Thirty-Year Experience With ACL Reconstruction Using Patellar Tendon: A Critical Evaluation of Revision and Reoperation

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

Background

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

Purpose

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

Study Design

Systematic review; Level of evidence, 4.

Methods

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

Results

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

Conclusion

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

Return to Sports: A Risky Business? A Systematic Review with Meta-Analysis of Risk Factors for Graft Rupture Following ACL Reconstruction

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.

Our Preferred Technique for Bone-Patellar Tendon-Bone Allograft Preparation

Anterior cruciate ligament (ACL) reconstruction is an increasingly common procedure as orthopaedic patients seek to remain active longer in life, resulting in more ligamentous knee injuries. Graft selection is at the forefront of decision making in knee reconstruction, with advantages and disadvantages to various grafts, including allograft to autograft. Although the gold standard for the ACL reconstruction of elite athletes and highly active patients has traditionally been bone-patellar tendon-bone autograft (BTB), this graft is not without its disadvantages, such as increased operative time, increased postoperative pain, potential for anterior knee pain, larger incision, violation of the extensor mechanism, and potentially kneeling pain. Soft tissue autografts (hamstring, quadriceps) offer a good alternative; however, they may be associated with higher rerupture rates, as well as associated donor site morbidity. Additionally, soft tissue allografts have a higher graft rupture rate. For this reason, it is the senior author's preference to perform allograft ACL reconstruction with BTB allograft in appropriately selected patients. We describe our technique for an efficient and reproducible BTB allograft preparation.

A Hybrid Transtibial Technique Combines the Advantages of Anteromedial Portal and Transtibial Approaches: A Prospective Randomized Controlled Trial

BACKGROUND

The anteromedial (AM) portal and transtibial (TT) approaches are 2 common anterior cruciate ligament (ACL) femoral tunnel drilling techniques, each with unique benefits and disadvantages. A hybrid TT (HTT) technique using medial portal guidance of a flexible TT guide wire has recently been described that may combine the strengths of both the AM portal and the TT approaches.

HYPOTHESIS

The HTT technique will achieve anatomic femoral tunnel apertures similar to the AM portal technique, with improved femoral tunnel length and orientation.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

A total of 30 consecutive patients with primary ACL tears were randomized to undergo the TT, AM portal, or HTT technique for femoral tunnel positioning at the time of reconstruction. All patients underwent 3-dimensional computed tomography of the operative knee at 6 weeks postoperatively. Femoral and tibial tunnel aperture positions and tunnel lengths, as well as graft bending angles in the sagittal and coronal planes, were measured.

RESULTS

Tibial tunnel lengths and aperture positions were identical between the 3 groups. The AM portal and HTT techniques achieved identical femoral aperture positions in regard to both height (P = .629) and depth (P = .582). By contrast, compared with the AM portal and HTT techniques, femoral apertures created with the TT technique were significantly higher (P < .001 and P < .001, respectively) and shallower (P = .014 and P = .022, respectively) in the notch. The mean femoral tunnel length varied significantly between the groups, measuring 35.2, 41.6, and 54.1 mm for the AM portal, HTT, and TT groups, respectively (P < .001). Last, there was no difference between the mean coronal (P = .190) and sagittal (P = .358) graft bending angles between the TT and HTT groups. By contrast, compared with the TT and HTT techniques, femoral tunnels created with the AM portal technique were significantly more angulated in the coronal plane (17.7° [P < .001] and 12.5° [P = .006], respectively) and sagittal plane (13.5° [P < .001] and 10.5° [P = .013], respectively).

CONCLUSION

This prospective randomized controlled trial found that the HTT technique achieved femoral aperture positions equally as anatomic as the AM portal technique but produced longer, less angulated femoral tunnels, which may help reduce graft strain and mismatch. As such, this hybrid approach may represent a beneficial combination of both the TT and the AM portal techniques.

REGISTRATION

NCT02795247 (ClinicalTrials.gov identifier).

One sixth of primary anterior cruciate ligament reconstructions may undergo reoperation due to complications or new injuries within 2 years

PURPOSE

To analyse the incidence, types and risk factors for reoperation within 2 years of primary anterior cruciate ligament reconstruction (ACLR).

METHODS

Our clinic registry was used to identify primary ACLRs, performed from 2005 to 2015, and reoperations performed on the ipsilateral knee within 2 years at our institution. Reoperations were identified using procedural codes and analysis of medical records. A logistic regression analysis was used to evaluate risk factors for reoperation.

RESULTS

A total of 6030 primary ACLRs were included. A total of 1112 (18.4%) reoperations performed on 1018 (16.9%) primary ACLRs were identified. The most common reoperations were screw removal (n = 282, 4.7%), meniscus procedures (n = 238, 3.9%), cyclops removal/notchplasty (n = 222, 3.7%) and reoperations due to graft rupture (n = 146, 2.4%), including revision ACLR. Age < 30 years (OR 1.57; 95% CI 1.37-1.80; P < 0.001), female gender (OR 1.33; 95% CI 1.17-1.51; P < 0.001), medial meniscus repair (OR 1.55; 95% CI 1.23-1.97; P < 0.001), lateral meniscus resection (OR 1.26; 95% CI 1.07-1.49; P = 0.005) and lateral meniscus repair (OR 1.38; 95% CI 1.03-1.85; P = 0.02) at primary ACLR were found to be risk factors for reoperation.

CONCLUSION

One sixth of all primary ACLRs underwent reoperation due to complications or new injuries within 2 years. The most common reoperations were screw removal, meniscus procedures, cyclops removal/notchplasty and reoperations due to graft rupture, including revision ACLR. Younger age (< 30 years), female gender, medial meniscus repair and lateral meniscus resection or repair at primary ACLR were associated with an increased risk of reoperation. This study provides clinicians with important data to inform patients about the short-term reoperation rates, the most common reoperation procedures and risk factors for reoperation after primary ACLR.

LEVEL OF EVIDENCE

III.

Performance and Return to Sport After Anterior Cruciate Ligament Reconstruction in Professional Baseball Players

Background:

Anterior cruciate ligament reconstruction (ACLR) is the gold standard treatment for ACL tears to allow baseball players to return to sport (RTS). The optimal graft type and femoral tunnel drilling technique are currently unknown.

Hypothesis:

There is a high rate of RTS in professional baseball players after ACLR, with no significant difference in RTS rates or performance between cases and controls or between graft types or femoral drilling techniques.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

All professional baseball players who underwent ACLR between 2010 and 2015 were included. Demographic and performance data (pre- and postoperative) for each player were recorded. Performance metrics were then compared between cases and matched controls.

Results:

A total of 124 players (mean age, 23.7 ± 4.1 years; 83% minor league players) underwent ACLR. Of these, 80% returned to sport (73% to the same or higher level) at a mean 310 ± 109 days overall and 333 ± 126 days at the same or higher level. The most common graft type was an ipsilateral bone–patellar tendon–bone (BTB) autograft (n = 87; 70%). A total of 91 players underwent concomitant meniscal debridement or repair. No significant difference in any of the primary performance metrics existed from before to after ACLR. Compared with matched controls, no significant difference existed in RTS rates or any performance metrics after ACLR. No significant difference existed in RTS rates or primary performance outcome measures between graft types or femoral drilling techniques.

Conclusion:

The RTS rate for professional baseball players after ACLR was 80%. No significant difference in performance metrics existed between BTB and hamstring autografts or between femoral drilling techniques. Furthermore, no significant difference in performance or RTS rates existed between cases and matched controls. Femoral drilling technique and graft type did not affect performance and RTS rates in professional baseball players after ACLR.

Anterior Cruciate Ligament Repair Outcomes: An Updated Systematic Review of Recent Literature

PURPOSE

To critically review recent literature on outcomes following primary surgical repair of the anterior cruciate ligament (ACL).

METHODS

In December 2018, a search of the MEDLINE database was conducted for English language articles reporting clinical outcomes of ACL repair from 2003 to 2018. Included studies were evaluated for patient demographics, patient-reported outcome measures, return to sports/work, patient satisfaction, and postoperative complications. Subgroup analysis was conducted for studies that included patients with only type 1/proximal ACL ruptures.

RESULTS

Twenty-eight studies satisfied the inclusion criteria, comprising 2,401 patients (52.3% male, 35.7% female, 12.0% unspecified gender) with mean age ranging from 6.0 to 43.3 years. Most studies were conducted in Europe (82.1%), were level of evidence IV (60.7%), and were designed as case series (57.1%). Fourteen investigations (50.0%) used primary suture repair and 14 (50.0%) used dynamic intraligamentary stabilization. Preoperative ranges for Lysholm, International Knee Documentation Committee Score subjective, and Tegner scores were 28 to 100, 94.1 to 100, and 2 to 9, respectively. Postoperative ranges for the same measures were 80 to 100, 54.3 to 98, and 3.67 to 7, respectively. Time to return to sport/work ranged from 3.1 ± 3.3 to 17.4 ± 1.5 weeks. Frequency of rerupture, revision ACL surgery, and overall reoperations were as high as 23.1%, 33.3%, and 51.5%, respectively. Overall ACL repair survivorship ranged from 60.0% to 100.0%. In subgroup analysis for proximal ruptures treated with repair, the rates of revision ACL reconstruction (ACLR) and total reoperations were as high as 12.9% and 18.2%, respectively.

CONCLUSIONS

Based on our cumulative findings across 2,401 patients from the 28 included studies, it appears that ACLR results in better survivorship and patient-perceived postoperative improvement when compared with ACL repair. At present, ACLR appears to remain the superior treatment strategy in the vast majority of cases.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II to IV studies.