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Cordasco FA, Hidalgo Perea S, Uppstrom TJ, Chipman DE, Pascual-Leone N, Aitchison AH, Lijesen E, Ann Asaro L, Green DW. Quadriceps Tendon Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: 3-Year Clinical and Patient-Reported Outcomes. Am J Sports Med 2024:3635465241255641. [PMID: 38877730 DOI: 10.1177/03635465241255641] [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: 06/16/2024]
Abstract
BACKGROUND The rate of anterior cruciate ligament (ACL) rupture in active, skeletally immature patients is increasing. Although hamstring tendon autograft (HTA) was previously deemed the gold standard, recent studies have shown HTA to have a high failure rate in this high-risk population of young competitive athletes, and quadriceps tendon autograft (QTA) has yielded excellent preliminary outcomes in some studies examining this population. PURPOSE To evaluate 3-year clinical and patient-reported functional outcomes of primary ACL reconstruction (ACLR) with soft tissue QTA in skeletally immature patients. STUDY DESIGN Case series; Level of evidence, 4. METHODS Skeletally immature patients who underwent ACLR with a full-thickness soft tissue QTA were included. Preoperative patient and surgical data were collected. The ACLR technique was selected predicated upon skeletal age and included all-epiphyseal and complete transphyseal techniques. Patients were followed for a minimum of 2 years with successive clinical visits or were contacted via telephone. Patients who did not have minimum 2-year follow-up after 3 contact attempts via telephone were excluded. Information regarding return to sports (RTS) and concomitant or subsequent surgical procedures was collected. Pediatric International Knee Documentation Committee (Pedi-IKDC), Hospital for Special Surgery Functional Activity Brief Scale (HSS Pedi-FABS), and Single Assessment Numeric Evaluation (SANE) scores were collected. RESULTS Of 85 adolescent patients aged 11.1 to 17.6 years (mean age, 14.1 ± 1.2 years), 2 patients were determined to be lost to follow-up after 3 failed contact attempts. Of the patients included in this study (N = 83), 26 patients (31%) underwent all-epiphyseal and 57 patients (69%) underwent complete transphyseal ACLR. Additionally, 48 patients (58%) underwent concomitant lateral extra-articular tenodesis using the iliotibial band with a modified Lemaire technique. The mean follow-up time was 3.7 ± 1.2 years (range, 2-7 years). Twenty (24%) patients had subsequent surgical procedures, of which 3 (4%) were due to graft failures. At a mean 3-year follow-up, the mean Pedi-IKDC, HSS Pedi-FABS, and SANE scores were 90, 23, and 94 respectively; the RTS rate was 100%; and the rate of RTS at the previous level of performance was 93%. CONCLUSION Use of a soft tissue QTA for ALCR in a high-risk skeletally immature population of athletes resulted in excellent postoperative outcomes with low rates of graft failure and high return to sport rates.
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Affiliation(s)
- Frank A Cordasco
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Sofia Hidalgo Perea
- Pediatric Orthopedic Surgery Service, Hospital for Special Surgery, New York, New York, USA
| | - Tyler J Uppstrom
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Danielle E Chipman
- Pediatric Orthopedic Surgery Service, Hospital for Special Surgery, New York, New York, USA
| | - Nicolas Pascual-Leone
- Pediatric Orthopedic Surgery Service, Hospital for Special Surgery, New York, New York, USA
| | | | - Emilie Lijesen
- Pediatric Orthopedic Surgery Service, Hospital for Special Surgery, New York, New York, USA
| | - Lori Ann Asaro
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Daniel W Green
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Pediatric Orthopedic Surgery Service, Hospital for Special Surgery, New York, New York, 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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Hidalgo Perea S, Chipman DE, Cordasco FA, Lin KM, Gorelick D, Asaro LA, Green DW. Association of Quadriceps Tendon Harvest for ACL Reconstruction With Development of Osteochondritis Dissecans of the Patella in Pediatric Patients. Orthop J Sports Med 2024; 12:23259671231219712. [PMID: 38379578 PMCID: PMC10878225 DOI: 10.1177/23259671231219712] [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: 07/06/2023] [Accepted: 07/31/2023] [Indexed: 02/22/2024] Open
Abstract
Background There are various reported complications after primary anterior cruciate ligament reconstruction (ACLR) necessitating additional surgery in skeletally immature patients, regardless of technique and autograft type. Purpose To analyze the rate and type of complications encountered with soft tissue quadriceps tendon autograft (QTA) for ACLR in patients ≤18 years as well as the overall rate of second surgery, unrelated to the use of the QTA. Study Design Case series; Level of evidence, 4. Methods A total of 141 patients ≤18 years who underwent ACLR with a QTA and had minimum 6-month follow-up were included. All patients underwent ACLR by utilizing a full-thickness soft tissue QTA. Complications associated with the QTA harvest site and use of QTA were reported. Results The mean age of the included cohort (84 men, 57 women) was 14.8 ± 1.6 years. The average follow-up was of 2.0 ± 1.2 years. A total of 30 (21%) patients had a subsequent complication that required surgical intervention; in 11 (8%) patients, the complication was specifically associated with the use of a QTA, whereas in 19 (13%) patients, the complication was related to the ACLR. In addition, 13 (9%) patients underwent a contralateral ACLR procedure. Of the QTA-related complications, 2 patients developed osteochondritis dissecans (OCD)-like lesions in the superior aspect of the patella, 2 patients had injured their quadriceps extensor mechanism and required surgical repair, and 8 patients had a subsequent procedure to remove nonabsorbable sutures used for donor site quadriceps tendon closure. One of the patients who underwent the removal of nonabsorbable sutures also had an arthroscopic debridement of patellar chondral damage. Conclusion We reported complications encountered with soft tissue QTA for ACLR. The complication rate for QTA harvest was 8%. However, given that the removal of nonabsorbable sutures from the donor site was caused by the surgical technique used, the revised nonsuture-related complication rate for QTA graft harvest was 2%. Although the use of a QTA has recently gained popularity due to its high return-to-sport and low graft-failure rates, surgeons should be aware of the complications associated with using this graft type.
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Affiliation(s)
- Sofia Hidalgo Perea
- Pediatric Orthopaedic Service, Hospital for Special Surgery, New York, New York, USA
- Renaissance School of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Danielle E. Chipman
- Pediatric Orthopaedic Service, Hospital for Special Surgery, New York, New York, USA
| | - Frank A. Cordasco
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Kenneth M. Lin
- Department of Sports Medicine, Stanford University Hospital, Palo Alto, California, USA
| | - Danielle Gorelick
- Pediatric Orthopaedic Service, Hospital for Special Surgery, New York, New York, USA
| | - Lori A. Asaro
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Daniel W. Green
- Pediatric Orthopaedic Service, Hospital for Special Surgery, New York, New York, USA
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Doxey SA, Kleinsmith RM, Huyke-Hernández FA, Schweitzer A, Only AJ, Tompkins M, Kweon CY, Cunningham BP. Improved Patient-reported Outcomes in Patients Aged 16 and Younger at Two Years After Anterior Cruciate Ligament Reconstruction Despite Relatively High Rates of Reinjury and Repeat Surgery. J Pediatr Orthop 2024; 44:106-111. [PMID: 38031490 DOI: 10.1097/bpo.0000000000002567] [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: 12/01/2023]
Abstract
BACKGROUND Anterior cruciate ligament reconstruction (ACLR) in adolescent patients, particularly those aged 16 and under, are increasingly common procedure that lacks robust clinical and patient-reported outcome (PRO) data. The purpose of this study was to report 2-year PROs of patients receiving ACLR aged 16 or younger using the single assessment numerical evaluation (SANE) and knee injury and osteoarthritis outcome score (KOOS). Secondary aims included characterizing treatment characteristics, return to sport (RTS), and clinical outcomes. METHODS The institutional PRO database was queried for patients receiving ACLR from 2009 to 2020. Patients aged older than 16, revision procedures, concomitant ligament repairs/reconstructions, and patients without full outcome data at 2 years were excluded. Outcomes over 2 years after ACLR included SANE, KOOS, reinjuries, reoperations, and time to RTS. RESULTS A total of 98 patients were included with an average age of 15.0 years. Most patients were females (77.6%). Bone-tendon-bone autograft (69.4%) was the most used. Average RTS was 8.7 months (range: 4.8 to 24.0 mo), with 90% of patients eventually returning to sport. A total of 23 patients (23.5%) experienced a reinjury and 24.5% (n = 24) underwent reoperation. Timing to RTS was not associated with reinjury, but patients who returned between 9.5 and 13.7 months did not sustain reinjuries. Mean KOOS and SANE scores at 2 years were 87.1 and 89.1, respectively, with an average improvement of +18.4 and +22.9, respectively. Change in KOOS was negatively impacted by reinjury to the anterior cruciate ligament graft and reoperation (anterior cruciate ligament failure: +10.0 vs 19.3, P = 0.081, respectively; reoperation: +13.2 vs +20.1, P = 0.051, respectively), though these did not reach statistical significance. CONCLUSION Patients experienced improved SANE and KOOS scores after ACLR. Rates of reinjury and reoperation were relatively high and negatively impacted PRO scores but were not associated with the timing of RTS. Adolescent patients should be counseled regarding the risk of subsequent ipsilateral and contralateral knee injury after ACLR. LEVEL OF EVIDENCE Level IV-case series.
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Affiliation(s)
- Stephen A Doxey
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington
| | - Rebekah M Kleinsmith
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington
| | - Fernando A Huyke-Hernández
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington
| | - Adam Schweitzer
- Department of Orthopaedic Surgery, Des Moines University College of Osteopathic Medicine, Des Moines, IA
| | - Arthur J Only
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN
| | - Marc Tompkins
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington
| | | | - Brian P Cunningham
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington
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Retzky JS, Chipman DE, Mintz DN, Cordasco FA, Green DW. Association of Lateral Extra-Articular Tenodesis With Improved Graft Maturity on MRI 2 Years After ACL Reconstruction With Quadriceps Tendon Autograft in Skeletally Immature Athletes. Orthop J Sports Med 2024; 12:23259671231211885. [PMID: 38188621 PMCID: PMC10768604 DOI: 10.1177/23259671231211885] [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: 06/01/2023] [Accepted: 06/20/2023] [Indexed: 01/09/2024] Open
Abstract
Background Quadriceps tendon autograft (QTA) has recently gained popularity in the treatment of anterior cruciate ligament (ACL) ruptures in pediatric patients. The addition of lateral extra-articular tenodesis (LET) to an ACL reconstruction (ACLR) has been found to reduce the risk of ACL retear in high-risk patients. Purpose To (1) compare ACL graft maturity using signal intensity ratios (SIRs) on magnetic resonance imaging (MRI) scans in skeletally immature patients undergoing ACLR with QTA either with or without concomitant LET and (2) evaluate LET safety by calculating the physeal disturbance-related reoperation rate in the ACLR+LET group. Study Design Cohort study; Level of evidence, 3. Methods The records of patients aged ≤18 years who underwent ACLR between 2015 and 2021 were reviewed retrospectively. Patients undergoing ACLR with QTA who had open distal femoral and proximal tibial physes on MRI scans and a minimum 2-year follow-up data were included. SIR values were measured on sagittal MRI scans by averaging the signal at 3 regions of interest along the ACL graft and dividing by the signal of the posterior cruciate ligament at its insertion. Statistical analysis was performed to evaluate differences in SIR values at 6 months, 1 year, and 2 years postoperatively in patients who underwent ACLR alone versus ACLR+LET. Results Overall, 29 patients were included in the study: 16 patients in the ACLR+LET group and 13 patients in the ACLR-only group. There were no significant differences in SIR values between groups at the 6-month or 1-year postoperative timepoints. At 2 years postoperatively, the median SIR of the ACLR+LET group was significantly lower than that of the ACLR-only group on both univariate (1.33 vs 1.86, respectively, P = .0012) and multivariate regression analyses adjusting for both sex and surgical technique (β = -0.49 [95% CI, -0.91 to -0.05]; P = .029). There were no cases of reoperation for physeal disturbance in patients who underwent ACLR+LET. Conclusion The addition of LET to an ACLR with QTA was associated with lower average SIR values and thus improved graft maturity at 2 years postoperatively compared with ACLR alone in skeletally immature patients. The addition of LET to an ACLR was found to be safe in skeletally immature patients.
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Sun B, Vivekanantha P, Khalik HA, Slawaska-Eng D, Kay J, Johnson J, de Sa D. Approximately half of pediatric or adolescent patients undergoing revision anterior cruciate ligament reconstruction return to the same level of sport or higher: A systematic review. Knee Surg Sports Traumatol Arthrosc 2024; 32:181-195. [PMID: 38226741 DOI: 10.1002/ksa.12030] [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: 10/05/2023] [Revised: 11/09/2023] [Accepted: 12/05/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE To summarise the surgical techniques and clinical outcomes in paediatric and adolescent patients undergoing revision anterior cruciate ligament reconstruction (r-ACLR). METHODS Three databases (MEDLINE, PubMed and EMBASE) were searched from inception to 29 July 2023. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, surgical details, patient-reported outcome measures (PROMs), rates of instability, rupture and return to sport (RTS) were extracted. RESULTS Eight studies comprising 706 (711 knees) patients were included (48.7% female). The mean age at r-ACLR was 17.1 years (range: 16.5-18.0). Autografts (67.5%) were more common than allografts (32.2%) in revision, with bone-patellar tendon-bone (BPTB) being the most prevalent autograft source (59.6%). Bone grafts were used in seven patients (4.8% of 146 patients). The most common femoral and tibial fixation techniques were interference screws (37.6% and 38.1%, of 244 patients, respectively). The most common tunnelling strategy was anatomic (69.1% of 236 patients), and meniscus repairs were performed in 39.7% of 256 patients. The re-rupture rate was 13.0% in 293 patients. RTS at the same level or higher was 51.6% in 219 patients. The mean (SD) Lysholm score was 88.1 (12.9) in 78 patients, the mean (SD) Tegner score was 6.0 (1.6) in 78 patients, and the mean (SD) IKDC score was 82.6 (16.0) in 126 patients. CONCLUSION R-ACLR in paediatric and adolescent patients predominantly uses BPTB autografts and interference screw femoral and tibial fixation with concomitant meniscal procedures. Rates of re-rupture and RTS at the same level or higher were 13.0% and 51.6%, respectively. Information from this review can provide orthopaedic surgeons with a comprehensive understanding of the most commonly used operative techniques and their outcomes for revision ACLR in this population. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Bryan Sun
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Prushoth Vivekanantha
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Hassaan A Khalik
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - David Slawaska-Eng
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey Kay
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Jansen Johnson
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Khurana K, Pisulkar G. Functional Rehabilitation of Anterior Cruciate Ligament Tear in the Pediatric Population: A Comprehensive Review. Cureus 2023; 15:e49863. [PMID: 38170114 PMCID: PMC10759723 DOI: 10.7759/cureus.49863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 12/03/2023] [Indexed: 01/05/2024] Open
Abstract
Pediatric sports injuries are a growing concern due to increased youth participation in sports. Effective rehabilitation strategies are essential for ensuring optimal recovery, restoring knee function, and preventing long-term consequences. This research aims to explore and evaluate various functional rehabilitation approaches tailored to pediatric anterior cruciate ligament (ACL) tear injuries. Functional rehabilitation of ACL tears in pediatric sports injuries is an important area of research due to the unique considerations and challenges that arise when treating ACL injuries in young athletes. Over the last 20 years, there has been a well-documented uptick in ACL injuries among pediatric populations. This rise can be attributed to the growing involvement of the younger population in competitive sports, as well as heightened awareness regarding sports-linked injuries. This study highlights the importance of early surgical reconstruction in children to enable a quick return to sports and prevent long-term cartilage and meniscal damage resulting from instability. The use of physeal-sparing ACL reconstruction techniques, particularly hamstring autografts, is recommended for favorable clinical outcomes while minimizing growth disturbances. This study offers valuable insights for healthcare professionals and researchers, serving as a reference to guide optimal approaches in managing pediatric ACL injuries and achieving successful results in this field.
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Affiliation(s)
- Khushi Khurana
- Orthopaedics and Rehabilitation, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Gajanan Pisulkar
- Orthopaedic Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Aldag L, Dallman J, Henkelman E, Herda A, Randall J, Tarakemeh A, Morey T, Vopat BG. Various Definitions of Failure Are Used in Studies of Patients Who Underwent Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2023; 5:100801. [PMID: 37766857 PMCID: PMC10520319 DOI: 10.1016/j.asmr.2023.100801] [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: 03/04/2023] [Accepted: 08/10/2023] [Indexed: 09/29/2023] Open
Abstract
Purpose To conduct a literature review to assess the definitions of anterior cruciate ligament reconstruction (ACLR) failure used throughout the orthopaedic literature. Methods A systematic search of Embase, Ovid Medline, SPORTDiscus, and Web of Science was conducted by a university librarian to identity level I-IV clinical studies on ACLR failure. Inclusion criteria consisted of patients who underwent ACLR and included a definition of failure of ACLR. Patients who underwent anterior cruciate ligament (ACL) repairs, animal/cadaver studies, review studies, non-English language articles, and non-full text articles were excluded. Failure data were extracted from each study and categorized. Other data that were extracted included follow-up time after ACLR, failure reoperation rate, and failure reoperation procedure. Descriptive statistics was used to analyze the data. Results Out of 2,775 studies, 104 (3.75%) met inclusion criteria and were analyzed in this review. The most common definition of ACLR failure included the use of a physical examination, specifically Lachman's test (21/104 [20.2%]), anterior laxity assessment, or a Pivot-Shift test (24/104 [35.2%]) or undergoing or requiring revision ACLR (39/104 [37.5%]). Although some studies used quantitative tests or imaging to help define "failure," others simply defined it as graft rerupture that was otherwise not defined (22/104 [22.5%]). Other common definitions included: the use of imaging (magnetic resonance imaging/radiographs) to confirm graft re-rupture (37/104 [35.6%]), patient-reported outcomes (recurrent instability)/patient reported outcomes measures (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Tegner) (18/104 [17.3%]), and the use of an arthrometer (KT-1000/2000, Rollimeter, or Kneelax) (17/104 [16.3%]). The least common definitions included graft failure or rerupture confirmed by arthroscopy (13/104 [12.5%]) and nonrevision surgery (2/104 [1.0%]). The failure rate of this procedure ranged from 0% to 100% depending on the definition of "failure." Conclusion In this study, we found that a variety of definitions of failure are used among studies published in the orthopaedic literature. The most common criteria for failure of ACLR were the results of physical examination tests (35%), the need for undergoing a revision ACLR (36%), and the use of imaging to diagnose the failure (34%). About 17% of studies included in this review used patient-reported outcomes, specifically recurrent instability, or PROMs (IKDC, KOOS, Tegner) in their assessment of failure of ACLR. The least used definitions of "failure" of ACLR included nonrevision ACLR surgery (2%). Although some studies used similar tests or categories in their definition of failure, there were a variety of score and grade cutoff points between them. Level of Evidence Level IV, systematic review of Level II-IV studies.
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Affiliation(s)
- Levi Aldag
- Department of Orthopaedic Surgery and Sports Medicine, the University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Johnathan Dallman
- Department of Orthopaedic Surgery and Sports Medicine, the University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Erik Henkelman
- Department of Orthopaedic Surgery and Sports Medicine, the University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Ashley Herda
- Department of Health, Sport, and Exercise Sciences, University of Kansas, Lawrence, Kansas, U.S.A
| | - Jeffrey Randall
- Department of Orthopaedic Surgery and Sports Medicine, the University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Armin Tarakemeh
- Department of Orthopaedic Surgery and Sports Medicine, the University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Tucker Morey
- Department of Orthopaedic Surgery and Sports Medicine, the University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Bryan G. Vopat
- Department of Orthopaedic Surgery and Sports Medicine, the University of Kansas Health System, Kansas City, Kansas, U.S.A
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Kay J, Liotta ES, Sugimoto D, Heyworth BE. Assessment of Return to Sport After ACL Reconstruction With Soft Tissue Autograft in Adolescent Athletes: Quadriceps Versus Hamstring Tendon. Orthop J Sports Med 2023; 11:23259671231207113. [PMID: 38021299 PMCID: PMC10676070 DOI: 10.1177/23259671231207113] [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: 04/18/2023] [Accepted: 05/19/2023] [Indexed: 12/01/2023] Open
Abstract
Background Quadriceps tendon soft tissue autograft represents an increasingly popular graft option for anterior cruciate ligament reconstruction (ACLR), particularly for adolescents, some of whom have an open physis, precluding use of graft options with bone plugs. Purpose/Hypothesis The purpose of this study was to quantify return-to-sport performance assessments in adolescents at 6 months after ACLR with all-soft tissue quadriceps tendon autograft (ACLR-Q) versus hamstring tendon autograft (ACLR-HS). It was hypothesized that ACLR-Q would be associated with improved hamstring strength and hamstring-to-quadriceps (HS:Q) ratios compared with ACLR-HS, albeit with decreased quadriceps strength. Study Design Cross-sectional study; Level of evidence, 3. Methods Included were patients aged 12 to 19 years who underwent primary ACLR by a single surgeon and who completed a return-to-sport performance assessment between 5 and 9 months postoperatively. The performance assessment included manual muscle strength tests (hamstring, quadriceps, hip abductor and adductor), dynamic balance test (Y-balance), and functional hop tests (single hop, triple hop, crossover hop, 6-m timed hop). Data were converted to limb symmetry indices, and limb symmetry index deficits were compared between the ACLR-Q and ACLR-HS cohorts using the Student t test or Wilcoxon-Mann-Whitney test. Results An initial cohort of 90 ACLR-Q patients was compared with 54 ACLR-HS patients, with no significant differences in patient characteristics. Differences in meniscal repair rates, however, prompted use of propensity score matching on age, sex, body mass index, meniscectomy, and meniscal repair to produce comparable subcohorts. The matching resulted in 67 ACLR-Q and 52 ACLR-HS patients. Hamstring strength deficits were significantly greater in ACLR-HS versus ACLR-Q patients (-40.5% vs -5.7%; P < .001). Quadriceps strength deficits were significantly greater in ACLR-Q versus ACLR-HS patients (-12.8% vs -0.4%; P < .001). ACLR-Q patients had a significantly greater HS:Q ratio on the operative knee (P < .001) and significantly higher Y-balance composite score deficits (-2.9% vs -0.4%; P = .01) than ACLR-HS patients. There were no significant differences in hop test performance between groups. Conclusion Adolescent athletes who underwent ACLR-Q showed significantly greater quadriceps strength deficits but significantly smaller hamstring strength deficits than those who underwent ACLR-HS, leading to more favorable HS:Q ratios in ACLR-Q patients at 6 months postoperatively.
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Affiliation(s)
- Jeffrey Kay
- Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
- Division of Sports Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Elizabeth S. Liotta
- Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Dai Sugimoto
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, USA
- Faculty of Sport Sciences, Waseda University, Tokyo, Japan
| | - Benton E. Heyworth
- Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
- Division of Sports Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Pauw AHJ, Buck TMF, Gokeler A, Tak IJR. Reconsideration of Return-to-Sport Decision-Making After Pediatric ACL Injury: A Scoping Review. Sports Health 2023; 15:898-907. [PMID: 36715226 PMCID: PMC10606966 DOI: 10.1177/19417381221146538] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
CONTEXT Up to 90% of pediatric athletes return to sport (RTS) after anterior cruciate ligament reconstruction (ACL-R); however, <50% RTS at the same level and second ACL injury rates are up to 32%. OBJECTIVES (1) Determine which physical and patient-reported outcome measures guide clinical decision-making on RTS in pediatric athletes after ACL-R and (2) present a framework with insights from cognitive and neurophysiological domains to enhance rehabilitation outcomes. DATA SOURCES PubMed, CINAHL, Embrase, and Cochrane library databases and gray literature. STUDY SELECTION Data on pediatric (<18 years) ACL-R patients, RTS, tests, and decision-making were reported in 1214 studies. Two authors independently reviewed titles and abstract, excluding 962 studies. Gray literature and cross-reference checking resulted in 7 extra studies for full-text screening of 259 studies. Final data extraction was from 63 eligible studies. STUDY DESIGN Scoping review. LEVEL OF EVIDENCE Level 4. DATA EXTRACTION Details on study population, aims, methodology, intervention, outcome measures, and important results were collected in a data chart. RESULTS Studies included 4456 patients (mean age, 14 years). Quadriceps and hamstring strength (n = 25), knee ligament arthrometer (n = 24), and hop tests (n = 22) were the most-reported physical outcome measures guiding RTS in <30% of studies with cutoff scores of limb symmetry index (LSI) ≥85% or arthrometer difference <3 mm. There were 19 different patient-reported outcome measures, most often reporting the International Knee Documentation Committee (IKDC) (n = 24), Lysholm (n = 23), and Tegner (n = 15) scales. Only for the IKDC was a cutoff value of 85% reported. CONCLUSION RTS clearance in pediatric ACL-R patients is not based on clear criteria. If RTS tests were performed, outcomes did not influence time of RTS. Postoperative LSI thresholds likely overestimate knee function since biomechanics are impaired despite achieving RTS criteria. RTS should be considered a continuum, and biomechanical parameters and contextual rehab should be pursued with attention to the individual, task, and environment. There is a need for psychological monitoring of the ACL-R pediatric population.
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Affiliation(s)
| | - Tristan Marcel Frank Buck
- Amsterdam Collaboration on Health and Safety in Sports, Department of Public and Occupational Health, Amsterdam Movement Sciences, VU University Medical Centre, Amsterdam, the Netherlands
| | - Alli Gokeler
- Amsterdam Collaboration on Health and Safety in Sports, Department of Public and Occupational Health, Amsterdam Movement Sciences, VU University Medical Centre, Amsterdam, the Netherlands
- Amsterdam University of Applied Sciences, Faculty of Health, Amsterdam, the Netherlands
| | - Igor Joeri Ramon Tak
- Amsterdam Collaboration on Health and Safety in Sports, Department of Public and Occupational Health, Amsterdam Movement Sciences, VU University Medical Centre, Amsterdam, the Netherlands
- Fysiotherapie Utrecht Oost, Utrecht, the Netherlands
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11
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Verhagen S, Dietvorst M, Delvaux E, van der Steen MC, Janssen R. Clinical outcomes of different autografts used for all-epiphyseal, partial epiphyseal or transphyseal anterior cruciate ligament reconstruction in skeletally immature patients - a systematic review. BMC Musculoskelet Disord 2023; 24:630. [PMID: 37537529 PMCID: PMC10401849 DOI: 10.1186/s12891-023-06749-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 07/24/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Different types of grafts can be used for anterior cruciate ligament reconstruction (ACLR). There is little published data regarding skeletally immature patients. The purpose of this systematic review was to assess the clinical outcomes and complications for different autograft types used in all-epiphyseal, transphyseal and partial epiphyseal/hybrid ACLR in skeletally immature children and adolescents. METHODS PubMed, Embase and Cochrane databases were systematically searched for literature regarding ACLR using hamstrings, quadriceps or bone-patellar-tendon-bone (BPTB) autografts in skeletally immature patients. Studies were included if they examined at least one of the following outcomes: graft failure, return to sport(s), growth disturbance, arthrofibrosis or patient reported outcomes and had a minimum follow-up of 1 year. Case reports, conference abstracts and studies examining allografts and extra-articular or over-the-top ACL reconstruction techniques were excluded. Graft failure rates were pooled for each graft type using the quality effects model of MetaXL. A qualitative synthesis of secondary outcomes was performed. RESULTS The database search identified 242 studies. In total 31 studies were included in this review, comprising of 1358 patients. Most patients (81%) were treated using hamstring autograft. The most common used surgical technique was transphyseal. The weighted, pooled failure rate for each graft type was 12% for hamstring tendon autografts, 8% for quadriceps tendon autografts and 6% for BPTB autografts. Confidence intervals were overlapping. The variability in time to graft failure was high. The qualitative analysis of the secondary outcomes showed similar results with good clinical outcomes and low complication rates across all graft types. CONCLUSIONS Based on this review it is not possible to determine a superior graft type for ACLR in skeletally immature. Of the included studies, the most common graft type used was the hamstring tendon. Overall, graft failure rates are low, and most studies show good clinical outcomes with high return to sports rates.
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Affiliation(s)
- S Verhagen
- Department of Orthopaedic Surgery & Trauma, PO box, Máxima, Eindhoven, 5600 PD, MC, The Netherlands.
| | - M Dietvorst
- Department of Orthopaedic Surgery & Trauma, PO box, Máxima, Eindhoven, 5600 PD, MC, The Netherlands
| | - Ejlg Delvaux
- MMC Academy, Máxima, Veldhoven, MC, The Netherlands
| | - M C van der Steen
- Department of Orthopaedic Surgery & Trauma, PO box, Máxima, Eindhoven, 5600 PD, MC, The Netherlands
- Department of Orthopaedic Surgery & Trauma, Catharina Hospital Eindhoven, PO box 1350, Eindhoven, 5602 ZA, The Netherlands
| | - Rpa Janssen
- Department of Orthopaedic Surgery & Trauma, PO box, Máxima, Eindhoven, 5600 PD, MC, The Netherlands
- Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Chair Value‑Based Health Care, Department of Paramedical Sciences, Fontys University of Applied Sciences, Eindhoven, The Netherlands
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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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13
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Romanchuk NJ, Livock H, Lukas KJ, Del Bel MJ, Benoit DL, Carsen S. Criteria Used to Determine Unrestricted Return to Activity After ACL Reconstruction in Pediatric and Adolescent Patients: A Systematic Review. Orthop J Sports Med 2023; 11:23259671231154540. [PMID: 36909673 PMCID: PMC9996745 DOI: 10.1177/23259671231154540] [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: 09/22/2022] [Accepted: 10/11/2022] [Indexed: 03/14/2023] Open
Abstract
Background The rates of anterior cruciate ligament (ACL) graft failure or contralateral ACL rupture range from 17% to 30% in pediatric patients after ACL reconstruction (ACLR). A contributing factor to the high reinjury rate in this population may be the limited evidence regarding appropriate criteria for allowing unrestricted return to activity (RTA) postoperatively. Purpose To review the literature and identify the most commonly used criteria when determining unrestricted RTA after ACLR in pediatric patients. Study Design Systematic review; Level of evidence, 4. Methods A search was performed of the Medline/PubMed, Cochrane Central Register of Controlled Trials, Embase, CINAHL, and SPORTDiscus databases using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The authors identified studies that included pediatric patients (<19 years of age) and specified the criteria used to determine RTA after ACLR. Results A total of 27 articles met all criteria for review, of which 13 studies only used 1 criterion when determining RTA. Objective criteria were the most common type of criteria for RTA (17 studies). Strength tests (15 studies) and hop tests (10 studies) were the most commonly used tasks when deriving RTA criteria. Only 2 studies used validated questionnaires to assess the patient's physiological readiness for RTA, and only 2 studies used an objective assessment of movement quality before RTA. Conclusion Only 14 of the 27 reviewed studies reported using >1 criterion when determining RTA. Furthermore, few studies used patient-reported outcome measures or lower limb kinematics as RTA criteria, indicating that more research is needed to validate these metrics in the pediatric population.
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Affiliation(s)
- Nicholas J Romanchuk
- Biomedical Engineering Program, Faculty of Engineering, University of Ottawa, Ottawa, Ontario, Canada
| | - Holly Livock
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Kenneth J Lukas
- Division of Orthopaedic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael J Del Bel
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel L Benoit
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Sasha Carsen
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,Division of Orthopaedic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Singh H, Glassman I, Sheean A, Hoshino Y, Nagai K, de Sa D. Less than 1% risk of donor-site quadriceps tendon rupture post-ACL reconstruction with quadriceps tendon autograft: a systematic review. Knee Surg Sports Traumatol Arthrosc 2023; 31:572-585. [PMID: 36255474 DOI: 10.1007/s00167-022-07175-0] [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: 06/21/2022] [Accepted: 09/15/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE The purpose of this study is to develop a comprehensive complications profile for quadriceps tendon-autograft anterior cruciate ligament reconstruction (QT ACL-R). METHODS A traditional and grey literature search was conducted in accordance with PRISMA and R-AMSTAR guidelines. PubMed, EMBASE, MEDLINE, CINAHL, Cochrane, Web of Science, and many grey literature sources were searched from inception to May 29, 2022. All studies were searched and screened in duplicate with included studies being of all levels of evidence, reporting complications, and with patients of all ages undergoing primary ACL reconstruction with quadriceps tendon autograft in the last 15 years. Studies were excluded if they had cadaveric or animal subjects or were reviews. Risk of bias assessment was conducted using MINORS criteria for non-randomised studies and Cochrane's RoB 2.0 for randomised studies. Data were summarised with weighted event rates generated under a random-effects model. RESULTS A total of 55 studies (5315 reconstructions) were included: 32 used quadriceps tendon with bone block (B-QT), 19 used all-soft tissue quadriceps tendon (S-QT), and four did not report the QT graft subtype used. Included patients had an age range of 6.2-58 years and an average reported follow-up time of 28.1 months (range, 6-90 months) for non-randomised studies and 34.3 months (range, 0.233-120 months) for randomised studies. Pooled incidence rates for clinically relevant major complications included contralateral ACL injury at 6.0%, postoperative meniscal issues at 5.4%, cyclops lesions at 4.8%, graft failure at 4.1%, patellar fracture at 2.2%, hardware removal at 1.7%, infection at 1.5%, and donor-site quadriceps tendon rupture at 0.7%. Pooled incidence rates for clinically relevant minor complications included anterior knee pain at 9.7%, kneeling pain at 9.5%, sensation deficits at 4.4%, loss of extension at 4.2%, donor-site tendinopathy at 3.9%, cosmetic issues at 1.8%, and hematoma at 1.5%. CONCLUSIONS QT ACL-R resembles other graft types in its rates and types of postoperative complications. In this exploratory systematic review, no complications of QT ACL-R were found to be disproportionately represented in the literature. This graft type should remain an option with comparable complication rates to other graft choices. LEVEL OF EVIDENCE Level IV. REGISTRATION This study was preregistered under PROSPERO with preregistration code CRD42022302078.
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Affiliation(s)
- Harasees Singh
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Isaac Glassman
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Andrew Sheean
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kanto Nagai
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, Hamilton, ON, Canada.
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Petersen W, Bierke S, Stöhr A, Stoffels T, Häner M. A systematic review of transphyseal ACL reconstruction in children and adolescents: comparing the transtibial and independent femoral tunnel drilling techniques. J Exp Orthop 2023; 10:7. [PMID: 36695820 PMCID: PMC9877258 DOI: 10.1186/s40634-023-00577-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/19/2023] [Indexed: 01/26/2023] Open
Abstract
PURPOSE Aim of this systematic review was to analyze the outcome after transphyseal ACL reconstruction in children and adolescents regarding the femoral drilling technique. METHODS A systematic literature search was carried out in various databases on studies on transphyseal ACL reconstruction in children and adolescents. The literature search was limited to the last 20 years. Primary outcome criterion was the failure rate. Secondary outcome criteria were growth disturbances such as leg length discrepancies or deformities and clinical scores. The present study was registered prospectively ( www.crd.york.ac.uk/PROSPERO ; CRD42022345964). RESULTS A total of 22 retrospective or prospective case series (level 4 evidence) were identified that reported on transphyseal ACL reconstruction in children and adolescents. The overall failure/rupture rate after transphyseal ACL reconstruction was 11.0%. The overall ACL rupture rate of the contralateral side was 9.7%. No statistical significant difference in the failure rates between independent and transtibial drilling techniques could be detected ((p = 0.76/p = 0.28)). Furthermore no statistical significant differences in the rate of reported growth disturbances between independent and transtibial drilling techniques were shown (p = 0.15). The reported clinical scores at follow-up (mean follow-up 5.05 years) revealed good to very good results. CONCLUSION This systematic review demonstrates that children and adolescents have a relatively high failure rate after transpyseal ACL reconstruction without any statistically significant differences between independent or transtibial drilling techniques regarding reruptur rates or the rate of growth disturbances. The results of this systematic review warrant a comparison of both techniques for femoral tunnel drilling in a controlled randomized trial.
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Affiliation(s)
- Wolf Petersen
- grid.461755.40000 0004 0581 3852Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus, Caspar Theyß Strasse 27-31, 14193 Berlin, Grunewald, Berlin Germany
| | - Sebastian Bierke
- grid.461755.40000 0004 0581 3852Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus, Caspar Theyß Strasse 27-31, 14193 Berlin, Grunewald, Berlin Germany
| | - Amelie Stöhr
- Orthopädische Chirurgie München, Munich, Germany
| | | | - Martin Häner
- grid.461755.40000 0004 0581 3852Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus, Caspar Theyß Strasse 27-31, 14193 Berlin, Grunewald, Berlin Germany
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16
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Tan TK, Subramaniam AG, Ebert JR, Radic R. Quadriceps Tendon Versus Hamstring Tendon Autografts for Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med 2022; 50:3974-3986. [PMID: 34470509 DOI: 10.1177/03635465211033995] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Autograft choice in anterior cruciate ligament reconstruction (ACLR) remains controversial, with increasing interest in the usage of quadriceps tendon (QT) autograft versus traditional hamstring tendon (HT) use. The current study undertakes an in-depth review and comparison of the clinical and functional outcomes of QT and HT autografts in ACLR. HYPOTHESIS The QT autograft is equivalent to the HT autograft and there will be little or no significant difference in the outcomes between these 2 autografts. STUDY DESIGN Systematic review and meta-analysis; Level of evidence, 4. METHODS The PUBMED, EMBASE, MEDLINE, and CENTRAL databases were systematically searched from their inception until November 2020. All observational studies comparing ACLR QT and HT autografts were assessed for their methodological quality. Patient outcomes were compared according to patient-reported outcome measures (International Knee Documentation Committee [IKDC], Cincinnati, Lysholm, Tegner, and visual analog scale [VAS] measures), knee extensor and flexor torque limb symmetry indices (LSIs), hamstring to quadriceps (H/Q) ratios, functional hop capacity, knee laxity, ipsilateral graft failure, and contralateral injury. RESULTS A total of 20 observational studies comprising 28,621 patients (QT = 2550; HT = 26,071) were included in the quantitative meta-analysis. In comparison with patients who received an HT autograft, those who received a QT autograft had similar postoperative Lysholm (mean difference [MD], 0.67; P = .630), IKDC (MD, 0.48; P = .480), VAS pain (MD, 0.04; P = .710), and Cincinnati (MD, -0.85; P = .660) scores; LSI for knee flexor strength (MD, 6.06; P = .120); H/Q ratio (MD, 3.22; P = .160); hop test LSI (MD, -1.62; P = .230); pivot-shift test grade 0 (odds ratio [OR], 0.80; P = .180); Lachman test grade 0 (OR, 2.38; P = .320), side-to-side laxity (MD, 0.09; P = .650); incidence of graft failure (OR, 1.07; P = .830) or contralateral knee injury (OR, 1.22; P = .610); and Tegner scores (MD, 0.11; P = .060). HT autografts were associated with a higher (better) side-to-side LSI for knee extensor strength (MD, -6.31; P = .0002). CONCLUSION In this meta-analysis, the use of the QT autograft was equivalent to the HT autograft in ACLR, with comparable graft failure and clinical and functional outcomes observed. However, HT autografts were associated with better LSI knee extensor strength.
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Affiliation(s)
- Tze Khiang Tan
- Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | | | - Jay R Ebert
- University of Western Australia, School of Human Sciences (Exercise and Sport Science), Perth, Western Australia, Australia
| | - Ross Radic
- Perth Orthopaedics and Sports Medicine Research Institute, West Perth, Western Australia, Australia
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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: 7] [Impact Index Per Article: 3.5] [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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Turati M, Caliandro M, Gaddi D, Piatti M, Rigamonti L, Zanchi N, Di Benedetto P, Boerci L, Catalano M, Zatti G, Ollivier M, Bigoni M. Clinical outcomes and complications after anterior cruciate ligament reconstruction with bone-patellar tendon-bone in patient Tanner 3 and 4: a systematic review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03402-z. [PMID: 36307618 PMCID: PMC10368545 DOI: 10.1007/s00590-022-03402-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 09/28/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Clinical outcomes and potential complications associated with Bone-Patellar Tendon-Bone (BPTB) graft in skeletally immature ACL reconstruction (ACLR) are poorly defined. Considering that in Tanner 1-2 patients this kind of graft is not recommended, we focused our systematic review on the evaluation of all the studies in the literature that reported clinical outcomes and rate of complications of the ACLR using BPTB graft in Tanner 3-4 patients. METHODS This review was conducted in accordance with the PRISMA statement. PubMed, Cochrane Library, EMBASE and Scopus were examined from 1965 to 2020 using different combinations of the following keywords: "ACL reconstruction", "skeletally immature", "young", "patellar tendon" and "BPTB". The database search yielded 742 studies, on which we performed a primary evaluation. After carrying out a full-text evaluation for the inclusion criteria, 4 studies were included in the final review and assessed using the Newcastle-Ottawa scale. Ninety-six cases with mean age of 14.2 years were reported. RESULTS Good stability and functional outcomes were reported with a mean follow-up of 49.5 months. Return to sport rate ranged from 91.7% to 100%. A KT-1000 side-to-side difference higher than 5 mm was observed in five patients (5.2%). No lower limb length discrepancy and angulation were reported. Graft rupture rate was 5.2%. CONCLUSION According to these results, BTPB graft could be a good choice in Tanner 3-4 patients who want to achieve their preinjury sport level with a low risk of growth disturbances and graft failure. Further investigations in a wider population are needed.
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Affiliation(s)
- Marco Turati
- Orthopedic Department, San Gerardo Hospital, Monza, Italy.
- School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy.
- Transalpine Center of Pediatric Sports Medicine and Surgery, University of Milano-Bicocca - Hospital Couple Enfant, Monza (Italy), Grenoble, France.
- Department of Paediatric Orthopedic Surgery, Hospital Couple Enfants, Grenoble Alpes University, Grenoble, France.
| | - Marco Caliandro
- School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy
- Transalpine Center of Pediatric Sports Medicine and Surgery, University of Milano-Bicocca - Hospital Couple Enfant, Monza (Italy), Grenoble, France
| | - Diego Gaddi
- Transalpine Center of Pediatric Sports Medicine and Surgery, University of Milano-Bicocca - Hospital Couple Enfant, Monza (Italy), Grenoble, France
- Department of Orthopaedic and Trauma, Policlinico San Pietro Hospital, Ponte San Pietro, Bg, Italy
| | - Massimiliano Piatti
- Transalpine Center of Pediatric Sports Medicine and Surgery, University of Milano-Bicocca - Hospital Couple Enfant, Monza (Italy), Grenoble, France
- Department of Orthopaedic and Trauma, Policlinico San Pietro Hospital, Ponte San Pietro, Bg, Italy
| | - Luca Rigamonti
- School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy
- Transalpine Center of Pediatric Sports Medicine and Surgery, University of Milano-Bicocca - Hospital Couple Enfant, Monza (Italy), Grenoble, France
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Nicolò Zanchi
- School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy
- Transalpine Center of Pediatric Sports Medicine and Surgery, University of Milano-Bicocca - Hospital Couple Enfant, Monza (Italy), Grenoble, France
- Department of Orthopaedics & Rehabilitation, College of Medicine, The Pennsylvania State University, University Park, PA, USA
| | - Paolo Di Benedetto
- Medical Department (DAME), University of Udine, Udine, Italy
- Clinic of Orthopaedics, Friuli Centrale Healthcare and University Trust (ASUFC), Udine, Italy
| | - Linda Boerci
- School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy
- Transalpine Center of Pediatric Sports Medicine and Surgery, University of Milano-Bicocca - Hospital Couple Enfant, Monza (Italy), Grenoble, France
| | - Marcello Catalano
- School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy
- Transalpine Center of Pediatric Sports Medicine and Surgery, University of Milano-Bicocca - Hospital Couple Enfant, Monza (Italy), Grenoble, France
- Department of Orthopedics and Traumatology, Clinica Ars Medica, Gravesano, Ticino, Switzerland
| | - Giovanni Zatti
- Orthopedic Department, San Gerardo Hospital, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy
- Transalpine Center of Pediatric Sports Medicine and Surgery, University of Milano-Bicocca - Hospital Couple Enfant, Monza (Italy), Grenoble, France
| | - Matthieu Ollivier
- Department of Orthopedics and Traumatology, St. Marguerite Hospital, APHM, CNRS, ISM, Institute of Movement and Locomotion, Aix Marseille University, Marseille, France
| | - Marco Bigoni
- School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900, Monza, Italy
- Transalpine Center of Pediatric Sports Medicine and Surgery, University of Milano-Bicocca - Hospital Couple Enfant, Monza (Italy), Grenoble, France
- Department of Orthopaedic and Trauma, Policlinico San Pietro Hospital, Ponte San Pietro, Bg, Italy
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Runer A, Suter A, Roberti di Sarsina T, Jucho L, Gföller P, Csapo R, Hoser C, Fink C. Quadriceps tendon autograft for primary anterior cruciate ligament reconstruction show comparable clinical, functional, and patient-reported outcome measures, but lower donor-site morbidity compared with hamstring tendon autograft: A matched-pairs study with a mean follow-up of 6.5 years. J ISAKOS 2022; 8:60-67. [PMID: 36216218 DOI: 10.1016/j.jisako.2022.08.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 07/26/2022] [Accepted: 08/29/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To compare clinical and functional outcomes of patients after primary anterior cruciate ligament reconstruction (ACLR) using quadriceps tendon- (QT-A) and hamstring tendon (HT-A) autograft with a minimum follow-up (FU) of 5 years. METHODS Between 2010 and 2014, all patients undergoing ACLR were recorded in a prospectively administered database. All patients with primary, isolated QT-A ACLR and without any concomitant injuries or high grade of osteoarthritis were extracted from the database and matched to patients treated with HT-A. Re-rupture rates, anterior-posterior (ap) knee laxity, single-leg hop test (SLHT) performance, distal thigh circumference (DTC) and patient-reported outcome measures (PROMs) were recorded. Between group comparisons were performed using chi-square-, independent-samples T- or Mann-Whitney-U tests. RESULTS 45 QT-A patients were matched to 45 HT-A patients (n = 90). The mean FU was 78.9 ± 13.6 months. 18 patients (20.0%/QT-A: N = 8, 17.8%; HT-A: n = 10, 22.2%; p = .60) sustained a graft rupture and 17 subjects (18.9%/QT-A: n = 9, 20.0%; HT-A: n = 8, 17.8%; p = .79) suffered a contralateral ACL injury. In high active patients (Tegner activity level ≥ 7) rerupture rates increased to 37.5% (HT-A) and 22.2% (QT-A; p = .32), respectively. Patients with graft failure did not differ between both groups in terms of mean age at surgery (QT-A: 26.5 ± 11.6 years, HT-A: 23.3 ± 9.5 years, p = .63) or graft thickness (mean graft square area: QT-A: 43.6 ± 4.7 mm2, HT-A: 48.1 ± 7.9 mm2, p = .27). No statistical between-group differences were found in ap knee laxity side-to-side (SSD) measurements (QT-A: 1.9 ± 1.2 mm, HT-A: 2.1 ± 1.5 mm; p = .60), subjective IKDC- (QT-A: 93.8 ± 6.8, HT-A: 91.2 ± 7.8, p = .17), Lysholm- (QT-A 91.9 ± 7.2, HT-A: 91.5 ± 9.7, p = .75) or any of the five subscales of the KOOS score (all p > .05). Furthermore, Tegner activity level (QT-A: 6(1.5), HT-A: 6(2), p = .62), VAS for pain (QT-A: 0.5 ± 0.9, HT-A: 0.6 ± 1.0, p = .64), Shelbourne-Trumper score (QT-A: 96.5 ± 5.6, HT-A: 95.2 ± 8.2, p = .50), Patient and Observer Scar -Assessment scale (POSAS) (QT-A: 9.4 ± 3.2, HT-A: 10.7 ± 4.9, p = .24), SSD-DTC (QT-A: 0.5 ± 0.5, HT.- A: 0.5 ± 0.6, p = .97), return to sports rates (QT-A: 82.1%, HT-A: 86.7%) and SLHT (QT -A: 95.9 ± 3.8%, HT-A: 93.7 ± 7.0%) did not differ between groups. Donor-site morbidity (HT-A n = 14, 46.7%; QT-A n = 3, 11.5%; p = .008) was statistically significantly lower in the QT-A group. Five patients (11.1%) of the HT-group and three patients (6.7%) in the QT-group required revision surgery (p = .29). CONCLUSION Patient-reported outcome measures, knee laxity, functional testing results and re-rupture rates are similar between patients treated with QT- and HT- autografts. However, patients with QT-autograft have a smaller tibial postoperative scar length and lower postoperative donor-site morbidity. There is a tendency towards higher graft rupture rates in highly active patients treated with HT autograft. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Armin Runer
- Department of Orthopedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria; Department for Sports Orthopaedics, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Aline Suter
- Gelenkpunkt - Sports and Joint Surgery, Innsbruck, Austria
| | | | - Lena Jucho
- Department of Orthopedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Peter Gföller
- Gelenkpunkt - Sports and Joint Surgery, Innsbruck, Austria
| | - Robert Csapo
- Gelenkpunkt - Sports and Joint Surgery, Innsbruck, Austria; Centre for Sport Science and University Sports, University of Vienna, Vienna, Austria
| | | | - Christian Fink
- Gelenkpunkt - Sports and Joint Surgery, Innsbruck, Austria; Private University for Health Sciences, Medical Informatics and Technology (UMIT), ISAG, Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Austria.
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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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21
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Dai W, Leng X, Wang J, Cheng J, Hu X, Ao Y. Quadriceps Tendon Autograft Versus Bone-Patellar Tendon-Bone and Hamstring Tendon Autografts for Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med 2022; 50:3425-3439. [PMID: 34494906 DOI: 10.1177/03635465211030259] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The best type of autograft for anterior cruciate ligament (ACL) reconstruction remains debatable. HYPOTHESIS Compared with bone-patellar tendon-bone (BPTB) and hamstring tendon (HT) autografts, the quadriceps tendon (QT) autograft has comparable graft survival as well as clinical function and pain outcomes. STUDY DESIGN Meta-analysis; Level of evidence, 4. METHODS A systematic literature search was conducted in PubMed, Embase, Scopus, and the Cochrane Library to July 2020. Randomized controlled trials (RCTs) and observational studies reporting comparisons of QT versus BPTB or HT autografts for ACL reconstruction were included. All analyses were stratified according to study design: RCTs or observational studies. RESULTS A total of 24 studies were included: 7 RCTs and 17 observational studies. The 7 RCTs included 388 patients, and the 17 observational studies included 19,196 patients. No significant differences in graft failure (P = .36), the International Knee Documentation Committee (IKDC) subjective score (P = .39), or the side-to-side difference in stability (P = .60) were noted between QT and BPTB autografts. However, a significant reduction in donor site morbidity was noted in the QT group compared with the BPTB group (risk ratio [RR], 0.17 [95% CI, 0.09-0.33]; P < .001). No significant differences in graft failure (P = .57), the IKDC subjective score (P = .25), or the side-to-side stability difference (P = .98) were noted between QT and HT autografts. However, the QT autograft was associated with a significantly lower rate of donor site morbidity than the HT autograft (RR, 0.60 [95% CI, 0.39-0.93]; P = .02). A similar graft failure rate between the QT and control groups was observed after both early and late full weightbearing, after early and late full range of motion, and after using the QT autograft with a bone plug and all soft tissue QT grafts. However, a significantly lower rate of donor site morbidity was observed in the QT group compared with the control group after both early and late full weightbearing, after early and late full range of motion, and after using the QT autograft with a bone plug and all soft tissue QT grafts. No difference in effect estimates was seen between RCTs and observational studies. CONCLUSION The QT autograft had comparable graft survival, functional outcomes, and stability outcomes compared with BPTB and HT autografts. However, donor site morbidity was significantly lower with the QT autograft than with BPTB and HT autografts.
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Affiliation(s)
- Wenli Dai
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Xi Leng
- Medical Imaging Center, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jian Wang
- Department of Orthopedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jin Cheng
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Xiaoqing Hu
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Yingfang Ao
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
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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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23
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Zhang K, Beshay T, Murphy B, Sheean A, de Sa D. Quadriceps Tendon Anterior Cruciate Ligament Reconstruction: A Systematic Review of Postoperative Rehabilitation and Complication Profiles. Arthroscopy 2022; 38:2062-2072.e1. [PMID: 34942315 DOI: 10.1016/j.arthro.2021.12.020] [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: 09/12/2021] [Revised: 12/09/2021] [Accepted: 12/12/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purposes of this study are to explore current elements for postoperative rehabilitation protocol after quadriceps tendon-anterior cruciate ligament reconstruction (QT-ACLR), outline general timelines for progression of those elements, and explore their associated complication rates and profiles. METHODS In accordance with PRISMA guidelines, 5 online databases (EMBASE, MEDLINE, CINAHL, Cochrane, and PubMed) were searched and screened in duplicate using predetermined criteria for studies on the aforementioned patient population. Descriptive statistics are presented. RESULTS A total of 56 studies were included, with 31 studies using quadriceps tendon with bone block (B-QT) and 26 studies using all-soft tissue quadriceps tendon (S-QT). The majority of studies permitted full weightbearing and range of motion (ROM) within the first 12 postoperative weeks, and motion-controlled braces within 6 weeks. Isometric exercises were initiated within 1 week after surgery, closed-chain exercises within 12 weeks, and open-chain and sports-specific exercises within 36 weeks. Complication profiles were similar between graft types and included graft failure (1.2%-1.6%), cyclops syndrome (0.4%-0.7%), and persistent stiffness (0.9%). CONCLUSIONS Current postoperative rehabilitation strategies in ACLR with QT offer a complication profile comparable to those reported with other graft types. Based on the included rehabilitation regimen, these protocols should focus on early ROM, specifically on achieving full extension, alongside isometric quadriceps strengthening. Progression to closed- and open-chain exercises should follow in a progressive manner, similar to existing protocols in ACLR. Adjuncts such as motion-controlled bracing and continuous passive motion machines may be used if graft protection is prioritized. This review highlights the need for comparison of defined protocols against one another in the setting of QT-ACLR. LEVEL OF EVIDENCE IV, systematic review of Level I-IV studies.
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Affiliation(s)
- Kailai Zhang
- Department of Physical Medicine and Rehabilitation, McMaster University, Hamilton, Ontario, Canada.
| | - Tony Beshay
- Faculty of Science, McMaster University, Hamilton, Ontario, Canada
| | - Ben Murphy
- Niagara Orthopedic Institute Hamilton, Hamilton, Ontario, Canada
| | - Andrew Sheean
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas, U.S.A
| | - Darren de Sa
- Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario, Canada
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Guarino A, Farinelli L, Iacono V, Screpis D, Piovan G, Rizzo M, Mariconda M, Zorzi C. Lateral extra-articular tenodesis and anterior cruciate ligament reconstruction in young patients: clinical results and return to sport. Orthop Rev (Pavia) 2022; 14:33696. [PMID: 35774923 PMCID: PMC9239354 DOI: 10.52965/001c.33696] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 12/23/2021] [Indexed: 03/24/2024] Open
Abstract
Lateral extra-articular tenodesis (L.E.T.) have been proposed to reduce the tibia's anterior translation and internal rotation in concomitant to Anterior cruciate ligament (A.C.L.) reconstruction. Recent studies show that the addition of L.E.T. to A.C.L. reconstruction results in a statistically significant reduction in graft failure. The purpose of the present study was to evaluate the clinical outcomes, complications, and rate of return to preinjury sports level in pediatric patients who underwent combined A.C.L. reconstruction with L.E.T. at a minimum 2-year follow-up. The authors retrospectively evaluated 42 pediatric patients at high risk of graft failure who experienced ACLR connected to L.E.T. IKDC and Tegner-Lysholm Knee Scores Scale were used to assess clinical outcomes, and the Tegner Activity Scale to evaluate the return to sport. No graft failure or subsequent surgery related to A.C.L. reconstruction occurred. Furthermore, 88% of patients returned to the sport. Satisfactory clinical results were obtained on a short and medium-term follow-up. These findings help to consider this procedure for active adolescents at a high risk of graft failure to enhance A.C.L. reconstruction.
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Affiliation(s)
- Amedeo Guarino
- Section of Orthopaedics. Department of Public Health, Federico II University, Naples (NA), Italy
| | - Luca Farinelli
- Clinical Orthopaedics Departement of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona(AN), Italy
| | - Venanzio Iacono
- Department of Orthopaedic Surgery, IRCCS Sacro Cuore - Don Calabria in Negrar (VE), Italy
| | - Daniele Screpis
- Department of Orthopaedic Surgery, IRCCS Sacro Cuore - Don Calabria in Negrar (VE), Italy
| | - Gianluca Piovan
- Department of Orthopaedic Surgery, IRCCS Sacro Cuore - Don Calabria in Negrar (VE), Italy
| | - Maria Rizzo
- Section of Orthopaedics. Department of Public Health, Federico II University, Naples (NA), Italy
| | - Massimo Mariconda
- Section of Orthopaedics. Department of Public Health, Federico II University, Naples (NA), Italy
| | - Claudio Zorzi
- Department of Orthopaedic Surgery, IRCCS Sacro Cuore - Don Calabria in Negrar (VE), Italy
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Dhillon MS, Rangasamy K, Rajnish RK, Gopinathan NR. Paediatric Anterior Cruciate Ligament (ACL) Injuries: Current Concepts Review. Indian J Orthop 2022; 56:952-962. [PMID: 35669018 PMCID: PMC9123120 DOI: 10.1007/s43465-022-00611-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/09/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Over the past two decades, there has been a documented increase in paediatric ACL injuries because of a rise in younger age sports participation at the competitive level, awareness about sports-related injuries, and advanced imaging modalities. METHODS A PubMed electronic database search was done, which revealed 1366 hits over the last five years (2016 - 2020). Finally, 37 articles that contributed to new findings were included. This review was conducted based on predefined research questions. RESULTS AND CONCLUSION Early surgical reconstruction is recommended in children due to the increasing demand for early return to sports and to prevent the instability that can lead to progressive cartilage and meniscal damage. With the evolution of several "physeal sparing" ACL reconstruction (ACLR) techniques, a favorable clinical outcome with less growth disturbance is achievable. Although different autograft options are available, hamstring autografts are most commonly preferred. A specific pattern of a bone bruise not extending into the metaphysis, and lateral meniscus tears are the most common associated injuries. Following paediatric ACLR, complications like graft rupture and contralateral ACL injuries are two to three folds higher than with adult ACLR. Unprepared early return to sports is one of the reasons for increased complication rates in children; thus, clearance criteria for return to sports need to be standardized, and early return to sports (< 9 months post ACLR) should be avoided. Neuromuscular training protocols are recommended to minimize complications like graft ruptures.
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Affiliation(s)
- Mandeep Singh Dhillon
- grid.415131.30000 0004 1767 2903Department of Orthopaedics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Karthick Rangasamy
- grid.415131.30000 0004 1767 2903Department of Orthopaedics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rajesh Kumar Rajnish
- grid.413618.90000 0004 1767 6103Department of Orthopaedics, AIIMS, Bilaspur, India
| | - Nirmal Raj Gopinathan
- grid.415131.30000 0004 1767 2903Department of Orthopaedics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Etzel CM, Nadeem M, Gao B, Boduch AN, Owens BD. Graft Choice for Anterior Cruciate Ligament Reconstruction in Women Aged 25 Years and Younger: A Systematic Review. Sports Health 2022; 14:829-841. [PMID: 35343326 PMCID: PMC9631041 DOI: 10.1177/19417381221079632] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
CONTEXT Although anterior cruciate ligament (ACL) tears are relatively common in athletic populations, few studies have systematically reviewed graft choice in young women. OBJECTIVE To quantitatively and qualitatively examine reported outcomes for graft choice in women aged 25 years and younger undergoing primary ACL reconstruction. DATA SOURCE A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. An electronic search in the PubMed (includes MEDLINE) and EMBASE databases was completed using a combination of key terms. STUDY SELECTION Studies were included if they reported graft choice outcomes in women aged 25 years and younger. STUDY DESIGN Systematic review. LEVEL OF EVIDENCE Level 4. DATA EXTRACTION The following information was extracted: title, author, year of publication, number of female patients and age, graft type, follow-up, and patient-reported outcome measures. The following outcome scores were identified as being reported or not reported by each study: graft failure, contralateral ACL (CACL) rupture, IKDC (International Knee Documentation Committee), graft survival (Kaplan-Meier), Lysholm, Tegner, KT-1000, kneeling pain, return to sport, and Lachman. RESULTS Of 1170 identified articles, 16 met inclusion criteria, reporting on 1385 female patients aged 25 years and younger. Comparison of 655 bone-patellar tendon-bone (BPTB) versus 525 hamstring tendon (HT) autografts showed significant differences in mean failure rate between BPTB autografts (6.13% ± 2.58%) and HT autografts (17.35% ± 8.19%), P = 0.001. No statistically significant differences in CACL failure rates were found between BPTB autografts and HT autografts (P = 0.25). Pooled results for IKDC were possible in 3 of the HT autograft studies, showing a mean score of 88.31 (95% CI 83.53-93.08). Pooled Lysholm score results were possible in 2 of the HT autograft studies, showing a mean score of 93.46 (95% CI 91.90-95.01). CONCLUSION In female patients aged 25 years and younger, BPTB autografts showed significantly less graft failure compared with HT autografts. However, BPTB autografts had comparable patient-reported outcomes compared with HT autografts with the available data. The overall state of evidence for graft choice in female patients aged 25 years and younger is low. Future studies should report statistics by age and sex to allow for further analysis of graft choice for this specific population that is known to be more vulnerable to ACL injury.
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Affiliation(s)
- Christine M Etzel
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Maheen Nadeem
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Burke Gao
- Department of Orthopedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Abigail N Boduch
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Brett D Owens
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Asai K, Nakase J, Ishikawa T, Yoshimizu R, Kimura M, Ozaki N, Tsuchiya H. Differences in cellular and microstructural properties of the semitendinosus muscle tendon between young and adult patients. J Orthop Sci 2022; 27:478-485. [PMID: 33714680 DOI: 10.1016/j.jos.2021.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/30/2020] [Accepted: 01/08/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Poor outcomes associated with anterior cruciate ligament reconstruction in paediatric patients are a major concern. The tendon structure and its cellular characteristics are key factors that affect the mechanical properties of tendons. This study aimed to evaluate the effects of growth on the cellular and microstructural properties of the tendon of the semitendinosus muscle in humans. METHODS Semitendinosus muscle tendon samples from 76 patients who underwent ligament reconstruction were examined and divided into three groups: immature (10.8 ± 2.7 years old), young (16.5 ± 1.8 years old), and adult (35.2 ± 8.6 years old), based on age and the state of the epiphyseal plate in the distal femur. The number of tendon cells per unit area was assessed, and the major-to-minor-length ratio of the tendon cell nuclei was calculated to evaluate the shape of the nuclei using haematoxylin and eosin staining. The collagen fibril diameter and distribution were determined using electron microscopy. RESULTS The major-to-minor-length ratio of the tendon cell nuclei significantly increased with age (p-value; immature vs. young: 0.018, young vs adult: 0.001, immature vs adult: 0.001). The shape of the tendon cell nuclei was rounder in the immature group and more elongated in the adult group. A significant decrease in the number of tendon cells was observed with age (immature: 565 ± 134/mm2, young: 356 ± 105/mm2, adult: 272 ± 81/mm2; p-value: immature vs young: 0.001, young vs adult: 0.012, immature vs adult: 0.001). The mean fibril diameter in the immature group was significantly smaller (p-value: immature vs young: 0.018, young vs adult: 0.001, immature vs adult: 0.001). The distribution of the collagen fibrils changed from right skewed in the immature group to flat in the adult group. CONCLUSIONS The characteristics of the tendon cells and the microstructure of collagen in muscle tendons significantly changed with age.
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Affiliation(s)
- Kazuki Asai
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa University, 13-1 Takara-machi, 920-8641, Kanazawa, Japan
| | - Junsuke Nakase
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa University, 13-1 Takara-machi, 920-8641, Kanazawa, Japan.
| | - Tatsuya Ishikawa
- Department of Functional Anatomy, Graduate School of Medical Science Kanazawa University, 13-1 Takara-machi, 920-8640, Kanazawa, Japan
| | - Rikuto Yoshimizu
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa University, 13-1 Takara-machi, 920-8641, Kanazawa, Japan
| | - Mitsuhiro Kimura
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa University, 13-1 Takara-machi, 920-8641, Kanazawa, Japan
| | - Noriyuki Ozaki
- Department of Functional Anatomy, Graduate School of Medical Science Kanazawa University, 13-1 Takara-machi, 920-8640, Kanazawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa University, 13-1 Takara-machi, 920-8641, Kanazawa, Japan
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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: 8] [Impact Index Per Article: 4.0] [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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Weaver A, Ness BM, Roman DP, Giampetruzzi N, Cleland JA, Pace JL, Crepeau AE. Short-term isokinetic and isometric strength outcomes after anterior cruciate ligament reconstruction in adolescents. Phys Ther Sport 2021; 53:75-83. [PMID: 34875528 DOI: 10.1016/j.ptsp.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/24/2021] [Accepted: 11/26/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To examine differences in knee strength outcomes after ACL reconstruction according to quadriceps tendon (QT) or hamstring tendon (HT) autograft in adolescents. DESIGN Retrospective cohort. METHODS Surgical and clinical outcome data were collected. Analyses were conducted separately for female and male cohorts and grouped by graft type (HT or QT). A Mann-Whitney U test of independent samples was used to examine group differences according to graft type. RESULTS 107 females (age = 15.6 ± 1.5 years) and 94 males (age = 15.7 ± 1.5 years) were included. Mean time since surgery ranged from 7.2 to 7.9 months. Those with a QT autograft had decreased normalized isokinetic quadriceps peak torque on the involved limb compared to the HT group (p < 0.01, ES = 0.71-0.89). Normalized isometric hamstring peak torque was decreased for those with HT autograft in the female cohort (p = 0.02, ES = 0.57). CONCLUSION Normalized isokinetic quadriceps peak torque was reduced by 18-20% on the involved limb in those with a QT autograft. Normalized isometric hamstring peak torque was decreased by 13% for those with HT autograft in the female cohort. Method of strength testing may be an important consideration to fully appreciate strength deficits after ACL reconstruction according to graft type.
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Affiliation(s)
- Adam Weaver
- Connecticut Children's, Sports Physical Therapy, Farmington, CT, USA
| | - Brandon M Ness
- Doctor of Physical Therapy Program, Tufts University School of Medicine, Boston, MA, USA
| | - Dylan P Roman
- Connecticut Children's, Sports Physical Therapy, Farmington, CT, USA.
| | | | - Joshua A Cleland
- Doctor of Physical Therapy Program, Tufts University School of Medicine, Boston, MA, USA
| | - J Lee Pace
- Elite Sports Medicine at Connecticut Children's, Hartford, CT, USA; UConn Health, Division of Sports Medicine, Department of Orthopedics, Farmington, CT, USA
| | - Allison E Crepeau
- Elite Sports Medicine at Connecticut Children's, Hartford, CT, USA; UConn Health, Division of Sports Medicine, Department of Orthopedics, Farmington, CT, USA
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Jarvis DL, Vance DD, Reinke EK, Riboh JC. Hybrid Transtibial Femoral Preparation for Transphyseal Anterior Cruciate Ligament Reconstruction: A Radiographic Comparison With the Transtibial and Anteromedial Portal Techniques. Orthop J Sports Med 2021; 9:23259671211054509. [PMID: 34820462 PMCID: PMC8607486 DOI: 10.1177/23259671211054509] [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: 07/08/2021] [Accepted: 08/06/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Transphyseal anterior cruciate ligament (ACL) reconstruction remains the most
commonly used technique for pubescent patients. The transtibial (TT)
drilling technique creates vertical and central femoral tunnels to minimize
the physeal area of injury at the expense of a nonanatomic femoral tunnel.
The hybrid TT (HTT) technique offers the potential of an anatomic femoral
position with tunnel geometry similar to that using the TT technique. Purpose/Hypothesis: The purpose was to perform a radiographic comparison of the HTT technique
with TT and anteromedial portal (AM) techniques in adolescent patients
undergoing transphyseal ACL reconstruction. It was hypothesized that femoral
tunnels created during HTT would be similar to TT tunnels but significantly
more vertical and central than AM tunnels. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively screened primary transphyseal ACL reconstructions
performed in adolescents at our institution between 2013 and 2019. The
youngest 20 eligible patients were selected from each technique cohort: TT,
AM, and HTT. Postoperative radiographs were assessed for the coronal femoral
tunnel angle, as well as the location of the tunnel-physis penetration on
the anteroposterior and lateral views. Physeal lesion surface area was
calculated. Data were compared among the 3 groups using 1-way analysis of
variance followed by pairwise comparisons. Results: Included were 47 patients with a mean ± SD age of 14.3 ± 1.2 years (n = 9
with TT, 18 with AM, and 20 with HTT techniques). The coronal tunnel angle
was significantly more vertical in the TT (60.7° ± 7.2°) and HTT (54.4° ±
5.7) groups as compared with the AM group (48.8° ± 5.9; P =
.0037 and P = .02, respectively). There was no significant
difference between the TT and HTT groups (P = .066). The
only significant finding regarding femoral tunnel location was that the HTT
tunnels (28.9% ± 4.8%) penetrated the physis more centrally than did the AM
tunnels (20.0% ± 5.1%; P = .00002) on lateral
radiographs. Conclusion: The HTT technique presents an option for transphyseal ACL reconstruction,
with femoral tunnel obliquity and estimated physeal disruption similar to
that of the TT technique and significantly less than that of the AM
technique. The HTT technique also results in the most central physeal
perforation of all techniques, predominantly in the sagittal plane.
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Affiliation(s)
- D Landry Jarvis
- School of Medicine, Duke University, Durham, North Carolina, USA
| | - Danica D Vance
- School of Medicine, Duke University, Durham, North Carolina, USA
| | - Emily K Reinke
- School of Medicine, Duke University, Durham, North Carolina, USA
| | - Jonathan C Riboh
- School of Medicine, Duke University, Durham, North Carolina, USA
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Cohen D, Slawaska-Eng D, Almasri M, Sheean A, de Sa D. Quadricep ACL Reconstruction Techniques and Outcomes: an Updated Scoping Review of the Quadricep Tendon. Curr Rev Musculoskelet Med 2021; 14:462-474. [PMID: 34755275 DOI: 10.1007/s12178-021-09726-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an up-to-date summary on the most recent literature examining techniques and outcomes in anterior cruciate ligament (ACL) reconstruction using quadriceps tendon (QT) which will enable surgeons to make well informed evidence-based decisions when choosing a particular graft option and technique in ACL reconstruction. RECENT FINDINGS Several RCTs and systematic reviews have been published recently on this topic, and overall, there were no differences found between the QT, HT, and BPTB groups in patient-reported outcomes, stability testing, or graft re-rupture rates. In terms of strength testing, the QT group did have inferior knee extensor strength on isokinetic testing when compared to the HT group, whereas the HT group had inferior knee flexor strength compared to the QT group. No differences were found on strength testing between the QT and BPTB groups. Currently, two large RCTs, the Stability2 and SQuASH trials, are ongoing examining the effectiveness of the QT vs BPTB with or without LET and QT vs HT in the pediatric population which will help shed further light on the effectiveness of the QT as a graft choice in ACL reconstruction. The findings of this scoping review demonstrate that the QT is an excellent graft option in ACL reconstruction both in the primary and revision settings, among adult and pediatric populations. This review provides surgeons with further assurance when selecting QT autograft in ACL reconstruction.
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Affiliation(s)
- Dan Cohen
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - David Slawaska-Eng
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Mahmoud Almasri
- Mercy Health - Cincinnati Sports Medicine and Orthopaedic Center, Cincinnati, OH, USA
| | - Andrew Sheean
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada. .,McMaster University Medical Centre, 1200 Main St West, 4E, Hamilton, Ontario, L8N 3Z5, Canada.
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Quadriceps tendon has a lower re-rupture rate than hamstring tendon autograft for anterior cruciate ligament reconstruction – A meta-analysis. J ISAKOS 2021; 7:87-93. [DOI: 10.1016/j.jisako.2021.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Aitchison AH, Alcoloumbre D, Mintz DN, Hidalgo Perea S, Nguyen JT, Cordasco FA, Green DW. MRI Signal Intensity of Quadriceps Tendon Autograft and Hamstring Tendon Autograft 1 Year After Anterior Cruciate Ligament Reconstruction in Adolescent Athletes. Am J Sports Med 2021; 49:3502-3507. [PMID: 34612708 DOI: 10.1177/03635465211040472] [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 Hamstring tendon autograft (HTA) is a common graft choice for anterior cruciate ligament (ACL) reconstruction (ACLR) in skeletally immature patients. Recently, the use of quadriceps tendon autograft (QTA) has shown superior preliminary outcomes in this population. PURPOSE To evaluate graft maturity by comparing magnetic resonance imaging (MRI) signal intensity of HTA versus QTA used in primary ACLR. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS All patients under the age of 18 years who underwent a primary ACLR by the senior authors using either an HTA or a QTA were retrospectively reviewed. A total of 70 skeletally immature patients (37 in the HTA group and 33 in the QTA group) with an available MRI at 6 and 12 months postoperatively were included. Signal intensity ratio (SIR) was measured on sagittal MRI by averaging the signal at 3 regions of interest along the ACL graft and dividing by the signal of the tibial footprint of the posterior cruciate ligament. Statistical analysis was performed to determine interrater reliability and differences between time points and groups. RESULTS Age, sex, and type of surgery were not associated with any differences in SIR. There was no significant difference in SIR between groups on the 6-month MRI. However, the SIR of the QTA group was significantly less than in the HTA group on the 12-month MRI (2.33 vs 2.72, respectively; P = .028). Within the HTA group, there was no significant difference in SIR at either MRI time point. In the QTA group, there was a significant decrease in SIR between the 6-month and 12-month postoperative MRI (2.70 vs 2.33, respectively; P = .045). CONCLUSION These findings suggest improved graft maturation, remodeling, and structural integrity of the QTA compared with the HTA between 6 and 12 months postoperatively. This provides evidence that, at 1 year postoperatively, QTA may have a superior rate of incorporation and synovialization as compared with the HTA.
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Affiliation(s)
- Alexandra H Aitchison
- Division of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - David Alcoloumbre
- Division of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Douglas N Mintz
- Division of Radiology & Imaging, Hospital for Special Surgery, New York, New York, USA
| | - Sofia Hidalgo Perea
- Division of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Joseph T Nguyen
- Hospital for Special Surgery, Epidemiology and Biostatistics Department, New York, New York, USA
| | - Frank A Cordasco
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Daniel W Green
- Division of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
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The outcomes of quadriceps tendon autograft for anterior cruciate ligament reconstruction in adolescent athletes: a retrospective case series. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:739-744. [PMID: 34110467 DOI: 10.1007/s00590-021-03032-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 06/02/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Multiple graft options exist for anterior cruciate ligament (ACL) reconstruction in an adolescent athlete. Patellar tendon harvest can lead to anterior knee pain, while hamstring tendon harvest can affect knee flexion strength and alter mechanics. Allograft is less desirable in pediatric patients due to the higher failure rate and slight risk of disease transmission. Quadriceps tendon autograft has rarely been reported for adolescent ACL reconstruction in the USA, but is an excellent option due to its large size, low donor site morbidity, and versatility. The purpose of this study is to report the outcomes of adolescents who have undergone ACL reconstruction using quadriceps tendon autograft. METHODS Twenty-two ACL reconstructions using the quadriceps autograft were performed on 21 pediatric patients by the senior author between 2010 and 2017. The patient's demographics, injury characteristics, imaging, physical examination findings, operative findings, outcomes and sports were recorded. RESULTS The average age at the time of surgery was 15 years. Two patients had open physes; the remainder had closing physes. 64% of patients had additional meniscal tears and 76% had bony contusions. The average duration of follow-up was 2.8 years (range 2-5 years). At final follow-up, there were no angular deformities or leg length discrepancies. The average quadriceps atrophy of the operative leg was 4 mm. The average Lysholm score was 98. 86% of patients returned to sports. No patients had re-rupture of their operative ACL. No incidences of infections, numbness, or anterior knee pain were reported. Two patients had a second arthroscopy for re-injury, revealing new meniscal tears but intact ACL grafts. CONCLUSIONS Use of quadriceps tendon autograft for ACL reconstruction in adolescent patients allows reliable return to sport with minimal complications. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Saper M, Wong C, Strauss N. Adolescent Patients Exhibit Significant Improvements in Strength and Functional Performance From 6 to 9 Months After ACL Reconstruction With Quadriceps Autograft. Arthrosc Sports Med Rehabil 2021; 3:e837-e843. [PMID: 34195652 PMCID: PMC8220612 DOI: 10.1016/j.asmr.2021.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 01/27/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose To investigate differences between the 6-month and 9-month return to sport (RTS) assessments in adolescent patients undergoing anterior cruciate ligament reconstruction (ACLR) with quadriceps tendon autograft. Methods A retrospective review was performed of consecutive adolescent patients who underwent ACLR between June 2017 and October 2019. Patients completed a structured RTS test 6 and 9 months after surgery consisting of isometric and isokinetic strength testing, the Lower Quarter Y-Balance Test, and single-legged hop testing. The recovery of muscle strength, assessed via isometric/isokinetic and hop testing, was defined by a limb symmetry index (LSI) ≥90%. Differences were compared between the 2 RTS test time points. Results In total, 27 patients (16 female, 11 male) were identified with a mean age of 15 years (range, 13-17 years). There were statistically significant improvements in isometric quadriceps strength (LSI, 85.0 ± 17.2 vs 92.5 ± 11.3; P = .04) and hamstring strength (LSI, 87.9 ± 11.2 vs 99.0 ± 10.5; P < .01). There were improvements in isokinetic knee extension at both 60°/s (LSI, 75.2 ± 16.7 vs 83.3 ± 13.8) and 180°/s (LSI, 79.9 ± 15.4 vs 83.4 ± 11.2), but the differences were only statistically significant at 60°/s (P = .02 and P = .17, respectively). There were no significant differences in isokinetic testing of knee flexion at either 60°/s or 180°/s. There were no statistically significant differences in the anterior reach component of the Lower Quarter Y-Balance Test at 6 and 9 months. Patients demonstrated statistically significant improvements on single- legged hop testing with mean LSIs >95% for each of the 4 tests at 9 months postop. Conclusions Adolescent patients undergoing ACLR with quadriceps tendon autograft demonstrated significant improvements in quadriceps strength between 6 and 9 months postoperatively. Level of Evidence Level IV, therapeutic case series.
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Affiliation(s)
- Michael Saper
- Departments of Orthopedics and Sports Medicine, Seattle, Washington, USA.,Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, USA
| | - Chris Wong
- Rehabilitation Medicine, Seattle Children's, Seattle, Washington, USA
| | - Nicole Strauss
- Departments of Orthopedics and Sports Medicine, Seattle, Washington, USA
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Heyworth BE, Zheng ET, Vavken P, Liotta ES, Kramer DE, Yen YM, Micheli LJ, Kocher MS. Early Outcomes of Adolescent ACL Reconstruction With Hybrid Hamstring Tendon Autograft-Allograft Versus Hamstring Tendon Autograft Alone. Orthop J Sports Med 2021; 9:2325967120979985. [PMID: 33553459 PMCID: PMC7841686 DOI: 10.1177/2325967120979985] [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: 06/11/2020] [Accepted: 07/07/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Small-diameter semitendinosus-gracilis tendon autografts may be encountered intraoperatively during anterior cruciate ligament reconstruction (ACLR); these have been shown to be at increased risk of graft rupture. One option that surgeons have pursued to reduce the theoretical failure rate of these smaller-diameter grafts is augmenting them with allograft material, thereby forming a larger-diameter hybrid autograft-allograft construct. Purpose/Hypothesis: The purpose of this study was to compare outcomes in adolescent athletes of primary ACLR using a hybrid autologous hamstring tendon and soft tissue allograft construct versus ACLR using small-diameter hamstring tendon autograft. The hypothesis was that the hybrid hamstring autograft-allograft construct would provide superior short-term results. Study Design: Cohort study; Level of evidence, 3. Methods: We performed a retrospective analysis of 47 patients aged between 12 and 20 years who underwent hybrid graft ACLR (mean diameter, 9.1 mm) at a single institution. Electronic medical records including clinic notes, radiographic images, operative notes, and pathology reports were reviewed for study analysis. A control group of 64 patients who underwent small-diameter hamstring reconstruction (mean diameter, 7.1 mm) without allograft supplementation was compiled. Corresponding clinical, radiographic, and surgical characteristics were collected for the control group to allow for comparative analysis. Results: Mean follow-up was 2.7 years for the hybrid cohort and 2.3 years for the control group. Despite a significantly larger mean graft diameter in the hybrid group as compared with the control group (P < .001), no significant difference in retear rate was seen between cohorts (hybrid, 9%; control, 13%; P = .554). Patients with hybrid anterior cruciate ligament constructs also underwent a comparable number of reoperations overall (P = .838). Functionally, all patients with adequate follow-up returned to sports, with no significant difference in time to return to sports between the groups (P = .213). Radiographically, hybrid graft constructs did not undergo a significantly larger degree of tunnel lysis (P = .126). Conclusion: A cohort of adolescents with hybrid anterior cruciate ligament grafts was shown to have retear rates and overall clinical results comparable with those of a control group that received small-diameter hamstring tendon autografts alone.
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Affiliation(s)
- Benton E Heyworth
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Evan T Zheng
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - Elizabeth S Liotta
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Mininder S Kocher
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Open Full-Thickness Quadriceps Tendon Autograft Harvest With Repair for Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2020; 9:e1459-e1465. [PMID: 33134047 PMCID: PMC7587024 DOI: 10.1016/j.eats.2020.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/05/2020] [Indexed: 02/03/2023] Open
Abstract
Historically, one of the most common graft choices for anterior cruciate ligament (ACL) reconstruction in the pediatric population has been the hamstring autograft. Although pediatric ACL reconstructions with a hamstring autograft have allowed a majority of children and adolescents to return to athletics, it has been reported that anywhere between 6% and 38% of these patients will go on to experience subsequent graft rupture. The quadriceps tendon autograft is an alternative to the hamstring tendon autograft that demonstrates superior preliminary outcomes, and we currently recommend it for skeletally immature patients undergoing primary and revision ACL reconstruction. This paper aims to describe our technique for an open full-thickness quadriceps tendon harvest with repair.
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Johnston TR, Hu J, Gregory B, Liles J, Riboh J. Transphyseal Anterior Cruciate Ligament Reconstruction Using Hybrid Transtibial Femoral Drilling and a Quadriceps Tendon Autograft. Arthrosc Tech 2020; 9:e1121-e1131. [PMID: 32874892 PMCID: PMC7451707 DOI: 10.1016/j.eats.2020.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 04/12/2020] [Indexed: 02/03/2023] Open
Abstract
Significant controversy exists regarding the optimal surgical technique for anterior cruciate ligament (ACL) reconstruction in adolescents with 1 to 3 years of skeletal growth remaining. Graft choice and physeal injury remain primary concerns given significantly elevated rates of failure of hamstring autograft reconstructions in this population, as well as risks of leg-length discrepancy and growth axis deviation. Traditional (more vertical) transtibial drilling of the femoral tunnel can reduce risks of physeal injury but has been shown to have less accuracy restoring the native femoral ACL footprint and associated incomplete knee stabilization. On the other hand, anteromedial and outside-in drilling yields improvements in the tunnel location and biomechanics but at the cost of a more oblique trajectory and greater risk of physeal injury. A hybrid transtibial pin technique using a Pathfinder guide facilitates femoral drilling with the "best of both worlds," allowing for reproduction of the native ACL footprint and a more physeal-respecting femoral tunnel. When combined with an all-soft tissue quadriceps tendon autograft and suspensory fixation, the hybrid transtibial method yields a reliable, safe, and robust construct with promising results for the young athlete. We describe our preferred graft harvest, tunnel drilling, and fixation techniques to minimize physeal risks and optimize outcomes.
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Affiliation(s)
- Tyler Robert Johnston
- Address correspondence to Tyler Robert Johnston, M.D., M.S., Department of Orthopaedic Surgery, Duke University Medical Center, Box 3615 Durham, NC, 27701, U.S.A.
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Quadriceps tendon autograft ACL reconstructed subjects overshoot target knee extension angle during active proprioception testing. Knee Surg Sports Traumatol Arthrosc 2020; 28:645-652. [PMID: 31776624 DOI: 10.1007/s00167-019-05795-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 11/07/2019] [Indexed: 01/18/2023]
Abstract
PURPOSE To compare the active joint position sense (JPS), muscle strength, and knee functions in individuals who had anterior cruciate ligament (ACL) reconstruction with quadriceps tendon autograft, hamstring tendon autograft, tibialis anterior allograft and healthy individuals. It was hypothesized that when compared to an age and gender-matched healthy control group, subjects who were post-ACL reconstruction would display impaired active joint position sense, knee extensor and flexor strength symmetry and knee function at 1 year post-surgery. A secondary hypothesis was that differences would exist between the quadriceps tendon autograft, hamstring tendon autograft and tibialis anterior allograft groups. METHODS Sixty-seven patients with ACL reconstruction and 20 healthy individuals were included. Active JPS reproduction was measured at 15°, 45° and 75° of knee flexion. International Knee Documentation Committee (IKDC) subjective score and one-leg hop test were used to assess the functional status of the patients. RESULTS The JPS detection was different at the 15° target angle between groups (F3.86 = 24.56, p < 0.001). A significantly higher proportion of quadriceps tendon autograft group patients failed to identify the 15° active JPS assessment position compared to the other groups (p < 0.0001). The quadriceps index was lower in patients compared to healthy individuals (p < 0.001), while the hamstring index was similar (n.s.). The knee functional outcomes were similar between ACL reconstructed groups and healthy controls (n.s.). CONCLUSION Knee proprioception deficits and impaired muscle strength were evident among patients at a mean 13.5 months post-ACL reconstruction compared with healthy controls. Patients who underwent ACL reconstruction using a quadriceps tendon autograft may be more likely to actively over-estimate knee position near terminal extension. Physiotherapists may need to focus greater attention on terminal knee extension proprioceptive awareness among this patient group. LEVEL OF EVIDENCE III.
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