OBJECTIVE The aim of this systematic review was to identify and quantify risk factors for graft rupture after ACLR. METHODS A systematic review with meta-analysis (PROSPERO CRD42020140129) based on PRISMA guidelines was performed. MEDLINE, CINAHL and EMBASE were searched from inception to September 2021. Prospective and retrospective studies addressing risk factors for graft rupture after ACLR in males/females of all ages were considered. Meta-analyses using a random effect model (effect measure: odds ratio [OR] with 95% confidence interval [CI]) were performed. The GRADE tool was used to assess evidence quality. RESULTS Following full-text screening of 310 relevant papers, 117 were eventually included, incorporating up to 133,000 individuals in each meta-analysis. Higher Tegner activity level (≥ 7 vs < 7) at primary injury (OR 3.91, 95% CI 1.69-9.04), increased tibial slope (degrees) (OR 2.21, 95% CI 1.26-3.86), lower psychological readiness to return to sport (RTS) (OR 2.18, 95% CI 1.32-3.61), early surgery (< 12 vs ≥ 12 months) (OR 1.87, 95% CI 1.58-2.22), RTS (pre-injury level) (OR 1.87, 95% CI 1.21-2.91) and family history of ACL injury (OR 1.76, 95% CI 1.34-2.31) were all associated with increased odds of graft rupture. Higher age (OR 0.47, 95% CI 0.39-0.59), female sex (OR 0.88, 95% CI 0.79-0.98), fewer self-reported knee symptoms pre-reconstruction (OR 0.81, 95% CI 0.69-0.95) and concomitant cartilage injuries (OR 0.70, 95% CI 0.62-0.79) instead decreased the odds. Meta-analysis revealed no association between body mass index, smoking, joint laxity, RTS time, knee kinematics, muscle strength or hop performance and graft rupture. CONCLUSION Conspicuous risk factors for graft rupture were mainly sports and hereditary related. Few studies investigated function-related modifiable factors or included sports exposure data.
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Affiliation(s)
- Anna Cronström
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.
- Department of Health Sciences, Lund University, Lund, Sweden.
| | - Eva Tengman
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
| | - Charlotte K Häger
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
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12
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Zakharia A, Lameire DL, Abdel Khalik H, Kay J, Uddandam A, Nagai K, Hoshino Y, de Sa D. Quadriceps tendon autograft for pediatric anterior cruciate ligament reconstruction results in promising postoperative function and rates of return to sports: A systematic review. Knee Surg Sports Traumatol Arthrosc 2022; 30:3659-3672. [PMID: 35445330 DOI: 10.1007/s00167-022-06930-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/03/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the performance of the quadriceps tendon (QT) autograft in pediatric anterior cruciate ligament reconstruction (ACLR). METHODS A systematic search of MEDLINE, PubMed, and EMBASE was conducted on March 1, 2021. Studies of all levels of evidence reporting outcomes and/or complications after QT autograft ACLR in pediatric patients (≤ 18 years old) were eligible for inclusion. Study demographics, patient demographics, reported outcomes, and complications were abstracted. Screening and data abstraction were designed in accordance with PRISMA and R-AMSTAR guidelines. Descriptive statistics were presented when applicable, with data for heterogeneous outcomes presented in narrative summary fashion. RESULTS A total of 14 studies examining 596 patients (46.3% female), mean age 15.4 years, were included in this systematic review. Mean postoperative Lysholm scores ranged from 94.0 to 99.5. Mean postoperative IKDC subjective scores ranged from 75.9 to 94.0. Limb symmetry index ranged from 96.8 ± 10.4 to 100.4 ± 7.6% across multiple hop tests. Return to sports (RTS) rates ranged from 88.9 to 91.7%. Eleven studies reported postoperative complications, whereby 16 patients (4.8%) experienced contralateral complications and injuries. Forty-six patients (9.4%) experienced ipsilateral complications, including ten graft failures (2.5%) and two growth disturbances (0.6%). CONCLUSIONS QT autograft ACLR in the pediatric population retains the potential of regaining a preinjury level of knee stability, and yields promising postoperative function and rates of RTS, yielding comparable outcomes relative to HT autograft and the reference-standard BPTB ACLR that have previously been described in the literature. Moreover, use of the QT autograft is associated with low rates of postoperative complications, including graft failure and growth disturbances in this active and high-risk patient population in observational studies to date. Therefore, clinical equipoise exists to further appraise the influence of QT autograft on postoperative outcomes compared to aforementioned autograft options in a randomized control trial fashion. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | - Darius L Lameire
- Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada
| | - Hassaan Abdel Khalik
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Jeffrey Kay
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Abhilash Uddandam
- MacSports Research Program, McMaster University, Hamilton, ON, Canada
| | - Kanto Nagai
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada.
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13
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Multiligament Knee Injuries in Young Athletes. Clin Sports Med 2022; 41:611-625. [DOI: 10.1016/j.csm.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Nester JR, Torino D, Sylvestre D, Young A, Ney SM, Fernandez MM, Cruz AI, Seeley MA. Risk of reoperation after primary anterior cruciate ligament reconstruction in children and adolescents. J Orthop Surg (Hong Kong) 2022; 30:10225536221122340. [PMID: 36031851 DOI: 10.1177/10225536221122340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
OBJECTIVE To examine the incidence and risk factors of any-cause reoperation after primary ACLR in children and adolescents. DESIGN Retrospective Cohort. SETTING Electronic medical records from a large tertiary care, single institution integrated healthcare delivery system. PATIENTS Patients were under the age of 18 years and had anterior cruciate ligament reconstruction. They were excluded if they had a multi-ligamentous knee injury or <1 year follow-up. INTERVENTIONS Patients were further identified to have undergone a subsequent knee operation ipsilaterally or contralateral ACLR. MAIN OUTCOME MEASURES The rate of any-cause reoperation was our primary outcome measure. RESULTS The median age was 16. There were 208 females (53.9%) and 178 males (46.1%) included. The median follow-up was 25 months with a minimum of 12 months (interquartile range: 16.0, 46.0). The rate of any-cause reoperation was 34.7%. There was no statistically significant difference between those who underwent reoperation versus those who did not undergo reoperation relative to age, sex, BMI, graft type, or the presence of concomitant meniscal injury. The rates of ipsilateral ACLR and contralateral ACLR at any time during the study period was 8.0% and 10.9% respectively. There was no statistically significant difference for rate of reoperation between graft types, between various concomitant injuries, between those who underwent meniscus repair or no repair. CONCLUSIONS This study reflects a 34.7% rate of a subsequent knee operation after ACLR in patients younger than 18 years. These findings can be used to inform pediatric patients undergoing primary ACLR on their risk of returning to the operating room.
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Affiliation(s)
- Jordan R Nester
- 2780GeisingerMedical Center, Danville, PA, USA.,159303Janet Weis Children's Hospital, Danville, PA, USA
| | - Daniel Torino
- 2780GeisingerMedical Center, Danville, PA, USA.,159303Janet Weis Children's Hospital, Danville, PA, USA
| | | | | | | | - Meagan M Fernandez
- 2780GeisingerMedical Center, Danville, PA, USA.,159303Janet Weis Children's Hospital, Danville, PA, USA
| | - Aristides I Cruz
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA.,Hasbro Children's Hospital, Providence, RI, USA
| | - Mark A Seeley
- 2780GeisingerMedical Center, Danville, PA, USA.,159303Janet Weis Children's Hospital, Danville, PA, USA
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Allahabadi S, Mittal A, Coughlan MJ, Kim AE, Hung NJ, Pandya NK. Outcomes, Including Graft Tears, Contralateral Anterior Cruciate Ligament Tears, and All-Cause Ipsilateral Knee Operations, are Similar for Adult-type, Transphyseal, and Partial Transphyseal Anterior Cruciate Ligament Reconstruction Using Hamstring Autograft in Pediatric and Adolescent Patients. Arthrosc Sports Med Rehabil 2022; 4:e1465-e1474. [PMID: 36033172 PMCID: PMC9402463 DOI: 10.1016/j.asmr.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 05/22/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Sachin Allahabadi
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco
| | - Ashish Mittal
- San Francisco Orthopedic Residency Program, St. Mary’s Medical Center, San Francisco
| | - Monica J. Coughlan
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco
| | - Arin E. Kim
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco
| | - Nicole J. Hung
- Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles
| | - Nirav K. Pandya
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco
- Benioff Children’s Hospital Oakland, University of California, San Francisco, Oakland, California, U.S.A
- Address correspondence to Nirav K. Pandya, M.D., Department of Orthopaedic Surgery, Benioff Children’s Hospital Oakland, University of California, San Francisco, 747 52nd St., Oakland, CA 94609.
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16
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Rider D, Gowd AK, Torres LF, Kaplin LW, Waterman BR. Rates of Anterior Cruciate Ligament Rerupture in Adolescent Patients with and without Patella Alta. J Knee Surg 2022. [PMID: 35798345 DOI: 10.1055/s-0042-1749608] [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] [Indexed: 02/07/2023]
Abstract
The objective of this study was to compare rates of anterior cruciate ligament (ACL) failure among adolescent patients to evaluate patella alta as a high-risk variable. Demographic and surgical data were retrospectively queried for patients ≤18 years of age with primary ACL reconstruction performed at a single academic center between 2011 and 2016 and minimum of 2-year clinical surveillance. Patellar height indices, including Caton-Deschamps index (CDI) and Insall-Salvati index (ISI), were retrospectively calculated from preoperative imaging to assess the presence of patella alta. Failure was defined as (1) ACL graft rerupture, (2) Lachman's grade 2 + , (3) presence of pivot shift, and (4) side-to-side difference of 3 mm on KT-1000 arthrometer. A total of 184 patients (84 females and 100 males) and 192 knees were identified, with an average age of 16.2 ± 1.8 years. Of these, 30 (15.63%) experienced ACL failure. Male sex was the only significant risk factor for rerupture (p = 0.026). The mean CDI was 1.06 ± 0.17 and mean ISI was 1.04 ± 0.15. Of the 49 knees that met criteria for patella alta on radiographic evaluation, rerupture occurred in seven (14.29%). Patella alta was not a significant risk factor for ACL failure among adolescent patients (p = 0.359 and 0.277). Only male sex was associated with increased rates of ACL failure. Age, graft selection technique, fixation construct, and presence of patella alta were not risk factors for reinjury. This study is a therapeutic case series and reflects level of evidence IV.
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Affiliation(s)
- Danielle Rider
- Department of Orthopedic Surgery, Wake Forest School of Medicine Ringgold Standard Institution, Bowman Gray Center for Medical Education, Winston-Salem, North Carolina
| | - Anirudh K Gowd
- Department of Orthopaedic Surgery, Wake Forest School of Medicine Ringgold Standard Institution, Winston-Salem, North Carolina
| | - LeeAnne F Torres
- Department of Orthopaedic Surgery, Wake Forest School of Medicine Ringgold Standard Institution, Winston-Salem, North Carolina
| | - Lisa W Kaplin
- Department of Orthopaedic Surgery, Orthopaedic Surgery and Rehabilitation Associates, Rockledge, Pennsylvania
| | - Brian R Waterman
- Department of Orthopaedics, William Beaumont Army Medical Center, El Paso, Texas
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17
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Maheshwer B, Polce EM, Parvaresh KC, Paul K, Yanke AB, Forsythe B, Bush-Joseph CA, Bach BR, Cole BJ, Verma NN, Kogan M, Chahla J. Establishing Clinically Significant Outcomes After Anterior Cruciate Ligament Reconstruction in Pediatric Patients. J Pediatr Orthop 2022; 42:e641-e648. [PMID: 35297390 DOI: 10.1097/bpo.0000000000002143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to establish clinically significant outcome values for the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) after anterior cruciate ligament reconstruction (ACLR) in the pediatric and adolescent populations and to assess factors that were associated with achieving these outcomes. METHODS Patients between the age of 10 to 21 who underwent ACLR between 2016 and 2018 were identified and patient-reported outcomes (PROs) were collected preoperatively and postoperatively. Intraoperative variables collected included graft choice, graft size (diameter), graft fixation method, and concomitant procedures. PROs collected for analysis were the International Knee Documentation Committee Score (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS). MCID and PASS were calculated using receiver operating characteristic with area under the curve analyses for delta (ie, baseline-to-postoperative change) and absolute postoperative PRO scores, respectively. RESULTS A total of 59 patients were included in the analysis. Of the entire study population, 53 (89.8%) reported satisfaction with their surgical outcome. The established MCID threshold values based on the study population were 33.3 for IKDC, 28.6 for (KOOS) Symptoms, 19.4 for Pain, 2.9 for activities of daily living (ADL), 45.0 for Sport, and 25.0 for Quality of Life (QoL). Postoperative scores greater than the following values corresponded to the PASS: 80.5 for IKDC, 75.0 (KOOS) Symptoms, 88.9 for Pain, 98.5 for ADL, 75.0 for Sport, and 68.8 for QoL. CONCLUSION Clinically meaningful outcomes including MCID and PASS were established for pediatric ACLR surgery using selected PRO measures, IKDC, and KOOS. Patient age, sex, graft type, and graft size were not associated with greater achievement of these outcomes. In contrast, collision sports, fixed-object high-impact rotational landing sports, and concomitant meniscectomy surgery were associated with a decreased likelihood of achieving clinically significant improvement. However, findings must be interpreted with caution due to limitations in follow-up and sample size. LEVEL OF EVIDENCE Level IV: case series.
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Affiliation(s)
- Bhargavi Maheshwer
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, OH
| | - Evan M Polce
- University of Wisconsin College of Medicine, Madison, WI
| | | | - Katlynn Paul
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Adam B Yanke
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Brian Forsythe
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | | | - Bernard R Bach
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Brian J Cole
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Nikhil N Verma
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Monica Kogan
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Jorge Chahla
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
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18
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Cancino B, Muñoz C, Tuca MJ, Birrer EAM, Sepúlveda MF. Anterior Cruciate Ligament Rupture in Skeletally Immature Patients. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202205000-00007. [PMID: 35588096 PMCID: PMC10531303 DOI: 10.5435/jaaosglobal-d-21-00166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 03/15/2022] [Indexed: 06/15/2023]
Abstract
In the past 20 years, sports injuries in pediatric and adolescent athletes have increased dramatically, with anterior cruciate ligament (ACL) injuries accounting for more than 25% of all knee injuries at this age. Diagnosis is based on detailed clinical history, physical examination, and imaging assessment, where magnetic resonance imaging plays a central role. The growing immature skeleton presents specific characteristics, which require unique methods for surgical reconstruction, ideally avoiding the physes or minimizing the risk of damaging them. Specific rehabilitation protocols are needed, and these patients face a higher risk of recurrent and contralateral ACL injury. Nonsurgical treatment or delayed reconstruction has been associated with persistent instability, activity modifications, worst functional outcomes, and increased risk of irreparable injuries to menisci and articular cartilage. Consequently, surgical stabilization is the preferred treatment for most patients, despite the eventual risk of angular deformities or limb-length discrepancies due to iatrogenic physeal injury. A variety of surgical techniques have been described, depending on the skeletal maturity and growth remaining. Targeted prevention programs play a key role in reducing the risk of ACL injury, are easy to implement, and require no additional equipment. High-quality evidence supports its use in all pediatric athletes.
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Affiliation(s)
- Benjamín Cancino
- From the Universidad Austral de Chile, Valdivia, Chile (Dr. Cancino, Dr. Muñoz, Dr. Birrer, and Dr. Sepúlveda); the Clínica Alemana, Santiago, Chile (Dr. Tuca); the Universidad del Desarrollo, Santiago, Chile (Dr. Tuca); the Hospital Clínico Mutual de Seguridad, Santiago, Chile (Dr. Tuca); and Hospital Base de Valdivia, Valdivia, Chile (Dr. Birrer, and Dr. Sepúlveda)
| | - Carlos Muñoz
- From the Universidad Austral de Chile, Valdivia, Chile (Dr. Cancino, Dr. Muñoz, Dr. Birrer, and Dr. Sepúlveda); the Clínica Alemana, Santiago, Chile (Dr. Tuca); the Universidad del Desarrollo, Santiago, Chile (Dr. Tuca); the Hospital Clínico Mutual de Seguridad, Santiago, Chile (Dr. Tuca); and Hospital Base de Valdivia, Valdivia, Chile (Dr. Birrer, and Dr. Sepúlveda)
| | - María Jesús Tuca
- From the Universidad Austral de Chile, Valdivia, Chile (Dr. Cancino, Dr. Muñoz, Dr. Birrer, and Dr. Sepúlveda); the Clínica Alemana, Santiago, Chile (Dr. Tuca); the Universidad del Desarrollo, Santiago, Chile (Dr. Tuca); the Hospital Clínico Mutual de Seguridad, Santiago, Chile (Dr. Tuca); and Hospital Base de Valdivia, Valdivia, Chile (Dr. Birrer, and Dr. Sepúlveda)
| | - Estefanía A. M. Birrer
- From the Universidad Austral de Chile, Valdivia, Chile (Dr. Cancino, Dr. Muñoz, Dr. Birrer, and Dr. Sepúlveda); the Clínica Alemana, Santiago, Chile (Dr. Tuca); the Universidad del Desarrollo, Santiago, Chile (Dr. Tuca); the Hospital Clínico Mutual de Seguridad, Santiago, Chile (Dr. Tuca); and Hospital Base de Valdivia, Valdivia, Chile (Dr. Birrer, and Dr. Sepúlveda)
| | - Matías F. Sepúlveda
- From the Universidad Austral de Chile, Valdivia, Chile (Dr. Cancino, Dr. Muñoz, Dr. Birrer, and Dr. Sepúlveda); the Clínica Alemana, Santiago, Chile (Dr. Tuca); the Universidad del Desarrollo, Santiago, Chile (Dr. Tuca); the Hospital Clínico Mutual de Seguridad, Santiago, Chile (Dr. Tuca); and Hospital Base de Valdivia, Valdivia, Chile (Dr. Birrer, and Dr. Sepúlveda)
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[Management status of anterior cruciate ligament injury in children and adolescents]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2022; 36:495-499. [PMID: 35426291 PMCID: PMC9011077 DOI: 10.7507/1002-1892.202112006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To summarize the current management of anterior cruciate ligament (ACL) injury in children and adolescents, in order to provide reference for the management of ACL injury in children and adolescents. METHODS The relevant literature at home and abroad in recent years was extensively accessed to summarize the management status of ACL injury in children and adolescent. RESULTS The number of ACL injury in children and adolescents is increasing every year. The diagnosis of ACL mainly depends on symptoms and signs. Rehabilitation, physeal-sparing techniques, partial transphyseal techniques, all-epiphyseal techniques, and transphyseal techniques are used to treat ACL injury in children and adolescents. CONCLUSION Dynamic monitoring of knee joint in children and adolescents should be strengthened. The best treatment for ACL injury in children and adolescents is selected according to the patients' actual age, bone age, Tanner stage, and physiological conditions such as menstruation, body growth speed, and other characteristics.
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20
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Ma R, Guess T, Echelmeyer D, Stannard JP. Bench to Bedside: A Multidisciplinary Approach toward the Unknowns after ACL Injuries to Drive Individual Success. MISSOURI MEDICINE 2022; 119:136-143. [PMID: 36036042 PMCID: PMC9339398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
ACL injury and surgery are increasing in prevalence. Several challenges exist that can be obstacles to an individual achieving success after ACL surgery. A knowledge of these risk factors alongside a multidisciplinary collaborative team approach can result in a greater likelihood of achieving individual success after ACL surgery.
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Affiliation(s)
- Richard Ma
- Gregory L. And Ann L. Hummel Distinguished Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, University of Missouri - Columbia School of Medicine (DOS UMC SOM) and with the Thompson Laboratory for Regenerative Orthopaedics (TLRO), Columbia, Missouri
| | - Trent Guess
- DOS UMC SOM and the Department of Physical Therapy, UMC SOM, Columbia, Missouri
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21
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De Petrillo G, Pauyo T, Franklin CC, Chafetz RS, Nault ML, Veilleux LN. Limited evidence for graft selection in pediatric ACL reconstruction: a narrative review. J Exp Orthop 2022; 9:9. [PMID: 35028782 PMCID: PMC8758832 DOI: 10.1186/s40634-022-00448-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/07/2022] [Indexed: 11/10/2022] Open
Abstract
Anterior cruciate ligament reconstruction is the preferred treatment to anterior cruciate ligament injury. With the increase in anterior cruciate ligament injuries in both adults and skeletally immature patients comes the need for individualized anterior cruciate ligament reconstruction graft selection whether it is the type of graft (auto vs. allograft) or the harvesting site (hamstrings, iliotibial band, quadriceps, patella). Several factors need to be considered preoperatively in order to optimize the patients' recovery and restore anterior cruciate ligament strength and function. These include age and bone maturity, preoperative knee flexor/extensor strength, sport participation, patient's needs and anatomical characteristics. This paper aims at bringing evidence supporting the use of a personalized approach in graft selection for faster and more efficient return to sport and propose a theoretical framework to support the approach.
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Affiliation(s)
- Gianni De Petrillo
- Shriners Children- Canada , 1003 Decarie Blvd, QC, H4A 0A9, Montreal, Canada
| | - Thierry Pauyo
- Shriners Children- Canada , 1003 Decarie Blvd, QC, H4A 0A9, Montreal, Canada
- Department of Surgery, McGill University, Montreal, Canada
| | | | | | - Marie-Lyne Nault
- Ste-Justine University Health Center, Montreal, Canada
- Department of Surgery, Université de Montréal, Montreal, Canada
| | - Louis-Nicolas Veilleux
- Shriners Children- Canada , 1003 Decarie Blvd, QC, H4A 0A9, Montreal, Canada.
- Department of Surgery, McGill University, Montreal, Canada.
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22
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Maletis GB, Funahashi TT, Inacio MCS, Paxton LW. Optimizing anterior cruciate ligament reconstruction: Individualizing the decision-making process using data from the Kaiser Permanente ACLR Registry: 2018 OREF award paper. J Orthop Res 2022; 40:29-42. [PMID: 33751638 DOI: 10.1002/jor.25020] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/09/2021] [Accepted: 03/02/2021] [Indexed: 02/04/2023]
Abstract
Despite years of study, controversy remains regarding the optimal graft for anterior cruciate ligament reconstruction (ACLR), suggesting that a single graft type is not ideal for all patients. A large community based ACLR Registry that collects prospective data is a powerful tool that captures information and can be analyzed to optimize surgery for individual patients. The studies highlighted in this paper were designed to optimize and individualize ACLR surgery and have led to changes in surgeon behavior and improvements in patient outcomes. Kaiser Permanente (KP) is an integrated health care system with 10.6 million members and more than 50 hospitals. Every KP member who undergoes an ACLR is entered into the Registry, and prospectively monitored. The Registry uses a variety of feedback mechanisms to disseminate Registry findings to the ACLRR surgeons and appropriately influence clinical practices and enhance quality of care. Allografts were found to have a 3.0 times higher risk of revision than bone-patellar tendon-bone (BPTB) autografts. Allograft irradiation >1.8 Mrad, chemical graft processing, younger patients, BPTB allograft, and male patients were all associated with a higher risk of revision surgery. By providing feedback to surgeons, overall allograft use has decreased by 27% and allograft use in high-risk patients ≤21 years of age decreased 68%. We have identified factors that influence the outcomes of ACLR. Statement of Clinical Significance: We found that information derived from an ACLR Registry and shared with the participating surgeons directly decreased the use of specific procedures and implants associated with poor outcomes.
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Affiliation(s)
- Gregory B Maletis
- Department of Orthopedics, Kaiser Permanente Baldwin Park, Baldwin Park, California, USA
| | - Tadashi T Funahashi
- Department of Orthopedics, Kaiser Permanente Sand Canyon, Irvine, California, USA
| | - Maria C S Inacio
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Liz W Paxton
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California, USA
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23
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Allahabadi S, Pandya NK. Allograft Medial Patellofemoral Ligament Reconstruction in Adolescent Patients Results in a Low Recurrence Rate of Patellar Dislocation or Subluxation at Midterm Follow-Up. Arthroscopy 2022; 38:128-138. [PMID: 34000323 DOI: 10.1016/j.arthro.2021.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/14/2021] [Accepted: 05/06/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate rates of recurrent instability in adolescent patients with medial patellofemoral ligament (MPFL) reconstruction with allograft and associations of anatomic risk factors with complications. METHODS A retrospective review identified patients of a single surgeon who underwent MPFL reconstruction with allograft for recurrent patellar instability with minimum 2-year follow-up. Surgical management was recommended after a minimum 6 weeks of nonoperative management and included MPFL reconstruction with gracilis allograft using a double-bundle technique. Preoperative radiographs were evaluated to assess physeal closure, lower-extremity alignment, trochlear morphology, and Insall-Salvati and Caton-Deschamps ratios. Magnetic resonance images were reviewed to evaluate the MPFL, trochlear morphology, and tibial tubercle trochlear groove distance (TT-TG). Descriptive statistics were used to characterize data. The primary outcome was recurrent instability. RESULTS 20 patients (24 knees; 18 knees in 14 females and 6 knees in 6 males; average age 15.7 years; range 11.5 to 19.6) underwent MPFL reconstruction with allograft (mean ± standard deviation follow-up 5.2 ± 1.7 years; range 2.2 to 8.1). Physes were open in 9 knees. The Insall-Salvati ratio was 1.09 ± 0.16, and the Caton-Deschamps index was 1.17 ± 0.15. Preoperatively, 19 patients were noted to have trochlear dysplasia, and TT-TG was 15.3 ± 3.9 mm. Three of 4 knees (16.7%) with non-hardware-related complications had open physes: 3 (12.5%) had recurrent instability, 2 of which underwent subsequent operation, and 1 sustained a patella fracture after a fall, requiring open reduction and internal fixation. The average Insall-Salvati ratio of these 4 patients was 1.21 ± 0.20, Caton-Deschamps index was 1.18 ± 0.17, and TT-TG was 17.5 ± 3.3 mm, none of which were statistically different from the group without complications. There were no clinically noted growth disturbances postoperatively. CONCLUSIONS MPFL reconstruction using allograft tissue may be performed safely in the pediatric and adolescent population with good outcomes at midterm follow-up, few complications, and a low rate of recurrent instability. LEVEL OF EVIDENCE IV, case series.
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Affiliation(s)
- Sachin Allahabadi
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, U.S.A
| | - Nirav K Pandya
- Department of Orthopaedic Surgery, Benioff Children's Hospital Oakland, University of California, San Francisco, San Francisco, California, U.S.A..
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24
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Current trends in the anterior cruciate ligament part II: evaluation, surgical technique, prevention, and rehabilitation. Knee Surg Sports Traumatol Arthrosc 2022; 30:34-51. [PMID: 34865182 DOI: 10.1007/s00167-021-06825-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 11/23/2021] [Indexed: 12/14/2022]
Abstract
Clinical evaluation and management of anterior cruciate ligament (ACL) injury is one of the most widely researched topics in orthopedic sports medicine, giving providers ample data on which to base their practices. The ACL is also the most commonly treated knee ligament. This study reports on current topics and research in clinical management of ACL injury, starting with evaluation, operative versus nonoperative management, and considerations in unique populations. Discussion of graft selection and associated procedures follows. Areas of uncertainty, rehabilitation, and prevention are the final topics before a reflection on the current state of ACL research and clinical management of ACL injury. Level of evidence V.
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25
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Matsuzaki Y, Chipman DE, Hidalgo Perea S, Green DW. Unique Considerations for the Pediatric Athlete During Rehabilitation and Return to Sport After Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2022; 4:e221-e230. [PMID: 35141555 PMCID: PMC8811511 DOI: 10.1016/j.asmr.2021.09.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/27/2021] [Indexed: 11/03/2022] Open
Abstract
Level of Evidence
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26
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Second Generation of Tissue-Engineered Ligament Substitutes for Torn ACL Replacement: Adaptations for Clinical Applications. Bioengineering (Basel) 2021; 8:bioengineering8120206. [PMID: 34940359 PMCID: PMC8698634 DOI: 10.3390/bioengineering8120206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/03/2021] [Accepted: 12/08/2021] [Indexed: 11/16/2022] Open
Abstract
The anterior cruciate ligament (ACL) of the knee joint is one of the strongest ligaments of the body and is often the target of traumatic injuries. Unfortunately, its healing potential is limited, and the surgical options for its replacement are frequently associated with clinical issues. A bioengineered ACL (bACL) was developed using a collagen matrix, seeded with autologous cells and successfully grafted and integrated into goat knee joints. We hypothesize that, in order to reduce the cost and simplify the model, an acellular bACL can be used as a substitute for a torn ACL, and bone plugs can be replaced by endobuttons to fix the bACL in situ. First, acellular bACLs were successfully grafted in the goat model with 18% recovery of ultimate tensile strength 6 months after implantation (94 N/mm2 vs. 520). Second, a bACL with endobuttons was produced and tested in an exvivo bovine knee model. The natural collagen scaffold of the bACL contributes to supporting host cell migration, growth and differentiation in situ post-implantation. Bone plugs were replaced by endobuttons to design a second generation of bACLs that offer more versatility as biocompatible grafts for torn ACL replacement in humans. A robust collagen bACL will allow solving therapeutic issues currently encountered by orthopedic surgeons such as donor-site morbidity, graft failure and post-traumatic osteoarthritis.
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27
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Takahashi T, Watanabe S, Ito T. Current and future of anterior cruciate ligament reconstruction techniques. World J Meta-Anal 2021; 9:411-437. [DOI: 10.13105/wjma.v9.i5.411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/09/2021] [Accepted: 10/25/2021] [Indexed: 02/06/2023] Open
Abstract
In recent years, anterior cruciate ligament (ACL) reconstruction has generally yielded favorable outcomes. However, ACL reconstruction has not provided satisfactory results in terms of the rate of returning to sports and prevention of osteoarthritis (OA) progression. In this paper, we outline current techniques for ACL reconstruction such as graft materials, double-bundle or single-bundle reconstruction, femoral tunnel drilling, all-inside technique, graft fixation, preservation of remnant, anterolateral ligament reconstruction, ACL repair, revision surgery, treatment for ACL injury with OA and problems, and discuss expected future trends. To enable many more orthopedic surgeons to achieve excellent ACL reconstruction outcomes with less invasive surgery, further studies aimed at improving surgical techniques are warranted. Further development of biological augmentation and robotic surgery technologies for ACL reconstruction is also required.
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Affiliation(s)
- Toshiaki Takahashi
- Department of Sports and Health Science, Ehime University, Matsuyama 790-8577, Ehime, Japan
| | - Seiji Watanabe
- Department of Orthopedic Surgery, Ehime University Graduate School of Medicine, Toon 791-0295, Ehime, Japan
| | - Toshio Ito
- Department of Orthopaedic Surgery, Murakami Memorial Hospital, Saijo 793-0030, Ehime, Japan
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28
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Distal Patellar Tendon Avulsion Associated with an ACL Tear in a Teenager: A Case Report and Review of the Literature. Case Rep Orthop 2021; 2021:6686487. [PMID: 34327033 PMCID: PMC8302369 DOI: 10.1155/2021/6686487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 07/03/2021] [Indexed: 11/27/2022] Open
Abstract
Distal patellar tendon avulsions are rare injuries in healthy individuals, and to date, no case affecting skeletally mature teenagers and adolescents has been reported. In the majority of cases, distal patellar tendon avulsions are associated with severe intra-articular knee lesions, signifying a high-energy trauma. We present the case of a 15.5-year-old female who was admitted to the emergency department after a knee injury. The mechanism of injury was a combination of landing after a jump off a scooter and sudden deceleration with a fixed foot. Lateral radiographs revealed a distal patellar tendon avulsion. An MRI was conducted to accurately diagnose concomitant lesions. The MRI revealed a complete tear of the ACL, and associated bone bruises on the lateral femoral condyle, and also on the posterolateral tibial plateau. A knee joint exam under general anesthesia demonstrated good stability during valgus stress testing and only a grade 1 positive Lachman test. Therefore, we decided to only reconstruct the extensor mechanism and to abstain from a primary ACL reconstruction. The presented case and review of the literature demonstrate the clinical relevance of this atypical lesion. In fact, a distal patellar tendon avulsion after physeal fusion of the proximal tibia should raise a strong suspicion of severe associated intra-articular knee lesions and requires prompt MRI investigation. However, controversy still exists regarding the management of these injuries, in particular concerning the question of whether to address both injuries in a single stage or in 2 stages.
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29
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Rauck RC, Apostolakos JM, Nwachukwu BU, Schneider BL, Williams RJ, Dines JS, Altchek DW, Pearle A, Allen A, Stein BS, Dines D, Ranawat A, Kelly A, Kelly B, Rose H, Maynard M, Strickland S, Coleman S, Hannafin J, MacGillivray J, Marx R, Warren R, Rodeo S, Fealy S, O'Brien S, Wickiewicz T. Return to Sport After Bone-Patellar Tendon-Bone Autograft ACL Reconstruction in High School-Aged Athletes. Orthop J Sports Med 2021; 9:23259671211011510. [PMID: 34250173 PMCID: PMC8239981 DOI: 10.1177/23259671211011510] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 01/12/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Anterior cruciate ligament (ACL) injuries are occurring with increasing frequency in the adolescent population. Outcomes after ACL reconstruction (ACLR) are inconsistently reported in homogeneous patient populations. Purpose/Hypothesis: To evaluate outcomes after bone–patellar tendon–bone (BTB) autograft ACLR in competitive high school–aged athletes by examining return to sport (RTS), patient satisfaction, and reinjury rates. Our hypothesis was that RTS rates and satisfaction will be high and reinjury rates will be low. Study Design: Case series; Level of evidence, 4. Methods: An institutional ACL registry was utilized to identify competitive high school–aged athletes (14-18 years old) who underwent primary ACLR using BTB autograft with a minimum 2-year follow-up. A postoperative questionnaire was administered to determine rates and types of RTS, quality of sports performance, reinjury, and satisfaction. Uni- and multivariable analyses were used to identify demographic, sport-specific, and clinical factors related to RTS. Results: A total of 53 patients were included (mean ± SD age at the time of surgery, 16.6 ± 1.34 years). Mean follow-up was 3.78 ± 0.70 years (range, 2.60-4.94 years). The overall ipsilateral ACL retear rate was 7.5% (n = 4). There were 10 subsequent ACL tears to the contralateral knee (19%). Forty-four (83%) patients successfully returned to at least their prior level of sport at a mean 10.5 ± 8.7 months (range, 3-48 months). Overall satisfaction was high, with 91% of patients very satisfied with the outcome. Higher confidence levels regarding performance of the reconstructed knee were associated with increased probability of RTS on multivariate analysis. Conclusion: BTB autograft ACLR results in high rates of RTS and satisfaction and low rates of subsequent ipsilateral ACL injuries in competitive high school–aged athletes. Patients with higher confidence in performance of the reconstructed knee are more likely to return to at least their prior level of sport.
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Affiliation(s)
- Ryan C Rauck
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - John M Apostolakos
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Benedict U Nwachukwu
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Brandon L Schneider
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Riley J Williams
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Joshua S Dines
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - David W Altchek
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | | | - Andrew Pearle
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Answorth Allen
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Beth Shubin Stein
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - David Dines
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Anil Ranawat
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Anne Kelly
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Bryan Kelly
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Howard Rose
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Michael Maynard
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Sabrina Strickland
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Struan Coleman
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Jo Hannafin
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - John MacGillivray
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Robert Marx
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Russell Warren
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Scott Rodeo
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Stephen Fealy
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Stephen O'Brien
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Thomas Wickiewicz
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Hospital for Special Surgery, New York, New York, USA
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30
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Allahabadi S, Feeley SE, Lansdown DA, Pandya NK, Feeley BT. Influential Articles on Pediatric and Adolescent Anterior Cruciate Ligament Injuries: A Bibliometric Analysis. Orthop J Sports Med 2021; 9:23259671211010772. [PMID: 34164558 PMCID: PMC8191091 DOI: 10.1177/23259671211010772] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 02/09/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The understanding of pediatric anterior cruciate ligament (ACL) injuries and optimal treatment has evolved significantly. Influential articles have been previously evaluated using article citations to determine impact. PURPOSE To identify and characterize the 50 most cited and recent influential articles relating to pediatric and adolescent ACL injuries, to examine trends in publication characteristics, and to evaluate correlations of study citations with quality of evidence. STUDY DESIGN Cross-sectional study. METHODS The top 50 most cited articles on pediatric and adolescent ACL injuries were gathered using the Web of Science and Scopus online databases by averaging the number of citations from each database. Articles from recent years were also aggregated and sorted by citation density (citations/year). Publication and study characteristics were recorded. Level of evidence and methodologic quality were assessed where applicable using the modified Coleman Methodology Score (mCMS), modified Jadad scale, and Methodological Index for Non-Randomized Studies (MINORS). Spearman correlation was used to evaluate the association between citation data and level of evidence or methodologic quality scorings. RESULTS The top 50 cited papers had a mean of 117.5 ± 58.8 citations (range, 58.5-288.5 citations), with a mean citation density of 9.4 ± 5.4 citations per year (range, 2.9-25.8 citations/year); 80% were published in 2000 or later, and 6% were considered basic science. Articles were mainly level 4 evidence (27/42; 64.3%), and none was level 1. There were moderate, significant associations between publication year and level of evidence (r S = -0.45; P = .0030) and citation density and publication year (r S = 0.59; P < .001). Mean methodologic quality scores were as follows: mCMS, 53 ± 7.2 (range, 39-68); modified Jadad scale, 3.2 ± 1.1 (range, 2-6); and MINORS, 11.2 ± 3.2 (range, 6-20). There was a significant, strong correlation between rank of mean citations and modified Jadad scale (r S = 0.76; P < .0001), suggesting poorer score associated with more mean citations. CONCLUSION Influential articles on pediatric and adolescent ACL injuries were relatively recent, with a low proportion of basic science-type articles. Most of the studies had a lower evidence level and poor methodologic quality scores. Higher methodologic quality did not correlate positively with citation data.
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Affiliation(s)
- Sachin Allahabadi
- Department of Orthopaedic Surgery, University of California, San Francisco; San Francisco, California, USA
| | - Sonali E. Feeley
- Department of Orthopaedic Surgery, University of California, San Francisco; San Francisco, California, USA
| | - Drew A. Lansdown
- Department of Orthopaedic Surgery, University of California, San Francisco; San Francisco, California, USA
| | - Nirav K. Pandya
- Department of Orthopaedic Surgery, University of California, San Francisco; San Francisco, California, USA
| | - Brian T. Feeley
- Department of Orthopaedic Surgery, University of California, San Francisco; San Francisco, California, USA
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31
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Partan MJ, Stapleton EJ, Atlas AM, DiMauro JP. Predicting Autologous Hamstring Graft Diameter in the Pediatric Population Using Preoperative Magnetic Resonance Imaging and Demographic Data. Am J Sports Med 2021; 49:1482-1491. [PMID: 33844606 DOI: 10.1177/03635465211001771] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstruction before 18 years of age has been linked with an increased risk for failure when the graft diameter is <8 mm. PURPOSE/HYPOTHESIS The purpose of this study was to determine whether autologous hamstring graft size can be reliably predicted with the use of preoperative magnetic resonance imaging (MRI) measurements. We hypothesized that the average of multiple axial cross-sectional area MRI measurements for the semitendinosus tendon and gracilis tendon would alone accurately predict graft diameter. Additionally, factoring in specific demographic data to the MRI cross-sectional areas would provide a synergistic effect to the accuracy of graft diameter predictions. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 2. METHODS We retrospectively reviewed 51 pediatric patients undergoing ACL reconstructions (age <18 years) performed using either a quadruple-strand semitendinosus tendon or combined double-bundle semitendinosus tendon-gracilis tendon autograft. Preoperative axial MRI scans at multiple points along the craniocaudal axis-specifically, at the level of the joint line, 3 cm cephalad to the medial tibial plateau, and 5 cm cephalad to the medial tibial plateau-were used to determine the combined cross-sectional area of the semitendinosus and gracilis tendons. The MRI measurements were analyzed using Pearson correlation as well as regression analysis to evaluate strength of correlation between measurements. Binomial linear regression was used to analyze the same predictive variables assessed by multiple regression. RESULTS The predicted graft diameter was within 0.5 mm of the intraoperative graft size in 37 of 51 (72.5%) patients and within 1 mm of the intraoperative graft size in 49 of 51 (96.1%). With the addition of demographics, the accuracy of predictions increased to 78.4% within 0.5 mm and 98% within 1 mm of the actual graft size. Additionally, 38 of 42 patients whose true graft diameter was ≥8 mm were correctly classified, giving a sensitivity of 90.4%. For those whose true graft diameter was <8 mm, 8 of 9 patients were correctly classified; therefore, the specificity was 88.9%. CONCLUSION The results of our study suggest that taking the average of multiple preoperative MRI measurements can be used to accurately predict autologous hamstring graft size when approaching pediatric patients undergoing ACL reconstruction.
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Affiliation(s)
- Matthew J Partan
- Department of Orthopaedic Surgery, Northwell Health Huntington Hospital, Huntington, New York, USA
| | - Erik J Stapleton
- Department of Orthopaedic Surgery, Northwell Health Huntington Hospital, Huntington, New York, USA
| | - Aaron M Atlas
- College of Osteopathic Medicine, New York Institute of Technology, Glen Head, New York, USA
| | - Jon-Paul DiMauro
- Department of Orthopaedic Surgery, Northwell Health Huntington Hospital, Huntington, New York, USA.,Donald and Barbara Zucker School of Medicine at Hofstra, Hempstead, New York, USA.,Department of Pediatric Orthopaedic Surgery, Cohen Children's Medical Center, New Hyde Park, New York, USA
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32
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Lombardi JA, Hoonjan A, Rodriguez N, Delossantos A, Monteiro G, Sandor M, Xu H. Porcine bone-patellar tendon-bone xenograft in a caprine model of anterior cruciate ligament repair. J Orthop Surg (Hong Kong) 2021; 28:2309499020939737. [PMID: 32715928 DOI: 10.1177/2309499020939737] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The use of human tissue-derived autografts and allografts continues to be the gold standard in anterior cruciate ligament (ACL) repair. However, autografts and allografts have their own set of associated risks. Many alternative options, including synthetic replacements, have failed to demonstrate long-term success. In this study, sterile acellular porcine bone-tendon-bone (BTB) xenografts were created using a proprietary process and tested against BTB autografts in goats for 13 and 52 weeks. At 13 weeks, all xenograft-implanted animals (n = 9) had subjective hind leg motor function (HLMF) that was categorized as either normal (score = 0) or a slight limp (score = 1) compared with two of nine autograft-implanted animals having a moderate limp (score = 2). At 39 weeks, there was HLMF improvement with each autograft-implanted and xenograft-implanted animal having normal HLMF or only a slight limp. At 13 weeks, six of nine animals in each group achieved normal anterior drawer scores, which increased to nine of nine animals in each group by 39 weeks. Both autografts and xenografts exhibited minimal inflammation with excellent integration of the fibrous tendon portion of the graft to host bone, as evidenced histologically by Sharpey's fiber formation. At 52 weeks, maximum mechanical load at failure for xenografts was 1092.0 ± 586.4 N compared with 1037.0 ± 422.6 N for autografts. These results demonstrate that a sterile acellular porcine BTB xenograft can perform equivalently to BTB autograft in a caprine model of ACL repair.
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Affiliation(s)
- Jared A Lombardi
- LifeCell Corporation (an Allergan affiliate), Research and Development Department, Bridgewater, NJ, USA
| | - Amardeep Hoonjan
- LifeCell Corporation (an Allergan affiliate), Research and Development Department, Bridgewater, NJ, USA
| | - Neil Rodriguez
- LifeCell Corporation (an Allergan affiliate), Research and Development Department, Bridgewater, NJ, USA
| | - Aubrey Delossantos
- LifeCell Corporation (an Allergan affiliate), Research and Development Department, Bridgewater, NJ, USA
| | - Gary Monteiro
- LifeCell Corporation (an Allergan affiliate), Research and Development Department, Bridgewater, NJ, USA
| | - Maryellen Sandor
- LifeCell Corporation (an Allergan affiliate), Research and Development Department, Bridgewater, NJ, USA
| | - Hui Xu
- LifeCell Corporation (an Allergan affiliate), Research and Development Department, Bridgewater, NJ, USA
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33
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Cruz AI, Beck JJ, Ellington MD, Mayer SW, Pennock AT, Stinson ZS, VandenBerg CD, Barrow B, Gao B, Ellis HB. Failure Rates of Autograft and Allograft ACL Reconstruction in Patients 19 Years of Age and Younger: A Systematic Review and Meta-Analysis. JB JS Open Access 2020; 5:e20.00106. [PMID: 34322650 PMCID: PMC8312832 DOI: 10.2106/jbjs.oa.20.00106] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Graft choice for pediatric anterior cruciate ligament reconstruction (ACLR) is determined by several factors. There is limited information on the use and outcomes of allograft ACLR in pediatric patients. The purpose of this systematic review and meta-analysis was to quantify reported failure rates of allograft versus autograft ACLR in patients ≤19 years of age with ≥2 years of follow-up. We hypothesized that there would be higher rates of failure for allograft compared with autograft ACLR in this population. METHODS PubMed/MEDLINE and Embase databases were systematically searched for literature regarding allograft and autograft ACLR in pediatric/adolescent patients. Articles were included if they described a cohort of patients with average age of ≤19 years, had a minimum of 2 years of follow-up, described graft failure as an outcome, and had a Level of Evidence grade of I to III. Qualitative review and quantitative meta-analysis were performed to compare graft failure rates. A random-effects model was created to compare failure events in patients receiving allograft versus autograft in a pairwise fashion. Data analysis was completed using RevMan 5.3 software (The Cochrane Collaboration). RESULTS The database search identified 1,604 studies; 203 full-text articles were assessed for eligibility. Fourteen studies met the inclusion criteria for qualitative review; 5 studies were included for quantitative meta-analysis. Bone-patellar tendon-bone (BTB) represented 58.2% (n = 1,012) of the autografts, and hamstring grafts represented 41.8% (n = 727). Hybrid allografts (autograft + supplemental allograft) represented 12.8% (n = 18) of all allograft ACLRs (n = 141). The unweighted, pooled failure rate for each graft type was 8.5% for BTB, 16.6% for hamstring, and 25.5% for allograft. Allografts were significantly more likely than autografts to result in graft failure (odds ratio, 3.87; 95% confidence interval, 2.24 to 6.69). CONCLUSIONS Allograft ACLR in pediatric and adolescent patients should be used judiciously, as existing studies revealed a significantly higher failure rate for allograft compared with autograft ACLR in this patient population. Additional studies are needed to improve the understanding of variables associated with the high ACLR failure rate among pediatric and adolescent patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Aristides I. Cruz
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Hasbro Children’s Hospital, Providence, Rhode Island
| | - Jennifer J. Beck
- Orthopaedic Institute for Children, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Matthew D. Ellington
- Dell Medical School, The University of Texas at Austin, and Central Texas Pediatric Orthopedics, Austin, Texas
| | - Stephanie W. Mayer
- Sports Medicine Center, Department of Orthopaedic Surgery, Children’s Hospital Colorado, University of Colorado, Denver, Colorado
| | - Andrew T. Pennock
- Rady Children’s Hospital, University of California San Diego, San Diego, California
| | - Zachary S. Stinson
- Nemours Children’s Hospital, University of Central Florida, Orlando, Florida
| | - Curtis D. VandenBerg
- Children’s Hospital of Los Angeles, Keck School of Medicine of USC, Los Angeles, California
| | - Brooke Barrow
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Burke Gao
- Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Henry B. Ellis
- Texas Scottish Rite Hospital for Children, University of Texas Southwestern, Dallas, Texas
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Rugg CM, Pitcher AA, Allen C, Pandya NK. Revision ACL Reconstruction in Adolescent Patients. Orthop J Sports Med 2020; 8:2325967120953337. [PMID: 33062768 PMCID: PMC7534089 DOI: 10.1177/2325967120953337] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/24/2020] [Indexed: 12/14/2022] Open
Abstract
Background: High failure rates have been documented after anterior cruciate ligament reconstruction (ACLR) in pediatric patients, and revision surgery is indicated due to high activity levels of children and adolescents. Purpose: To define trends in revision ACLR in patients who underwent initial ACLR at younger than 18 years. Study Design: Case series; Level of evidence, 4. Methods: An electronic medical record was used to retrospectively identify revision ACLR procedures performed by 2 surgeons between the years 2010 and 2016 in patients younger than 18 years at initial reconstruction. Descriptive information, intraoperative findings, surgical techniques, and rehabilitation data were recorded from initial and revision surgeries. Descriptive statistics were used. Results: A total of 32 patients (17 girls, 15 boys) met the inclusion criteria, with a mean age of 15.8 years at initial reconstruction. For initial reconstructions, 15 patients underwent transphyseal procedures, 3 patients underwent adult-type procedures using an anatomic reconstruction technique that did not take into account the physis, and 2 patients underwent partial intraepiphyseal procedures. Graft types included hamstring autograft (n = 17), allograft (n = 5), hybrid (n = 4), and bone–patellar tendon–bone autograft (BTB; n = 3). Average primary reconstruction graft diameter was 8.0 mm (girls, 7.72 mm; boys, 8.36 mm; P = .045). After initial reconstruction, 10 patients had postoperative protocol noncompliance, and 8 patients reported delayed recovery. Mean time to retear was 565 days (range, 25-1539 days). At revision, BTB autograft was used in 50% (n = 16), followed by hamstring autograph (31.3%; n = 10) and allograft (12.5%; n = 4); mean graft diameter was 9.05 mm. Chondral surgery was more common during revision (25% for revision vs 0% for index; P = .031). There were 4 patients who required staged reconstruction with bone grafting. At mean final follow-up of 29.5 months (SD, 22.2 months), there were 3 graft failures (9.4%) and 5 contralateral ACL ruptures (15.6%). Conclusion: Most patients with ACL graft failure were adequately treated with a single revision. Conversion from a soft tissue graft to a BTB autograft was the most common procedure. Infrequently, patients required staged reconstructions. Providers should have a high index of suspicion for associated intra-articular injuries resulting from graft failure in adolescent patients.
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Affiliation(s)
- Caitlin M Rugg
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Austin A Pitcher
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Christina Allen
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Nirav K Pandya
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
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Olvera D, Sathy BN, Kelly DJ. Spatial Presentation of Tissue-Specific Extracellular Matrix Components along Electrospun Scaffolds for Tissue Engineering the Bone-Ligament Interface. ACS Biomater Sci Eng 2020; 6:5145-5161. [PMID: 33455265 DOI: 10.1021/acsbiomaterials.0c00337] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The bone-ligament interface transitions from a highly organized type I collagen rich matrix to a nonmineralized fibrocartilage region and finally to a mineralized fibrocartilage region that interfaces with the bone. Therefore, engineering the bone-ligament interface requires a biomaterial substrate capable of maintaining or directing the spatially defined differentiation of multiple cell phenotypes. To date the appropriate combination of biophysical and biochemical factors that can be used to engineer such a biomaterial substrate remain unknown. Here we show that microfiber scaffolds functionalized with tissue-specific extracellular matrix (ECM) components can direct the differentiation of MSCs toward the phenotypes seen at the bone-ligament interface. Ligament-ECM (L-ECM) promoted the expression of the ligament-marker gene tenomodulin (TNMD) and higher levels of type I and III collagen expression compared to functionalization with commercially available type I collagen. Functionalization of microfiber scaffolds with cartilage-ECM (C-ECM) promoted chondrogenesis of MSCs, as evidenced by adoption of a round cell morphology and increased SRY-box 9 (SOX9) expression in the absence of exogenous growth factors. Next, we fabricated a multiphasic scaffold by controlling the spatial presentation of L-ECM and C-ECM along the length of a single electrospun microfiber construct, with the distal region of the C-ECM coated fibers additionally functionalized with an apatite layer (using simulated body fluid) to promote endochondral ossification. These ECM functionalized scaffolds promoted spatially defined differentiation of MSCs, with higher expression of TNMD observed in the region functionalized with L-ECM, and higher expression of type X collagen and osteopontin (markers of endochondral ossification) observed at the end of the scaffold functionalized with C-ECM and the apatite coating. Our results demonstrate the utility of tissue-specific ECM derived components as a cue for directing MSC differentiation when engineering complex multiphasic interfaces such as the bone-ligament enthesis.
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Affiliation(s)
- Dinorath Olvera
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin 2, Ireland.,Department of Mechanical and Manufacturing Engineering, School of Engineering, Trinity College Dublin, Dublin 2, Ireland
| | - Binulal N Sathy
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin 2, Ireland.,Department of Mechanical and Manufacturing Engineering, School of Engineering, Trinity College Dublin, Dublin 2, Ireland.,Centre for Nanosciences & Molecular Medicine, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, Kerala 682041, India
| | - Daniel J Kelly
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin 2, Ireland.,Department of Mechanical and Manufacturing Engineering, School of Engineering, Trinity College Dublin, Dublin 2, Ireland.,Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin 2, Ireland.,Advanced Materials and Bioengineering Research Centre (AMBER), Royal College of Surgeons in Ireland and Trinity College Dublin, Dublin 2, Ireland
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Fabricant PD, Brusalis CM, Schachne JM, Matava MJ. Which Metrics Are Being Used to Evaluate Children and Adolescents After ACL Reconstruction? A Systematic Review. Arthrosc Sports Med Rehabil 2020; 2:e417-e428. [PMID: 32875306 PMCID: PMC7451873 DOI: 10.1016/j.asmr.2020.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 04/15/2020] [Indexed: 01/10/2023] Open
Abstract
Purpose To identify a comprehensive list of outcome measures previously used in the literature to evaluate clinical outcomes after reconstruction of the anterior cruciate ligament (ACL) in patients 18 years of age or younger. Methods A literature search was performed by querying MEDLINE, Embase and Cochrane computerized databases for relevant articles that reported clinical outcomes in pediatric patients undergoing ACL reconstruction. Studies that were nonclinical, that reported on patients older than 19 years, that were not available in English, or that included fewer than 10 patients were excluded. Outcome measures of all eligible studies were recorded. Results We identified 77 studies published between 1986 and 2018 in 20 peer-reviewed journals. The mean age of the patients was 13.9 years. The ACL rerupture rate was reported in 60% of studies; 32 studies (42%) reported a rate of return to preinjury activity or sports. The use of adult-validated patient-reported outcome measures were reported in 63 (82%) articles. The Lysholm (64%), International Knee Documentation Committee (IKDC) (56%) and Tegner (37%) scores were the most commonly reported. Two patient-reported outcome measures designed for pediatric patients (the Pedi-IKDC and Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Pedi-FABS) were employed in 5 (6%) recent studies. Conclusions There is variability across studies in the metrics used to assess clinical outcomes following ACL reconstruction in children and adolescents. Validated pediatric-specific instruments were used infrequently. Clinical Relevance A large body of existing pediatric ACL-reconstruction literature relies on a variable set of outcome measures that have not been developed or validated for children and adolescents. More recently, contemporary studies have begun to employ pediatric- and adolescent-specific validated measures, yet their use remains uncommon.
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Affiliation(s)
- Peter D Fabricant
- Division of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A.,Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Christopher M Brusalis
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Jonathan M Schachne
- Division of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | | | - Matthew J Matava
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
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Tomaszewski R, Smyczek D, Woś-Cieśla I, Kluczewska E, Koszutski T, Wiktor Ł. Developmental changes in ACLs and semitendinosus tendons dimensions according to age in children. J Orthop Surg Res 2020; 15:363. [PMID: 32854724 PMCID: PMC7457293 DOI: 10.1186/s13018-020-01845-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/30/2020] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Managing anterior cruciate ligament (ACL) injuries in skeletally immature patients remains difficult. The main aim of this study was to retrospectively compile normative data on the cross-sectional area (CSA) of the semitendinosus tendon (ST) and the diameter of the ACL in children and young adults. METHODS Knee magnetic resonance imaging (MRI) examinations were performed for a 2-year period in 132 patients (83 female and 49 male patients). The mean age was 14.9 years (8-18 years). Measurements of the ST CSA were performed on axial views in greyscale by two independent researchers. The ACL diameter was measured as well. RESULTS The results show the CSA of the ST was related to age, and its growth was not linear. The highest growth rate of the CSA of the ST occurred at age 12-13 at the level of the femoral growth plate and at the level of the tibial plateau. The growth of the ACL diameter was linear until 18 years of age. CONCLUSIONS ST growth (measured in CSA increments) is almost complete at the age of 13, even though the growth is not linear. ACL growth measured in diameter increments proceeds linearly from 8 to 18 years of age. MRI is a clinically useful tool for assessing hamstring tendon grafts preoperatively. LEVEL OF EVIDENCE Level III, diagnostic studies.
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Affiliation(s)
- Ryszard Tomaszewski
- Department of Pediatric Traumatology and Orthopedy, Upper Silesian Child Centre, ul. Medykow 16, 40-752, Katowice, Poland. .,Faculty of Science and Technology, Institute of Biomedical Engineering, University of Silesia in Katowice, Katowice, Poland. .,Department of Trauma and Orthopaedic Surgery, Upper Silesian Child Health Centre in Katowice, Silesian University of Medicine, Katowice, Poland.
| | - Dominika Smyczek
- Department of Paediatric Surgery and Urology, Upper Silesian Child Health Centre in Katowice, Silesian University of Medicine, Katowice, Poland
| | - Izabela Woś-Cieśla
- Department of Radiology, Public Clinical Hospital in Zabrze, Silesian University of Medicine, Katowice, Poland
| | - Ewa Kluczewska
- Department of Radiology, Public Clinical Hospital in Zabrze, Silesian University of Medicine, Katowice, Poland
| | - Tomasz Koszutski
- Department of Paediatric Surgery and Urology, Upper Silesian Child Health Centre in Katowice, Silesian University of Medicine, Katowice, Poland
| | - Łukasz Wiktor
- Department of Trauma and Orthopaedic Surgery, Upper Silesian Child Health Centre in Katowice, Silesian University of Medicine, Katowice, Poland
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Kuršumović K, Charalambous CP. Relationship of Graft Type and Vancomycin Presoaking to Rate of Infection in Anterior Cruciate Ligament Reconstruction. JBJS Rev 2020; 8:e1900156. [DOI: 10.2106/jbjs.rvw.19.00156] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Abstract
BACKGROUND Revision anterior cruciate ligament (ACL) reconstruction in pediatric patients has not been well studied. The purpose of this study was to assess the demographics, technique, and results of ACL revision surgery in children and adolescents. METHODS This was a retrospective case series with outcomes assessment of patients 18 years old and younger who underwent revision ACL surgery over a 16-year period at a single institution. Medical records were reviewed for demographics, clinical and operative data, and patients were contacted for outcomes at a minimum of 1 year after revision surgery. RESULTS Ninety revision ACL reconstructions were performed by 7 surgeons in 88 patients (44 male, 44 female). Average patient age at the time of revision was 16.6 years (SD, 1.7), and 28.8% of patients were skeletally immature. Time to failure after primary ACL reconstruction was 1.28 years (SD, 1.1) and revision surgery was performed 1.56 years (SD, 1) after the index procedure. Revision graft type included allograft (61.1%), patellar tendon (21.1%), hamstring (16.7%), and iliotibial band (1.1%). There was a 20% graft reinjury rate. Subsequent surgical procedures after revision were required in 25.5% of knees. Twenty percent of revision reconstructions had contralateral ACL injuries, and this percentage was higher (33%) among those who went on to injure their revision graft. Median outcome scores collected from 44 patients (50%) at a mean of 5.1 years following surgery (SD, 3.4) were: Pedi-IKDC 79.9, Lysholm 84.5, and Tegner 9.0. Sixty-nine percent of patients reported returning to sports, however, only 55.2% of these reported being able to return to the same level of play. CONCLUSIONS Revision ACL reconstruction in pediatric patients was associated with suboptimal patient-reported outcomes, high complication rates, relatively high graft retear rates, high risk of contralateral ACL injury, and compromised return to sports rates. LEVEL OF EVIDENCE Level IV.
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Sun Y, Lovric V, Wang T, Oliver RA, Walsh WR. Effects of SCCO 2, Gamma Irradiation, and Sodium Dodecyl Sulfate Treatments on the Initial Properties of Tendon Allografts. Int J Mol Sci 2020; 21:ijms21051565. [PMID: 32106592 PMCID: PMC7084268 DOI: 10.3390/ijms21051565] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/07/2020] [Accepted: 02/15/2020] [Indexed: 01/05/2023] Open
Abstract
Sterile and decellularized allograft tendons are viable biomaterials used in reconstructive surgeries for dense connective tissue injuries. Established allograft processing techniques including gamma irradiation and sodium dodecyl sulfate (SDS) can affect tissue integrity. Supercritical carbon dioxide (SCCO2) represents a novel alternative that has the potential to decellularize and sterilize tendons with minimized exposure to denaturants, shortened treatment time, lack of toxic residues, and superior tissue penetration, and thus efficacy. This study attempted to develop a single-step hybrid decellularization and sterilization protocol for tendons that involved SCCO2 treatment with various chemical additives. The processed tendons were evaluated with mechanical testing, histology, scanning electron microscopy (SEM), and Fourier-transform infrared (FTIR) spectroscopy. Uniaxial mechanical testing showed that tendons treated with SCCO2 and additive NovaKillTM Gen2 and 0.1% SDS had significantly higher (p < 0.05) ultimate tensile stress (UTS) and Young's modulus compared to gamma-irradiated and standard-SDS-treated tendons. This was corroborated by the ultrastructural intactness of SCCO2-treated tendons as examined by SEM and FTIR spectroscopy, which was not preserved in gamma-irradiated and standard SDS-treated tendons. However, complete decellularization was not achieved by the experimented SCCO2-SDS protocols used in this study. The present study therefore serves as a concrete starting point for development of an SCCO2-based combined sterilization and decellularization protocol for allograft tendons, where additive choice is to be optimized.
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Ishibashi Y, Adachi N, Koga H, Kondo E, Kuroda R, Mae T, Uchio Y. Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of anterior cruciate ligament injury - Secondary publication. J Orthop Sci 2020; 25:6-45. [PMID: 31843222 DOI: 10.1016/j.jos.2019.10.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 10/12/2019] [Accepted: 10/16/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND This clinical guideline presents recommendations for the management of patients with anterior cruciate ligament (ACL) injury, endorsed by the Japanese Orthopaedic Association (JOA) and Japanese Orthopaedic Society of Knee, Arthroscopy and Sports Medicine (JOSKAS). METHODS The JOA ACL guideline committee revised the previous guideline based on "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which proposed a desirable method for preparing clinical guidelines in Japan. Furthermore, the importance of "the balance of benefit and harm" was also emphasized. This guideline consists of 21 clinical questions (CQ) and 23 background questions (BQ). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design. RESULTS We evaluated the objectives and results of each study in order to make a decision on the level of evidence so as to integrate the results with our recommendations for each CQ. For BQ, the guideline committee proposed recommendations based on the literature. CONCLUSIONS This guideline is intended to be used by physicians, orthopedic surgeons, physical therapists, and athletic trainers managing ACL injuries. We hope that this guideline is useful for appropriate decision-making and improved management of ACL injuries.
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Affiliation(s)
- Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Japan.
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Eiji Kondo
- Centre for Sports Medicine, Hokkaido University Hospital, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
| | - Tatsuo Mae
- Department of Sports Medical Biomechanics, Osaka University Graduate School of Medicine, Japan
| | - Yuji Uchio
- Department of Orthopaedic Surgery, Shimane University School of Medicine, Japan
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The incidence of paediatric ACL injury is increasing in Finland. Knee Surg Sports Traumatol Arthrosc 2020; 28:363-368. [PMID: 31222395 PMCID: PMC6994437 DOI: 10.1007/s00167-019-05553-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 06/05/2019] [Indexed: 01/06/2023]
Abstract
PURPOSE Anterior cruciate ligament (ACL) injury is a common knee injury in paediatric and adolescent patients. The population-based incidence of paediatric ACL injury is, however, unknown. Recent studies suggest increased ACL injury rates among adolescents, especially in active, sports-participating population. The purpose of this study was to investigate the population-based incidence rates of ACL injuries and trends in paediatric ACL reconstruction surgery. METHOD All ACL injuries were identified (ICD-10 diagnosis code S83.5) leading to hospitalisation or surgery using validated Finnish National Hospital Discharge Register (NHDR) data from 1997 to 2014. The sample comprised 19,961,205 Finnish residents aged less than 18 years at the time of injury. Hospital admissions with the diagnosis code S83.5 were analysed more thoroughly including, sex, age and the need for surgical interventions. RESULTS During the 18-year study period, 4725 subjects of the study population had sustained an ACL injury. The total ACL injury incidence in study population was 23.3 per 100,000 person-years. The median age of the patients at the time of injury was 16 years (range 4-17). The incidence of ACL injury increased with age, and the highest incidence was observed among 17-year old (113.5 per 100,000 person-years). Incidence rate did not differ between genders. From the total ACL injury population of 4725 hospitalisations, 3168 (67.0%) underwent ACL reconstruction, of which 2988 (94.3%) were treated with arthroscopic reconstruction and 180 (5.6%) with open surgery. In addition, 1557 (33.0%) were treated non-operatively without ACL reconstruction. The annual incidence of ACL injuries in the Finnish paediatric population has increased during the past 15 years. The lowest incidence rate was seen in 1999 (incidence of 17.7 per 100,000 person-years, 195 ACL injuries) and the highest in 2011 (incidence of 31.5 per 100,000 person-years, 346 ACL injuries). The highest increase in ACL injuries was seen in girls aged 13-15 years, with an increase of 143%. CONCLUSION ACL injury is not a negligible knee injury in the paediatric population. The incidence of paediatric ACL injury has increased during the past 15 years. Moreover, a twofold increase in incidence of paediatric ACL injury was noted during the last 10 years of the study period. Incidence rates among male and female paediatric patients were comparable. LEVEL OF EVIDENCE III.
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Gagliardi AG, Carry PM, Parikh HB, Albright JC. Outcomes of Quadriceps Tendon With Patellar Bone Block Anterior Cruciate Ligament Reconstruction in Adolescent Patients With a Minimum 2-Year Follow-up. Am J Sports Med 2020; 48:93-98. [PMID: 31743038 DOI: 10.1177/0363546519885371] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The incidence of anterior cruciate ligament (ACL) injury in the adolescent population is increasing. The quadriceps tendon-patellar bone autograft (QPA) has been established as a reliable graft choice for ACL reconstruction in the adult population. PURPOSE To investigate graft failure, ability to return to sport, patient-reported functional outcomes, joint laxity, and subsequent injury among adolescent patients >2 years after primary ACL reconstruction with the QPA. STUDY DESIGN Case series; Level of evidence, 4. METHODS Consecutive patients who underwent QPA ACL reconstruction performed by a single surgeon were identified from an existing database. Information available in the database included demographics, concomitant/subsequent injuries, surgical procedures, graft failure, return to sport, and Lachman examination collected by medical record review. Pediatric International Knee Documentation Committee (Pedi-IKDC) and Lysholm scores were collected by telephone or during a clinic visit >2 years postoperatively. RESULTS The final cohort included 81 of 104 consecutive adolescent patients aged 10 to 18 years (mean ± SD, 15.9 ± 1.7 years at the time of surgery) for whom follow-up information was collected at >2 years after surgery. The cumulative incidence of graft failure within the 36-month follow-up period was 1.2% (95% CI, 0.1%-11.4%). The rate of ipsilateral non-ACL injuries was similar (1.2%; 95% CI, 0.2%-7.6%). Contralateral ACL and non-ACL injuries requiring surgical intervention were documented in 9.8% (95% CI, 4.9%-19.5%). The median Pedi-IKDC score was 94 (interquartile range, 89-98). The median Lysholm score was 99.5 (interquartile range, 89.0-100.0). At 36 months after surgery, 87.9% (95% CI, 81.4%-94.9%) of individuals had returned to play. CONCLUSION The quadriceps tendon-patellar autograft is a novel graft that demonstrates excellent stability and favorable patient-reported outcomes. Based on these results, the QPA is a reliable choice for primary ACL reconstruction in adolescent patients.
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Affiliation(s)
- Alexia G Gagliardi
- Sports Medicine Center, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Patrick M Carry
- Sports Medicine Center, Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Orthopedics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Harin B Parikh
- Department of Orthopedics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Jay C Albright
- Sports Medicine Center, Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Orthopedics, School of Medicine, University of Colorado, Aurora, Colorado, USA
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Accadbled F, Gracia G, Laumonerie P, Thevenin-Lemoine C, Heyworth BE, Kocher MS. Paediatric anterior cruciate ligament tears: management and growth disturbances. A survey of EPOS and POSNA membership. J Child Orthop 2019; 13:522-528. [PMID: 31695820 PMCID: PMC6808070 DOI: 10.1302/1863-2548.13.190074] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The therapeutic algorithm of paediatric anterior cruciate ligament (ACL) tears remains controversial. The primary aim of the study was to describe variations in practice patterns among European Paediatric Orthopaedic Society (EPOS) and Pediatric Orthopaedic Society of North America (POSNA) members with respect to management of ACL tears in skeletally immature patients. The secondary objective was to determine the number, type and severity of growth disturbances associated with ACL reconstruction (ACLR). METHODS An email invitation to complete a 52-question survey was sent to all members of POSNA and EPOS. Data were collected automatically. Descriptive statistics were applied. RESULTS In all, 305 (25.4%) surgeon members responded. Only 182 (60%) of the participants treated ACL injuries in skeletally immature patients and completed the survey. A total of 17% of EPOS and 70% of POSNA members recommended ACLR within three months for a prepubescent paediatric ACL tear. In total, 61% of POSNA and 83% of EPOS members recommended ACLR within three months for a pubescent paediatric ACL tear. Epiphyseal tunnels were the preferred technique in prepubescent children (43% at the tibia and 49% at the femur), while transphyseal tunnels were recommended preferentially in pubescent children (85% at the tibia and 63% at the femur). In all, 5.5% of participants reported growth disturbances after ACLR. CONCLUSION Current practice patterns across the Atlantic remain varied and controversial. Consensus remains elusive; as such, research collaboration among societies will be important to develop an evidence-based treatment algorithm. The use of transphyseal tunnels has been reinforced. The number of cases of significant growth disturbance is minimal, yet worrisome. LEVEL OF EVIDENCE II.
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Affiliation(s)
- F. Accadbled
- Department of Orthopaedics, Children’s Hospital, CHU de Toulouse, France,Correspondence should be sent to F. Accadbled, Service de Chirurgie Orthopédique et Traumatologique, Hôpital des Enfants 330, Avenue de Grande Bretagne, 31059 Toulouse cedex 9, France.
| | - G. Gracia
- Department of Orthopaedics, Children’s Hospital, CHU de Toulouse, France
| | - P. Laumonerie
- Department of Orthopaedics, Children’s Hospital, CHU de Toulouse, France
| | | | - B. E. Heyworth
- Department of Orthopaedic Surgery, Division of Sports Medicine, Boston Children’s Hospital; and Harvard Medical School, Boston, Massachusetts, USA
| | - M. S. Kocher
- Department of Orthopaedic Surgery, Division of Sports Medicine, Boston Children’s Hospital; and Harvard Medical School, Boston, Massachusetts, USA
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Perkins CA, Busch MT, Christino M, Herzog MM, Willimon SC. Allograft Augmentation of Hamstring Anterior Cruciate Ligament Autografts Is Associated With Increased Graft Failure in Children and Adolescents. Am J Sports Med 2019; 47:1576-1582. [PMID: 31095404 DOI: 10.1177/0363546519849607] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstruction in adolescents is commonly performed with hamstring tendon autografts. Small graft diameter is one risk factor for graft failure and options to upsize the autologous hamstring graft include allograft augmentation and tripling one or both of the hamstring tendons. PURPOSE To evaluate the association of upsized hamstring graft constructs and graft rupture after ACL reconstruction. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A retrospective review was performed of patients 19 years of age and younger who underwent hamstring autograft ACL reconstruction with or without soft tissue allograft augmentation from 2012 to 2016. All patients were skeletally mature or had less than 2 years of growth remaining. Graft constructs included 4-strand doubled semitendinosus and gracilis autograft (4-STG), 5-strand tripled semitendinosus and doubled gracilis autograft (5-STG), and 6-strand doubled gracilis and semitendinosus autograft augmented with a soft tissue allograft (6-STGAllo). The primary outcome measure was graft rupture. RESULTS A total of 354 patients with a mean age of 15.3 years (range, 10-19 years) were included. Graft constructs included 4-STG (198 knees), 5-STG (91 knees), and 6-STGAllo (65 knees). The average diameter of the graft constructs was 8.3 mm for 4-STG, 8.9 mm for 5-STG, and 9.2 mm for 6-STGAllo ( P < .001). The mean follow-up was 26 months (range, 6-56 months). There were 50 (14%) graft ruptures and 24 (7%) contralateral ACL tears. The graft failure rates were 14% for 4-STG, 12% for 5-STG, and 20% for 6-STGAllo ( P = .51). The average time to graft failure was 16 months (range, 2-40 months). After adjusting for age and graft size, patients who had allograft-augmented grafts (6-STGAllo) had 2.6 (95% CI, 1.02, 6.50) times the odds of graft rupture compared with 4-STG. There was no significant difference in failure rate between patients who had 5-STG grafts compared with 4-STG (OR, 1.2; 95% CI, 0.5, 2.7). CONCLUSION ACL reconstruction with hamstring tendon autografts augmented with allografts has a significantly increased risk of graft rupture compared with comparably sized hamstring tendon autografts. In situations where the surgeon harvests an inadequately sized 4-strand autograft, we recommend obtaining a larger graft diameter by tripling the semitendinosus rather than augmenting with an allograft.
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Affiliation(s)
| | | | | | - Mackenzie M Herzog
- Professional Research Institute for Sports Medicine, Chapel Hill, North Carolina, USA
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Hulet C, Sonnery-Cottet B, Stevenson C, Samuelsson K, Laver L, Zdanowicz U, Stufkens S, Curado J, Verdonk P, Spalding T. The use of allograft tendons in primary ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2019; 27:1754-1770. [PMID: 30830297 DOI: 10.1007/s00167-019-05440-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 02/22/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE Graft choice in primary anterior cruciate ligament (ACL) reconstruction remains controversial. The use of allograft has risen exponentially in recent years with the attraction of absent donor site morbidity, reduced surgical time and reliable graft size. However, the published evidence examining their clinical effectiveness over autograft tendons has been unclear. The aim of this paper is to provide a current review of the clinical evidence available to help guide surgeons through the decision-making process for the use of allografts in primary ACL reconstruction. METHODS The literature in relation to allograft healing, storage, sterilisation, differences in surgical technique and rehabilitation have been reviewed in addition to recent comparative studies and all clinical systematic reviews and meta-analyses. RESULTS Early reviews have indicated a higher risk of failure with allografts due to association with irradiation for sterilisation and where rehabilitation programs and post-operative loading may ignore the slower incorporation of allografts. More recent analysis indicates a similar low failure rate for allograft and autograft methods of reconstruction when using non-irradiated allografts that have not undergone chemically processing and where rehabilitation has been slower. However, inferior outcomes with allografts have been reported in young (< 25 years) highly active patients, and also when irradiated or chemically processed grafts are used. CONCLUSION When considering use of allografts in primary ACL reconstruction, use of irradiation, chemical processing and rehabilitation programs suited to autograft are important negative factors. Allografts, when used for primary ACL reconstruction, should be fresh frozen and non-irradiated. Quantification of the risk of use of allograft in the young requires further evaluation. LEVELS OF EVIDENCE III.
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Affiliation(s)
- Christophe Hulet
- Department of Orthopedics and Traumatology, Caen University Hospital, Avenue Cote de Nacre, 14000, Caen, France
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hôpital Privé Jean Mermoz, Lyon, France
| | - Ciara Stevenson
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK
| | - Kristian Samuelsson
- Sahlgrenska University Hospital, Mölndal, Sweden
- Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lior Laver
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK
| | - Urszula Zdanowicz
- Carolina Medical Center, Pory 78, 02-757, Warsaw, Poland
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Suite 300, Pittsburgh, PA, 15219-3110, USA
| | - Sjoerd Stufkens
- Academic Medical Center Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Jonathan Curado
- Department of Orthopedics and Traumatology, Caen University Hospital, Avenue Cote de Nacre, 14000, Caen, France
| | - Peter Verdonk
- Antwerp Orthopedic Center, Monica Hospitals, Antwerp, Belgium
| | - Tim Spalding
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK.
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Condello V, Zdanowicz U, Di Matteo B, Spalding T, Gelber PE, Adravanti P, Heuberer P, Dimmen S, Sonnery-Cottet B, Hulet C, Bonomo M, Kon E. Allograft tendons are a safe and effective option for revision ACL reconstruction: a clinical review. Knee Surg Sports Traumatol Arthrosc 2019; 27:1771-1781. [PMID: 30242455 DOI: 10.1007/s00167-018-5147-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 09/14/2018] [Indexed: 12/23/2022]
Abstract
Revision anterior cruciate ligament reconstruction remains a challenge, especially optimising outcome for patients with a compromised knee where previous autogenous tissue has been used for reconstruction. Allograft tissue has become a recognized choice of graft for revision surgery but questions remain over the risks and benefits of such an option. Allograft tendons are a safe and effective option for revision ACL reconstruction with no higher risk of infection and equivalent failure rates compared to autografts provided that the tissue is not irradiated, or any irradiation is minimal. Best scenarios for use of allografts include revision surgery where further use of autografts could lead to high donor site morbidity, complex instability situations where additional structures may need reconstruction, and in those with clinical and radiologic signs of autologous tendon degeneration. A surgeon needs to be able to select the best option for the challenging knee facing revision ACL reconstruction, and in the light of current data, allograft tissue can be considered a suitable option to this purpose.Level of evidence IV.
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Affiliation(s)
- V Condello
- Department of Orthopaedics, Clinica Humanitas Castelli, Via Mazzini, 11, Bergamo, Italy
| | - U Zdanowicz
- Carolina Medical Center, Pory 78, 02-757, Warsaw, Poland.,McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Berardo Di Matteo
- Department of Biomedical Sciences, Humanitas University, Via Manzoni 113, Rozzano, 20089, Milan, Italy. .,Humanitas Clinical and Research Center, Via Manzoni 56, Rozzano, 20089, Milan, Italy.
| | - T Spalding
- University Hospitals Coventry and Warwickshire (UHCW), Coventry, UK
| | - P E Gelber
- Orthopaedic Department, ICATME-Institut Universitari Quirón-Dexeus, Universitat Autònoma Barcelona, Barcelona, Spain.,Orthopaedic Department, Hospital de Sant Pau, Universitat Autònoma, Barcelona, Spain
| | - P Adravanti
- U.O. Ortopedia, Clinica "Città di Parma", Parma, Italy
| | | | - S Dimmen
- Lovisenberg Diaconal Hospital, Lovisenberggt. 17, 0456, Oslo, Norway
| | - B Sonnery-Cottet
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hôpital Privé Jean Mermoz, Lyon, France
| | - C Hulet
- Department of Orthopaedic Surgery and Traumatology, Unit INSERM COMETE, UMR U1075, Caen University Hospital, Caen, France
| | - M Bonomo
- Orthopaedic Department, Sacro Cuore-Don Calabria Hospital, Via Don A. Sempreboni, 5, 37024, Negrar, VR, Italy
| | - E Kon
- Department of Biomedical Sciences, Humanitas University, Via Manzoni 113, Rozzano, 20089, Milan, Italy.,Humanitas Clinical and Research Center, Via Manzoni 56, Rozzano, 20089, Milan, Italy
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Häberli J, Bieri KS, Aghayev E, Eggli S, Henle P. Dynamic intraligamentary stabilization of anterior cruciate ligament repair: hardware removal has no effect on knee laxity at 2-year follow-up. Arch Orthop Trauma Surg 2019; 139:639-644. [PMID: 30649589 DOI: 10.1007/s00402-019-03113-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Dynamic intraligamentary stabilization (DIS) stabilizes the knee joint during anterior cruciate ligament (ACL) healing. After 6 months, tibial hardware removal is offered to the patients if local discomfort at the implant site is present. AIM This study compared knee laxity and functional scores 2 years after DIS between patients with and without hardware removal. It is hypothesized that it does not affect ACL healing. MATERIALS AND METHODS The study retrospectively analyzed prospectively collected data from 173 patients with either hardware removal (n = 47) or no additional intervention (n = 126). Inverse probability of treatment weighting using the propensity score was applied to balance the groups for baseline characteristics. The primary outcome was the side-to-side difference in knee laxity measured with the rolimeter at manual maximum force (Δ-Lachman). Secondary outcomes were the pivot-shift test and subjective scores. RESULTS Mean age was 34 years in both groups, and female gender was 47% (hardware removal group) and 50% (control group), respectively. No significant differences were found for Δ-Lachman (p = 0.09), pivot-shift test (p = 0.41), and subjective scores (p > 0.10) two years after DIS. CONCLUSION Knee laxity 2 years after DIS in patients with tibial hardware removal and patients without hardware removal was not significantly different. The groups were also similar regarding all the assessed functional scores. This study confirms the hypothesis that the healing ACL resumes its stabilizing role, and the hardware can be removed beginning 6 months after surgery without adverse consequences for joint stability. LEVEL OF EVIDENCE Case-control study, Level III.
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Affiliation(s)
- Janosch Häberli
- Sonnenhof Orthopaedic Center, Buchserstrasse 30, 3006, Bern, Switzerland
| | - Kathrin Susan Bieri
- Swiss RDL, Institute of Social and Preventive Medicine, University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland.
| | - Emin Aghayev
- Swiss RDL, Institute of Social and Preventive Medicine, University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland.,Spine Center, Schulthess Klinik, Lennghalde 2, 8008, Zurich, Switzerland
| | - Stefan Eggli
- Sonnenhof Orthopaedic Center, Buchserstrasse 30, 3006, Bern, Switzerland
| | - Philipp Henle
- Sonnenhof Orthopaedic Center, Buchserstrasse 30, 3006, Bern, Switzerland
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Incidence of graft failure with Achilles tendon allograft combined with RetroScrewTM tibial fixation in primary anterior cruciate ligament reconstruction. CURRENT ORTHOPAEDIC PRACTICE 2019. [DOI: 10.1097/bco.0000000000000739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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