Reconstruction of old anterior cruciate ligament injuries. No difference between the Kennedy LAD-method and traditional patellar tendon graft in a prospective randomized study of 40 patients with 4-year follow-up

Patellar tendon versus artificial grafts in anterior cruciate ligament reconstruction: a systematic review and meta-analysis

Background

The aim of anterior cruciate ligament reconstruction (ACLR) is to restore the function of the knee joint, protect the cartilage, and reduce the occurrence of osteoarthritis. However, due to the structural limitations of the human body, it is not possible to perform ACLR with conventional sutures. To restore normal functioning of the anterior cruciate ligament (ACL), a new ligament must be reconstructed in the position of the previous ACL.

Objective

To compare autografts and synthetic grafts in terms of postoperative knee stability and function

Search methods

The protocol for this study was registered with PROSPERO (CRD42021243451). Two reviewers independently searched the PubMed, Embase, and the Cochrane Library databases from database inception though February 10, 2021. The following search method was used: ((Autograft) OR (Autologous) OR (Autotransplant)) OR Artificial Ligament AND (Anterior Cruciate Ligament Injury [MeSH Terms]) AND (Randomized controlled trial [MeSH Terms]). Methodological quality was assessed by the Cochrane risk of bias tool.

Selection criteria

We only included randomized controlled trials (level I) that compared autograft and synthetic graft interventions in participants with ACL injury. We included trials that evaluated ACLR using at least one outcome (Lachman test, pivot shift test, IKDC grades, or complications).

Results

A total of 748 studies were identified in the initial literature search, and seven studies that examined only bone-patellar tendon-bone (BPTB) grafts compared with artificial grafts met the predetermined inclusion criteria. The results showed that BPTB grafts were associated with significantly better pivot shift test and Lachman test results and better IKDC grades and lower complication rates than synthetic grafts.

Conclusions

This review indicates that for adults, BPTB grafts perform more favorably than synthetic grafts in ACLR in terms of knee stability, function, and complication. More research is needed to compare autologous tendons and allogeneic tendons with artificial ligaments, especially in elderly individuals.

Level of evidence

Level I, systematic review and meta-analysis

The long-term outcomes of different grafts in anterior cruciate ligament reconstruction: a network meta-analysis

OBJECTIVES

To compare the long-term prognosis of patients with different types of grafts used in anterior cruciate ligament reconstruction (ACLR).

METHODS

PubMed, Ovid (MEDLINE and Embase) and the Cochrane library were searched up to Feb 2020. Eligible studies about different grafts in ACLR were searched for identifying the evidence comparing the long-term (mean or median follow-up time or the general description of the follow-up time≥2 years) knee outcomes of different grafts for ACLR. The final included articles and evaluation criteria were confirmed by the authors and senior clinicians to ensure the validity of the included articles. Lysholm score, the results of pivot shift test, Lachman test and International Knee Documentation Committee (IKDC) evaluation were selected as prognostic indicators. A Bayesian network meta-analysis was conducted.

RESULTS

A total of 30 articles were included in our network meta-analysis. Finally, we found that artificial graft or augmentation can provide the not bad Lysholm score but the worse result of IKDC evaluation for patients with ACLR compared with other types of grafts. Double-bundle hamstring autograft can provide a good Lysholm score as well as lower positive rate of pivot shift test and Lachman test. Patellar tendon autograft can provide the better result of IKDC evaluation. The patients with allogeneic tendon graft may get the higher positive rate of pivot shift test and Lachman test. Patients with single-bundle hamstring autograft may get the ordinary result of IKDC evaluation and Lysholm score.

CONCLUSIONS

Double-bundle hamstring autograft may be a better choice because of more items of good prognosis for the patients with ACLR. Patellar tendon autograft is a right choice which only shows the disadvantage on the Lysholm score. The prognosis of patients with single-bundle hamstring autograft is ordinary. The effect of artificial graft or augmentation needs more evidence to prove. Allogeneic tendon graft is not a better choice when compared with other grafts referred in our network meta-analysis.

TRANSLATIONAL POTENTIAL STATEMENT

In this study, we made a comprehensive comparison of the grafts commonly used in anterior cruciate ligament reconstruction. The evidence presented in this study provides a reference for clinicians to select a suitable anterior cruciate ligament graft.

Anterior Cruciate Ligament Reconstruction Using a Bone-Patellar Tendon-Bone Graft With and Without a Ligament Augmentation Device: A 25-Year Follow-up of a Prospective Randomized Controlled Trial

Background

Various grafts and ligament augmentation devices (LADs) have been used in the search for optimal reconstruction of the anterior cruciate ligament (ACL).

Purpose

To compare 25-year follow-up results after ACL reconstruction using a bone-patellar tendon-bone (BPTB) graft with or without the Kennedy LAD.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

One hundred patients undergoing ACL reconstruction between 1991 and 1993 were randomized into 2 groups: reconstruction using a BPTB graft alone (BPTB group, 51 patients) or a BPTB graft with the Kennedy LAD (LAD group, 49 patients). The 25-year follow-up evaluation included a clinical knee examination, patient-reported outcome measures, and an assessment of radiological osteoarthritis (OA) according to the Ahlbäck classification. Additional outcomes were reruptures and knee arthroplasty.

Results

Ninety-three patients (93%) were available for the follow-up evaluation: 48 patients in the BPTB group and 45 in the LAD group. Through telephone calls, 26 patients were excluded from further investigation because of reruptures and arthroplasty in the knee of interest; 67 patients were further investigated. A total of 43 of 44 (98%) and 42 of 44 (95%) patients had negative or 1+ Lachman and pivot-shift test results, respectively. The mean Lysholm score was 85 for the BPTB group and 83 for the LAD group. All mean Knee injury and Osteoarthritis Outcome Score (KOOS) subscale values were ≥73. There were no statistically significant differences between groups in any of these outcomes or regarding the Tegner score, radiological classification of OA, or number of ACL reruptures. Signs of radiological OA were detected in all patients, and severe radiological OA (Ahlbäck grade III, IV, or V) was detected in 32% of patients in the BPTB group and 21% of patients in the LAD group (P = .37). There were 12 patients in the BPTB group and 7 in the LAD group who had documented reruptures (P = .40). One patient in the BPTB group and 6 in the LAD group underwent knee arthroplasty (P = .054).

Conclusion

In the present study, there were no statistically significant differences between groups in any of the outcomes. After 25 years, 19% of patients had reruptures, 27% had severe radiological OA, and 7% underwent knee arthroplasty.

Synthetic devices for reconstructive surgery of the cruciate ligaments: a systematic review

PURPOSE

The role of synthetic devices in the management of the cruciate ligament-injured knee remains controversial. The aim of this systematic review was to assess the safety and efficacy of synthetic devices in cruciate ligament surgery.

METHODS

A systematic review of the electronic databases Medline, Embase, and The Cochrane Library (issue 1, 2014) on January 13, 2014, was performed to identify controlled and uncontrolled trials. Trials that assessed the safety and efficacy of synthetic devices for cruciate ligament surgery were included. The main variables assessed included rates of failure, revision, and noninfective effusion and synovitis. Patient-reported outcome assessments and complications were also assessed where reported.

RESULTS

From 511 records screened, we included 85 articles published between 1985 and 2013 reporting on 6 synthetic devices (ligament augmentation and reconstruction system [Ligament Augmentation and Reconstruction System (LARS; Surgical Implants and Devices, Arc-sur-Tille, France)]; Leeds-Keio [Xiros (formerly Neoligaments), Leeds, England]; Kennedy ligament augmentation device [3M, St Paul, MN]; Dacron [Stryker, Kalamazoo, MI]; Gore-Tex [W.L. Gore and Associates, Flagstaff, AZ]; and Trevira [Telos (limited liability company), Marburg, Germany]). The heterogeneity of the included studies precluded meta-analysis. The results were analyzed by device and then type of reconstruction (anterior cruciate ligament [ACL]/posterior cruciate ligament [PCL]/combined ACL and PCL). The lowest cumulative rates of failure were seen with the LARS device (2.6% for ACL and 1% for PCL surgery). The highest failure rate was seen in the Dacron ACL group (cumulative rate, 33.6%). Rates of noninfective synovitis and effusion ranged from 0.2% in the LARS ACL group to 27.6% in the Gore-Tex ACL group. Revision rates ranged from 2.6% (LARS) to 11.8% (Trevira-Hochfest; Telos). Recent designs, specifically the LARS, showed good improvement in the outcome scores. The mean preoperative and postoperative Lysholm knee scores were 54 and 88, respectively; the mean preoperative and postoperative Tegner activity scale scores were 3.3 and 6, respectively.

CONCLUSIONS

Preliminary results for newer-generation devices, specifically the LARS, show lower reported rates of failure, revision, and sterile effusion/synovitis when compared with older devices.

LEVEL OF EVIDENCE

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

Treatment of anterior cruciate ligament injuries with special reference to surgical technique and rehabilitation: an assessment of randomized controlled trials

PURPOSE

The primary aim was to investigate and assess the current evidence of randomized controlled trials (RCTs) on anterior cruciate ligament (ACL) injuries, with special reference to the choice of surgical techniques and aspects of rehabilitation. A secondary aim was to clarify relative strengths and weaknesses of the selected studies, resolve literature conflicts, and finally, evaluate the need for further studies.

METHODS

A PubMed database search using the key words "anterior cruciate ligament" was performed. The search was limited to only RCTs published in English during the period of January 1995 to March 2009. Articles concerning surgical technique and rehabilitation were obtained. After initial screening and subsequent quality appraisal based on the CONSORT (Consolidated Standards of Reporting Trials) Statement, a total of 70 articles were included in this review.

RESULTS

Initial graft tension and the use of a ligament augmentation device do not affect clinical outcome. Bioabsorbable screws and titanium screws produced equal clinical outcome, regardless of graft type. Radiographic signs of osteoarthritis develop in 50% of ACL-injured patients, regardless of treatment. Meniscectomy further increases the risk. Furthermore, the use of a postoperative knee brace does not affect the clinical outcome after ACL reconstruction. Closed kinetic chain exercises produced less pain and laxity while promoting better subjective outcome than open kinetic chain exercises after patellar tendon reconstruction.

CONCLUSIONS

In terms of quality assessment, several weaknesses pertaining to study design were discovered among the included RCTs, which intelligibly stress the need for further high-quality studies.

LEVEL OF EVIDENCE

Level II, systematic review of RCTs.

Treatment of anterior cruciate ligament injuries, part I

Anterior cruciate ligament injuries are common among athletes. Although the true natural history remains unclear, anterior cruciate ligament injuries are functionally disabling; they predispose the knee to subsequent injuries and the early onset of osteoarthritis. This article, the first in a 2-part series, was initiated with the use of the PubMed database and a comprehensive search of articles that appeared between January 1994 to the present, using the keywords anterior cruciate ligament. A total of 3810 citations were identified and reviewed to determine the current state of knowledge about the treatment of these injuries. Articles pertaining to the biomechanical behavior of the anterior cruciate ligament, the prevalence of anterior cruciate ligament injury, the natural history of the anterior cruciate ligament-deficient knee, injuries associated with anterior cruciate ligament disruption, risk factors for anterior cruciate ligament injury, indications for treatment of anterior cruciate ligament injuries, and nonoperative and operative treatments were obtained, reviewed, and served as the basis for part I. Part II, to be presented in another issue of this journal, includes technical aspects of anterior cruciate ligament surgery, bone tunnel widening, graft healing, rehabilitation after reconstruction, and the effect of sex, age, and activity level on the outcome of surgery. Our approach was to build on prior reviews and to provide an overview of the literature for each of the before-mentioned areas of study by summarizing the highest level of scientific evidence available. For the areas that required a descriptive approach to research, we focused on the prospective studies that were available; for the areas that required an experimental approach, we focused on the prospective, randomized controlled trials and, when necessary, the highest level of evidence available. We were surprised to learn that considerable advances have been made during the past decade regarding the treatment of this devastating injury.

Synovitic cyclops syndrome caused by a Kennedy ligament augmentation device

The cyclops lesion at the tibial attachment of the reconstructed ligament has been known to cause loss of knee extension. We present a case of knee extension loss because of a cyclops lesion caused by Kennedy ligament augmentation device synovitis at 10 years after ACL reconstruction in a 33-year-old man.

Anterior cruciate ligament reconstruction with and without a ligament augmentation device : results at 8-Year follow-up

BACKGROUND

Ligament augmentation devices have been used in anterior cruciate ligament reconstruction since the suggestion of Kennedy et al. in 1980 that such devices would allow grafts to heal faster and more safely.

HYPOTHESIS

Patients who had augmentation will have better outcomes after 8 years.

STUDY DESIGN

Prospective randomized case control study.

METHODS

Between 1991 and 1993, 100 patients were randomized to groups undergoing anterior cruciate ligament reconstruction with bone-patellar tendon-bone grafts with (49) or without (51) use of a Kennedy ligament augmentation device. Of these 100 patients, 94 were examined at an average of 8 years after surgery. Fifteen patients were excluded because of rupture in the other knee and 11 because of rerupture in the same knee.

RESULTS

Of the remaining 68 patients, the mean Lysholm function score was 84 in the augmentation group and 87 in the control group. There was a statistically significant relationship between preoperatively detected cartilage injury and osteoarthritis. Almost half of the patients had developed osteoarthritis. We observed no significant difference between the two groups concerning rerupture rate, Lysholm or Lachman test scores, or KT-1000 arthrometer measurements.

CONCLUSIONS

We found no positive long-term effects supporting the use of augmentation in anterior cruciate ligament reconstruction.

The ligament augmentation device: an historical perspective

Anterior cruciate ligament (ACL) injury is the most common ligament injury in the knee, and a significant number of patients may develop progressive instability and disability despite aggressive rehabilitation. Various materials have been used for its reconstruction. These include autografts, allografts, prosthetic ligaments, and synthetic augmentation of the biological tissue. The concept of ligament augmentation device (LAD) arose from the observation that biological grafts undergo a phase of degeneration and loss of strength before being incorporated. The LAD is meant to protect the biological graft during this vulnerable phase. However, it provokes an inflammatory reaction in the knee, and has been found to delay maturation of autogenous graft in humans. In experimental situations, the LAD has been found to share loads in a composite graft. It has also been found to be substantially stronger than the biological graft. However, in clinical situations no significant advantages have been observed with the use of LAD to augment patellar tendon or hamstring reconstruction of the chronic ACL-deficient knee or in the acute setting to augment repair of the torn ACL. There are very few reports of the use of LAD in reconstruction of the posterior cruciate ligament, and again these do not suggest any advantage in its use. Insertion of the LAD implies the introduction of a foreign material into the knee, has been associated with complications such as reactive synovitis and effusions, and may also be associated with an increased risk of infection. At present, there is no evidence that its routine use should be advocated in uncomplicated reconstructions of the ACL using biological grafts.

Braided polypropylene augmentation device in reconstructive surgery of the anterior cruciate ligament: long-term clinical performance of 594 patients and short-term arthroscopic results, failure analysis by scanning electron microscopy, and synovial histomorphology

Long-term clinical results and short-term arthroscopic and microscopic findings from two augmented reconstruction procedures for the ruptured anterior cruciate ligament are reported. The braided polypropylene ligament augmentation device (Kennedy model) was used with temporary double-end fixation in 279 patients to augment the attachment of the anterior cruciate ligament after acute proximal rupture and in 315 patients to augment a bone-tendon-bone autograft, mainly after chronic instability. Check arthroscopy was performed and the metal fixation hardware was removed after a mean of 11 months. Of the 569 patients evaluated, 101 partial or total breakages of the ligament augmentation device were found. Together with nine breakages detected late in the follow-up period, 110 (19.3%) failures were found. Most of these failures were accompanied by effusion that was immediately alleviated when the failed device was removed. No generalized synovitis was visible. Scanning electron microscopic analysis of 24 retrieved failed ligament augmentation devices showed fatigue to be the principal failure mode, together with local abrasion at the fracture. Synovial biopsies were taken during arthroscopy in 84 patients with and without ligament augmentation device-failure who had given informed consent, and histological evaluation revealed that in 21 patients, chronic but no acute synovial inflammation was found, and wear particles could be identified in foreign body cells in 17. Statistically, the presence of chronic synovitis was predicted neither by wear particles and foreign body cells nor by abrasion or fatigue failure of the ligament augmentation device. Irrespective of the failures, for which ligament augmentation device removal is recommended, in the final Orthopaedische Arbeitsgemeinschaft Knie evaluation (after a mean of 6.2 years), excellent and good clinical results were found in 83.6% of all 594 patients.

Anterior cruciate ligament reconstruction with the patellar tendon--augmentation or not? A 2-year follow-up of 82 patients

The aim of this bi-centre study was to assess the possible effects of the addition of the Kennedy ligament augmentation device (LAD) in the reconstruction of the anterior cruciate ligament (ACL). The method of reconstruction used was a modification of the Brückner and Broström procedures, using the medial third of the patellar tendon tunnelled through the proximal tibia into the lateral femoral condyle and fastened with pull-out sutures. Eighty-two patients with chronic ACL insufficiency and severe symptoms of instability in spite of physiotherapy were randomly selected for reconstruction with or without a LAD. The LAD-augmented knees had the synthetic augmentation stitched to and embedded into the autogenous tissue and the composite graft was pulled through a femoral tunnel and stapled proximally. The patients were followed up regularly and the 2-year results are presented here. The outcome in both groups was good. The augmented-knee group had a larger extension deficit 1 month post-operatively compared to the non-augmented knee group but a smaller extension deficit at the 2-year follow-up. There was no difference in the median of the Lysholm knee function score but there were more patients in the non-augmented group with a lower Lysholm knee function score at the 2-year follow-up.