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Tomihara T, Hashimoto Y, Okazaki S, Nishino K, Taniuchi M, Takigami J, Tsumoto S, Katsuda H. Bone-patellar tendon-bone autograft is associated with a higher rate of return to preinjury levels of performance in high-level athletes than anterior cruciate ligament reconstruction using hamstring autograft. Knee Surg Sports Traumatol Arthrosc 2024; 32:1384-1395. [PMID: 38558484 DOI: 10.1002/ksa.12144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/26/2024] [Accepted: 02/29/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE Return to preinjury levels of performance (RTP) is the main goal after anterior cruciate ligament reconstruction (ACL-R) for athletes when ACL graft rupture is a career-threatening event. The purpose of this study was to elucidate the associated factors for RTP and subsequent ACL injury after ACL-R using bone-patellar tendon-bone (BPTB) or hamstring (HT) autograft in high-level athletes with a minimum postoperative follow-up of 24 months. METHODS This retrospective study included 157 patients who had preinjury Tegner activity level of 9 and underwent primary ACL-R using BPTB (average age, 16.9 years; 35 males and 36 females) or HT (average age, 17.2 years; 49 males and 37 females). The mean follow-ups were 33.6 months in BPTB and 44.5 months in HT, respectively. The data were obtained based on routine clinical follow-ups and telephone interviews performed by the surgeon. Multivariate logistic regression analysis was conducted to determine the association of patient variables with RTP and subsequent ACL injury. RESULTS Ninety-nine patients (63.1%) were able to RTP. The rate of RTP in BPTB (74.6%) was significantly higher than that of HT (53.5%) (p < 0.05). The overall average timing of RTP after ACL-R was 10.0 months while that was significantly earlier in BPTB (9.7 months) than in HT (10.5 months) (p < 0.05). Twenty-three (14.6%) and 21 patients (13.4%) had ACL graft ruptures and ACL injuries in the contralateral knees, respectively. Multivariate analyses showed that BPTB (odds ratio [OR], 2.590; 95% confidence interval [CI], 1.300-5.160; p = 0.007) was associated with a higher potential for RTP after ACL-R. The incidence of ACL graft rupture after ACL-R decreased with BPTB (OR, 0.861; 95% CI, 0.770-0.962; p = 0.009). CONCLUSIONS The use of BPTB autograft was associated with a higher rate of RTP and a lower incidence of ACL graft rupture compared to ACL-R using HT autograft. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Tomohiro Tomihara
- Department of Orthopaedic Surgery, Shimada Hospital, Habikino, Japan
| | - Yusuke Hashimoto
- Department of Sport Sciences, Osaka University of Health and Sport Sciences, Sennan-gun, Japan
| | - Shiro Okazaki
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Habikino, Japan
| | - Kazuya Nishino
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Habikino, Japan
| | | | - Junsei Takigami
- Department of Orthopaedic Surgery, Shimada Hospital, Habikino, Japan
| | - Shuko Tsumoto
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Habikino, Japan
| | - Hiroshi Katsuda
- Department of Orthopaedic Surgery, Shimada Hospital, Habikino, Japan
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2
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Feichtinger X, Muji E, Domej MA, Pauzenberger L, Baierl A, Kocijan R, Loho G, Brandl G. Combined press-fit and extracortical fixation in patellar tendon anterior cruciate ligament reconstruction results in reliable graft fixation and early bone block incorporation. Knee 2023; 43:18-27. [PMID: 37210858 DOI: 10.1016/j.knee.2023.05.002] [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: 12/04/2022] [Revised: 02/19/2023] [Accepted: 05/02/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstruction with bone-patellar-tendon-bone (BPTB) autograft has the potential biological advantage of direct bone-to-bone healing over soft tissue grafts. The primary aim of this study was to investigate possible graft slippage and therefore fixation strength in a modified BPTB autograft technique with suspensory fixation on both sides for primary ACL reconstruction until bony integration takes place. METHODS Twenty-one patients undergoing primary ACL reconstruction with a modified BPTB autograft (bone-on-bone (BOB) technique) between August 2017 and August 2019 were included in this prospective study. A computed tomography (CT) scan of the affected knee was performed directly postoperatively, as well as 3 months postoperatively. Examiner-blinded parameters for graft slippage, early tunnel widening, bony incorporation, as well as remodeling of the autologous refilled patellar harvest site were investigated. RESULTS A series of 21 patients treated with a BPTB autograft with this technique underwent two CT investigations. Comparison of CT scans showed no bone block displacement and therefore no graft slippage in the patient cohort. Only one patient showed signs of early tunnel enlargement. Radiological bone block incorporation took place showing bony bridging of the graft to the tunnel wall in 90% of all patients. Furthermore, 90% showed less than 1 mm bone resorption of the refilled harvest site at the patella. CONCLUSIONS Our findings suggest graft fixation stability and reliability of anatomic BPTB ACL reconstruction with a combined press-fit and suspensory fixation technique by absence of graft slippage within the first 3 months postoperatively.
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Affiliation(s)
- Xaver Feichtinger
- Department of Orthopedic Surgery II, Herz-Jesu Hospital Vienna, Austria.
| | - Edin Muji
- Department of Orthopedic Surgery II, Herz-Jesu Hospital Vienna, Austria
| | - Marija Ana Domej
- Department of Orthopedic Surgery II, Herz-Jesu Hospital Vienna, Austria
| | - Leo Pauzenberger
- Department of Orthopedic Surgery II, Herz-Jesu Hospital Vienna, Austria
| | - Andreas Baierl
- Department of Statistics and Operations Research, The University of Vienna, Vienna, Austria
| | - Roland Kocijan
- Ludwig Boltzmann Institute of Osteology, 1st Medical Department at Hanusch Hospital, Vienna, Austria
| | - Gerald Loho
- Department of Orthopedic Surgery II, Herz-Jesu Hospital Vienna, Austria
| | - Georg Brandl
- Department of Orthopedic Surgery II, Herz-Jesu Hospital Vienna, Austria
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3
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Runer A, Keeling L, Wagala N, Nugraha H, Özbek EA, Hughes JD, Musahl V. Current trends in graft choice for primary anterior cruciate ligament reconstruction - part II: In-vivo kinematics, patient reported outcomes, re-rupture rates, strength recovery, return to sports and complications. J Exp Orthop 2023; 10:40. [PMID: 37014518 PMCID: PMC10073382 DOI: 10.1186/s40634-023-00601-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/22/2023] [Indexed: 04/05/2023] Open
Abstract
Postoperative patient satisfaction after anterior cruciate ligament reconstruction (ACL-R) is influenced mainly by the degree of pain, the need for reoperation, and functional performance in daily activities and sports. Graft choice has shown to have an influence on postoperative outcomes after ACL-R. While patient reported outcomes measurements do not differ between graft options, evidence shows that normal knee kinematics is not fully restored after ACL-R with an increase in postoperative anterior tibial translation (ATT). Postoperative graft rupture rates seem to favor bone-patella-tendon-bone (BPTB) and quadriceps tendon (QT) autografts over HT or allografts. While return to sports rates seem comparable between different graft types, postoperative extensor strength is reduced in patients with BPTB and QT whereas flexion strength is weakened in patients with HT. Postoperative donor site morbidity is highest in BPTB but comparable between HT and QT. With all graft options having advantages and drawbacks, graft choice must be individualized and chosen in accordance with the patient.
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Affiliation(s)
- Armin Runer
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA.
- Department for Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Laura Keeling
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nyaluma Wagala
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hans Nugraha
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopaedic and Traumatology, Faculty of Medicine, University of Udayana, / Prof. Dr. I.G.N.G. Ngoerah General Hospital, Denpasar, Bali, Indonesia
| | - Emre Anil Özbek
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopedics and Traumatology, Ankara University, Ankara, Turkey
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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4
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Runer A, Keeling L, Wagala N, Nugraha H, Özbek EA, Hughes JD, Musahl V. Current trends in graft choice for anterior cruciate ligament reconstruction - part I: anatomy, biomechanics, graft incorporation and fixation. J Exp Orthop 2023; 10:37. [PMID: 37005974 PMCID: PMC10067784 DOI: 10.1186/s40634-023-00600-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/22/2023] [Indexed: 04/04/2023] Open
Abstract
Graft selection in anterior cruciate ligament (ACL) reconstruction is critical, as it remains one of the most easily adjustable factors affecting graft rupture and reoperation rates. Commonly used autografts, including hamstring tendon, quadriceps tendon and bone-patellar-tendon-bone, are reported to be biomechanically equivalent or superior compared to the native ACL. Despite this, such grafts are unable to perfectly replicate the complex anatomical and histological characteristics of the native ACL. While there remains inconclusive evidence as to the superiority of one autograft in terms of graft incorporation and maturity, allografts appear to demonstrate slower incorporation and maturity compared to autografts. Graft fixation also affects graft properties and subsequent outcomes, with each technique having unique advantages and disadvantages that should be carefully considered during graft selection.
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Affiliation(s)
- Armin Runer
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA.
- Department for Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Laura Keeling
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nyaluma Wagala
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hans Nugraha
- Department of Orthopaedic and Traumatology, Faculty of Medicine, University of Udayana, / Prof. Dr. I.G.N.G. Ngoerah General Hospital, Denpasar, Bali, Indonesia
| | - Emre Anil Özbek
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopedics and Traumatology, Ankara University, Ankara, Turkey
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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5
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Pomenta Bastidas MV, Sastre S, Segur Vilalta JM, Rios J, Sabater M, Popescu D. Quadriceps tendon vs hamstring autograft in primary ACL reconstruction – a comparative study with minimum two-year follow-up. Acta Orthop Belg 2022; 88:347-354. [DOI: 10.52628/88.2.7306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Recently there has been growing interest in the quadriceps tendon (QUAD) as a valid option for reconstruction of the anterior cruciate ligament (ACLR). The aims of the study is to compare the out- comes achieved in anatomic ACLR involving QUAD vs. Hamstring (HT) autografts.
A total of 52 consecutive patients underwent an ACLR, 25 patients with QUAD graft and 27 with HT graft. The same surgical technique, fixation method and postoperative protocol were used in both groups. The following parameters were evaluated: functional status (Lysholm, Tegner, subjective IKDC scores), joint stability (Lachman and pivot shift tests), surgical reoperation rate, complications, degree of satisfaction and return to previous level of activity. Descriptive statistics were analysed using the Student’s t-test.
Forty four patients were evaluated (20 QUAD, 24 HT), with a mean follow-up of 27.4 months. Two patients were re-operated in the QUAD group (including one ACL revision), and one patient in the HT group required an ACL revision. There were no significant differences between the two groups in postoperative scores: Lysholm (96.05 vs. 96.05), IKDC (86.2 vs. 91.2) and Tegner (6 vs. 5) scales. The percentage of negative Lachman and pivot shift tests was similar in the two groups (45% vs. 50% and 40% vs. 45.8%, respectively). There were no significant differences between the groups in the degree of satisfaction (95.8% vs. 80%, p = .16) or in the percentage who returned to their previous level of activity (62.5% vs. 45%, p = .17).
The use of a QUAD graft in ACL reconstruction leads to similar clinical and functional outcomes to those obtained with HT.
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6
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Greif DN, Shallop BJ, Allegra PR, Cade WH, Minesinger KE, Luxenburg D, Kaplan LD, Baraga MG. A Comparison of Two-Year Anterior Cruciate Ligament Reconstruction Clinical Outcomes Using All-Soft Tissue Quadriceps Tendon Autograft With Femoral/Tibial Cortical Suspensory Fixation Versus Tibial Interference Screw Fixation. Arthroscopy 2022; 38:881-891. [PMID: 34252561 DOI: 10.1016/j.arthro.2021.06.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 06/04/2021] [Accepted: 06/28/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To contribute to future quadriceps tendon harvest and fixation guidelines in the setting of anterior cruciate ligament reconstruction by comparing 2-year patient-reported subjective knee outcome scores and incidence of graft-related complications between the shorter harvest all-inside tibial-femoral suspensory fixation (TFSF) approach versus the longer harvest standard tibial interference screw fixation technique. METHODS Patients who underwent primary anterior cruciate ligament reconstruction with all soft tissue quadriceps tendon autograft from January 2017 to May 2019 were identified for inclusion. Patients were matched into 2 cohorts of 62 based on reconstruction technique. All patients completed baseline and minimum 2-year International Knee Documentation Committee, Tegner Activity Level, and Lysholm questionnaires and were queried regarding subsequent procedures and complications to the operative knee. RESULTS Average graft length for the all-inside TFSF was 69.55 (95% confidence interval 68.99-70.19) mm versus 79.27 (95% confidence interval 77.21-81.34) mm in the tibial screw fixation cohort (P = .00001). Two-year Lysholm scores were greater in the TFSF cohort (P = .04) but were not clinically significant. There was no difference in 2-year International Knee Documentation Committee (P = .09) or Tegner (P = .69) scores between cohorts, but more patients in the TFSF cohort returned to or exceeded their baseline activity level compared with the tibial screw fixation cohort (73% vs 61%, P = .25). Seven patients in the TFSF cohort versus 13 in the tibial screw fixation cohort reported anterior knee pain or kneeling difficulty (P = .22). There were no differences in reported complications. CONCLUSIONS All-inside soft-tissue quadriceps tendon autograft with TFSF resulted in clinically comparable subjective outcome scores at 2 years to tibial screw fixation. There were also no differences in complications or reports of anterior knee pain or kneeling difficulty. All-inside TFSF can be a viable alternative to tibial screw fixation for all-soft tissue quadriceps autograft. LEVEL OF EVIDENCE III, comparative therapeutic trial.
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Affiliation(s)
- Dylan N Greif
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, Florida, U.S.A..
| | - Brandon J Shallop
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, Florida, U.S.A
| | - Paul R Allegra
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, Florida, U.S.A
| | - William H Cade
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, Florida, U.S.A
| | - Kayla E Minesinger
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, Florida, U.S.A
| | - Dylan Luxenburg
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, Florida, U.S.A
| | - Lee D Kaplan
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, Florida, U.S.A
| | - Michael G Baraga
- University of Miami Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, Florida, U.S.A
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7
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Kamiya T, Otsubo H, Suzuki T, Shiwaku K, Kitamura C, Teramoto A, Yamashita T. Hamstring Graft Prepared With Suture Tape Is Effective in Anterior Cruciate Ligament Reconstruction: A Biomechanical Analysis. Arthrosc Sports Med Rehabil 2021; 3:e1003-e1009. [PMID: 34430879 PMCID: PMC8365212 DOI: 10.1016/j.asmr.2021.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/18/2021] [Indexed: 11/25/2022] Open
Abstract
Purpose To investigate the graft diameters and mechanical properties of hamstring tendons sutured using different materials and techniques. Methods This study used 30 fresh, frozen human cadaveric semitendinosus tendons; the free ends of 10 specimens each were sutured by 2 No. 3 braided polyester sutures with the Krackow technique (BP group), SutureTape with the Krackow technique (ST group), or SutureTape Loop with the locking SpeedWhip technique (SL group). First, the changes in graft diameter from before suturing to after suturing were investigated. Each graft was pre-tensioned to 100 N for 3 cycles and then cyclically loaded to 200 N for 200 cycles. Elongation after cyclic loading and displacement in the 200th cycle were calculated. Finally, each specimen was loaded to failure. The ultimate failure load and stiffness were analyzed. These mechanical properties were statistically analyzed using 1-way analysis of variance. The level of statistical significance was set at P < .05. Results In the BP group, the changes in graft diameter were significantly larger than those in the ST and SL groups (P = .001). The elongation values after 200 cycles in the BP and ST groups were 3.1 ± 2.0 mm and 5.9 ± 3.4 mm, respectively. In the SL group, elongation (7.7 ± 3.6 mm) was significantly larger compared with that in the BP group (P = .037). In contrast, displacement in the 200th cycle was significantly smaller in the ST and SL groups compared with the BP group (P = .017). No statistically significant difference was evident for the ultimate failure loads among the 3 groups (P = .543). Conclusions The results of this study suggest that SutureTape may be an appropriate option for preparing the hamstring graft in anatomic anterior cruciate ligament (ACL) reconstruction. Clinical Relevance This biomechanical study shows the effectiveness of SutureTape in ACL graft preparation. Clinically, SutureTape may be of benefit in single- or double-bundle ACL reconstruction.
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Affiliation(s)
- Tomoaki Kamiya
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hidenori Otsubo
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Tomoyuki Suzuki
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Kousuke Shiwaku
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Chihiro Kitamura
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Atsushi Teramoto
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Toshihiko Yamashita
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
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8
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Vindfeld S, Strand T, Solheim E, Inderhaug E. Failed Meniscal Repairs After Anterior Cruciate Ligament Reconstruction Increases Risk of Revision Surgery. Orthop J Sports Med 2020; 8:2325967120960538. [PMID: 33195722 PMCID: PMC7605002 DOI: 10.1177/2325967120960538] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/19/2020] [Indexed: 11/15/2022] Open
Abstract
Background: Failed anterior cruciate ligament (ACL) reconstruction (ACLR) can lead to
reduced quality of life because of recurrent episodes of instability,
restrictions in level of activity, and development of osteoarthritis. A
profound knowledge of the causes of a failed surgery can ultimately help
improve graft survival rates. Purpose: To investigate the patient-related risks of inferior outcomes leading to
revision surgery after ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: From a prospective cohort of primary ACLRs performed at a single center,
patients who required later revision surgery were matched with a control
group of uneventful primary ACLRs. Patient characteristics, data from the
preoperative examinations, KT-1000 arthrometer laxity testing, Tegner
activity scale, International Knee Documentation Committee subjective score,
Knee injury and Osteoarthritis Outcome Score, and perioperative data from
the initial surgery were included. Results: A total of 100 revision cases and 100 matched controls, with a median
follow-up time of 11 years, were included in the study. Those who had
undergone revision surgery were younger at the time of reconstruction and
had a shorter time from injury to surgery than their matched controls
(P = .006). The control group—of uneventful ACLRs—had a
higher incidence of meniscal repair at reconstruction (P =
.024). Also, the revision group more frequently experienced later failure of
the previous meniscal repair (P = .004). Surgeon experience
was not found to affect the risk of revision ACL surgery. Those who had
undergone ACL revision surgery had more frequently received a hamstring
tendon graft size of <8 mm (P = .018) compared with the
controls. Conclusion: The current study demonstrated that failed meniscal repair and a hamstring
tendon graft size of <8 mm were associated with primary ACLR failure.
Also, younger age at the time of surgery and shorter time from injury to
surgery were found to affect the risk of undergoing revision ACL
surgery.
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Affiliation(s)
| | | | - Eirik Solheim
- Aleris Hospital Nesttun, Nesttun, Norway.,Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Eivind Inderhaug
- Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
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Samitier G, Vinagre G, Alentorn-Geli E, Sava M, Cugat R. All-Arthroscopic Meniscal Allograft Transplantation Technique with Bone Plugs and Preloaded Sutures. Arthrosc Tech 2020; 9:e1357-e1362. [PMID: 33024677 PMCID: PMC7528607 DOI: 10.1016/j.eats.2020.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/25/2020] [Indexed: 02/03/2023] Open
Abstract
The meniscus is an essential structure for the knee functioning and survival. Meniscectomy is the most common surgical procedure in orthopaedic surgery. Following total or subtotal meniscectomy, meniscal allograft transplantation (MAT) should be considered in symptomatic active young patients. Several MAT techniques have been described in the literature as an attempt to restore normal knee kinematics and potentially decrease the risk of developing knee osteoarthritis. The purpose of this article is to describe in detail an efficient and reproducible all-arthroscopic MAT technique with bone plugs and preloaded sutures.
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Affiliation(s)
| | - Gustavo Vinagre
- Department of Orthopaedic Surgery, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar,Address correspondence to Gustavo Vinagre, M.D., Ph.D., Department of Orthopaedic Surgery, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar.
| | - Eduard Alentorn-Geli
- Instituto Cugat, Hospital Quironsalud, Barcelona, Spain,Fundación García Cugat, Barcelona, Spain
| | - Maria Sava
- Western University of Health Sciences, Pomona, California, U.S.A
| | - Ramón Cugat
- Instituto Cugat, Hospital Quironsalud, Barcelona, Spain,Fundación García Cugat, Barcelona, Spain
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10
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Runer A, Csapo R, Hepperger C, Herbort M, Hoser C, Fink C. Anterior Cruciate Ligament Reconstructions With Quadriceps Tendon Autograft Result in Lower Graft Rupture Rates but Similar Patient-Reported Outcomes as Compared With Hamstring Tendon Autograft: A Comparison of 875 Patients. Am J Sports Med 2020; 48:2195-2204. [PMID: 32667271 DOI: 10.1177/0363546520931829] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Graft rupture is a devastating outcome after anterior cruciate ligament (ACL) reconstruction (ACLR). Little is known about graft rupture rates as well as clinical and functional outcomes after ACLR with quadriceps tendon (QT) autografts. PURPOSE To compare QT with hamstring tendon (HT) autografts in terms of the rates of graft and contralateral ACL rupture as well as patient-reported outcome measures. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS All primary ACLRs performed between 2010 and 2016 were followed prospectively for 24 months through the recording of graft ruptures and contralateral ACL injuries as well as patient-administered questionnaires. RESULTS A total of 875 patients were included in the study. Three factors-graft type, age group, and activity level-had a significant value in predicting the need for revision surgery. The odds of revision surgery were 5.5 times greater in children younger than 15 years than in adults older than 45 years, 3.6 times greater in patients with high activity levels than low activity levels, and 2.7 times greater in patients receiving an HT autograft as compared with a QT autograft. A significantly higher rate of ipsilateral graft ruptures versus contralateral ACL injuries was observed in the HT group (4.9% vs 2.3%; odds ratio, 2.1; P = .01) but not in the QT group (2.8% vs 2.3%). The difference in the ratios of graft and contralateral ACL ruptures was even more pronounced in highly active patients treated with HT autografts (11.1% vs 4.2%; odds ratio, 2.6; P = .01) as compared with QT autografts (5.0% vs 2.8%; P = .48). Two-year measures of Lysholm scores (mean ± SD: QT, 86.0 ± 22.3; HT, 89.4 ± 16.4) and Tegner activity scores (QT, 6.1 ± 2.0; HT, 5.7 ± 1.9) as well as visual analog scale pain (QT, 0.8 ± 1.3; HT, 0.7 ± 1.1) did not differ between grafts. CONCLUSION Graft choice does not influence clinical and functional outcomes 2 years after ACLR. However, 3 factors-graft type, age group, and activity level-have a significant value in predicting the need for revision surgery. Patients treated with HT autografts have a significantly higher, activity-dependent risk of revision surgery and experience more ipsilateral graft ruptures than subsequent contralateral ACL injuries when compared with patients treated with QT autografts. Young age and high activity level are significant predictors for ACL revision surgery.
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Affiliation(s)
- Armin Runer
- Department of Trauma Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Robert Csapo
- Gelenkpunkt-Sports and Joint Surgery, Innsbruck, Austria.,Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Institute for Sports Medicine, Alpine Medicine and Health Tourism, Private University for Health Sciences, Medical Informatics and Technology, Hall, Austria
| | | | - Mirco Herbort
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Institute for Sports Medicine, Alpine Medicine and Health Tourism, Private University for Health Sciences, Medical Informatics and Technology, Hall, Austria.,OCM Clinic, Munich, Germany
| | | | - Christian Fink
- Gelenkpunkt-Sports and Joint Surgery, Innsbruck, Austria.,Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Institute for Sports Medicine, Alpine Medicine and Health Tourism, Private University for Health Sciences, Medical Informatics and Technology, Hall, Austria
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Yue L, DeFroda SF, Sullivan K, Garcia D, Owens BD. Mechanisms of Bone Tunnel Enlargement Following Anterior Cruciate Ligament Reconstruction. JBJS Rev 2020; 8:e0120. [DOI: 10.2106/jbjs.rvw.19.00120] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abbreviated quantitative UTE imaging in anterior cruciate ligament reconstruction. BMC Musculoskelet Disord 2019; 20:426. [PMID: 31521135 PMCID: PMC6745079 DOI: 10.1186/s12891-019-2811-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 08/30/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Existing ultrashort echo time magnetic resonance imaging (UTE MRI) methods require prohibitively long acquisition times (~ 20-40 min) to quantitatively assess the clinically relevant fast decay T2* component in ligaments and tendons. The purpose of this study was to evaluate the feasibility and clinical translatability of a novel abbreviated quantitative UTE MRI paradigm for monitoring graft remodeling after anterior cruciate ligament (ACL) reconstruction. METHODS Eight patients who had Graftlink™ hamstring autograft reconstruction were recruited for this prospective study. A 3D double-echo UTE sequence at 3.0 Tesla was performed at 3- and 6-months post-surgery. An abbreviated UTE MRI paradigm was established based on numerical simulations and in vivo validation from healthy knees. This proposed approach was used to assess the T2* for fast decay component ([Formula: see text]) and bound water signal fraction (fbw) of ACL graft in regions of interest drawn by a radiologist. RESULTS Compared to the conventional bi-exponential model, the abbreviated UTE MRI paradigm achieved low relative estimation bias for [Formula: see text] and fbw over a range of clinically relevant values for ACL grafts. A decrease in [Formula: see text] of the intra-articular graft was observed in 7 of the 8 ACL reconstruction patients from 3- to 6-months (- 0.11 ± 0.16 ms, P = 0.10). Increases in [Formula: see text] and fbw from 3- to 6-months were observed in the tibial intra-bone graft ([Formula: see text]: 0.19 ± 0.18 ms, P < 0.05; Δfbw: 4% ± 4%, P < 0.05). Lower [Formula: see text] (- 0.09 ± 0.11 ms, P < 0.05) was observed at 3-months when comparing the intra-bone graft to the graft/bone interface in the femoral tunnel. The same comparisons at the 6-months also yielded relatively lower [Formula: see text] (- 0.09 ± 0.12 ms, P < 0.05). CONCLUSION The proposed abbreviated 3D UTE MRI paradigm is capable of assessing the ACL graft remodeling process in a clinically translatable acquisition time. Longitudinal changes in [Formula: see text] and fbw of the ACL graft were observed.
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Mickelson DT, Lefebvre T, Gall K, Riboh JC. Adjustable-Loop Femoral Cortical Suspensory Fixation for Patellar Tendon Anterior Cruciate Ligament Reconstruction: A Time Zero Biomechanical Comparison With Interference Screw Fixation. Am J Sports Med 2018; 46:1857-1862. [PMID: 29763336 DOI: 10.1177/0363546518771365] [Citation(s) in RCA: 8] [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 Adjustable-loop cortical buttons for femoral fixation of bone-tendon-bone grafts have potential advantages over interference screw fixation; however, these devices have not been benchmarked biomechanically against interference screws. Purpose/Hypothesis: The purpose was to compare the time zero biomechanical properties of commercially available, adjustable-loop cortical button and metallic interference screws for femoral fixation of bone-tendon-bone grafts. It was hypothesized that no significant differences would be found in biomechanical properties between fixation techniques. STUDY DESIGN Controlled laboratory study. METHODS Adjustable-loop cortical buttons (n = 8) and metallic interference screws (n = 8) were used to fix matched pairs of human bone-tendon-bone allografts in porcine distal femurs. These constructs were preconditioned (10 N to 50 N at 1 Hz, 10 cycles), subjected to cyclic loading (50 N to 250 N at 1 Hz, 500 cycles), and then pulled to failure at 20 mm/min. RESULTS The loads to failure (mean ± SD, 700 ± 256 N vs 688 ± 215 N, P = .92) and linear stiffnesses (219 ± 48 N/mm vs 218 ± 49 N/mm, P = .97) for the adjustable-loop cortical button and metallic interference screws, respectively, were not significantly different. Cyclic displacement was higher in the adjustable-loop cortical button group (2.1 ± 0.6 mm vs 1.3 ± 0.4 mm, P = .01). The mechanism of failure was different between groups, with bone block slippage occurring most commonly in the interference screw group (n = 5) and fracture of the bone block through the suture hole occurring most commonly in the adjustable-loop cortical button group (n = 6). CONCLUSION Adjustable-loop cortical buttons and interference screws have similar time zero failure loads, although cyclic displacement was higher with the adjustable-loop cortical buttons. The mean difference in displacement was less than 1 mm compared with the interference screw. CLINICAL RELEVANCE Adjustable-loop cortical buttons may be an acceptable alternative to an interference screw for femoral fixation of bone-tendon-bone grafts in anterior cruciate ligament reconstruction. The clinical relevance of the observed differences in cyclic displacement is unknown and should be evaluated in future studies.
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Affiliation(s)
- Dayne T Mickelson
- Duke Sports Science Institute, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Thomas Lefebvre
- Duke Sports Science Institute, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ken Gall
- Department of Mechanical Engineering, Duke University, Durham, North Carolina, USA
| | - Jonathan C Riboh
- Duke Sports Science Institute, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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Camp CL, Lebaschi A, Cong GT, Album Z, Carballo C, Deng XH, Rodeo SA. Timing of Postoperative Mechanical Loading Affects Healing Following Anterior Cruciate Ligament Reconstruction: Analysis in a Murine Model. J Bone Joint Surg Am 2017; 99:1382-1391. [PMID: 28816898 DOI: 10.2106/jbjs.17.00133] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Following anterior cruciate ligament (ACL) reconstruction, the mechanical loading of the tissues has a significant impact on tendon-to-bone healing. The purpose of this study was to determine the effect of the timing of the initiation of mechanical loading on healing of a tendon graft in a bone tunnel. METHODS ACL reconstruction using a flexor tendon autograft was performed in 56 mice randomized to 4 groups with differing times to initiation of postoperative mechanical loading: (1) immediate, (2) 5 days, (3) 10 days, or (4) 21 days following surgery. An external fixator was placed across the knee at the time of surgery and removed when mechanical loading was scheduled to commence. Following removal of the external fixator, animals were permitted free, unrestricted cage activity. All mice were killed on postoperative day 28, and tendon-to-bone healing was assessed by biomechanical testing, microcomputed tomography (micro-CT), and histological analysis. RESULTS The mean failure force (and standard deviation) of the reconstructed ACL at the time of sacrifice was highest for Group 2 (3.29 ± 0.68 N) compared with Groups 1, 3, and 4 (p = 0.008). Micro-CT bone volume fraction was greatest for Group 2 in the femoral tunnel (p = 0.001), tibial tunnel (p = 0.063), and both bones (p < 0.001). Similarly, histological analysis demonstrated a narrower scar tissue interface and increased direct contact at the tendon-bone interface (p = 0.012) for Group 2. CONCLUSIONS Following ACL reconstruction, a defined period of immobilization without weight-bearing appears to improve biomechanical strength of the healing tendon-bone interface, while prolonged periods without mechanical load and motion decrease the ultimate load to failure in this murine model. CLINICAL RELEVANCE The ideal period of restricted weight-bearing and motion following ACL reconstruction remains undefined. In a murine model, improved healing was noted for animals immobilized for a brief period of 5 days. This work may serve as an initial step in determining the ideal time period in a clinical population.
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Affiliation(s)
- Christopher L Camp
- 1Mayo Clinic, Rochester, Minnesota 2Tissue Engineering, Regeneration, and Repair Program, Hospital for Special Surgery, New York, NY
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Locke RC, Abraham AC, Killian ML. Orthopedic Interface Repair Strategies Based on Native Structural and Mechanical Features of the Multiscale Enthesis. ACS Biomater Sci Eng 2016; 3:2633-2643. [PMID: 32832593 DOI: 10.1021/acsbiomaterials.6b00599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The enthesis is an organ that connects a soft, aligned tissue (tendon/ligament) to a hard, amorphous tissue (bone) via a fibrocartilage interface. Mechanically, the enthesis sustains a dynamic loading environment that includes tensile, compressive, and shear forces. The structural components of the enthesis act to minimize stress concentrations and control stretch at the interface. Current surgical repair of the enthesis, such as in rotator cuff repair and anterior cruciate ligament reconstruction, aim to bridge the gap between the injured ends via reattachment of soft-to-hard tissues or graft replacement. In this review, we discuss the multiscale, morphological, and mechanical characteristics of the fibrocartilage attachment. Additionally, we review historical and recent clinical approaches to treating enthesis injury. Lastly, we explore new technological advancements in tissue-engineered biomaterials that have shown promise in preclinical studies.
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Affiliation(s)
- Ryan C Locke
- Department of Biomedical Engineering, University of Delaware, Newark, Delaware 19716, United States
| | - Adam C Abraham
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York 10032, United States
| | - Megan L Killian
- Department of Biomedical Engineering, University of Delaware, Newark, Delaware 19716, United States
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Clinically relevant biomechanics of the knee capsule and ligaments. Knee Surg Sports Traumatol Arthrosc 2015; 23:2789-96. [PMID: 25894747 DOI: 10.1007/s00167-015-3594-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 03/31/2015] [Indexed: 01/16/2023]
Abstract
The paper describes the concepts of primary and secondary restraints to knee joint stability and explains systematically how the tibia is stabilised against translational forces and rotational torques in different directions and axes, and how those vary across the arc of flexion-extension. It also shows how the menisci act to stabilise the knee, in addition to load carrying across the joint. It compares the properties of the natural stabilising structures with the strength and stiffness of autogenous tissue grafts and relates those strengths to the strength of graft fixation devices. A good understanding of the biomechanical behaviour of these various structures in the knee will help the surgeon in the assessment and treatment of single and multi-ligament injuries.
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