Quadriceps tendon autograft is becoming increasingly popular in revision ACL reconstruction

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Abstract

Purpose

To evaluate trends in revision anterior cruciate ligament reconstruction (ACL-R), with emphasis on intra-articular findings, grafts, and concurrent procedures. It was hypothesized that revision ACL-Rs over time show a trend toward increased complexity with increased use of autografts over allografts.

Methods

This was a two-center retrospective study including patients undergoing revision ACL-R between 2010 and 2020. Demographic and surgical data including intra-articular findings and concurrent procedures were collected and compared for the time periods 2010–2014 and 2015–2020. All collected variables were compared between three pre-defined age groups (< 20 years, 20–30 years, > 30 years), right and left knees, and males and females. A time series analysis was performed to assess trends in revision ACL-R.

Results

This study included 260 patients with a mean age of 26.2 ± 9.4 years at the time of the most recent revision ACL-R, representing the first, second, third, and fourth revision ACL-R for 214 (82%), 35 (14%), 10 (4%), and 1 (< 1%) patients, respectively. Patients age > 30 years showed a significantly longer mean time from primary ACL-R to most recent revision ACL-R (11.1 years), compared to patients age < 20 years (2.2 years, p < 0.001) and age 20–30 years (5.5 years, p < 0.05). Quadriceps tendon autograft was used significantly more often in 2015–2020 compared to 2010–2014 (49% vs. 18%, p < 0.001). A high rate of concurrently performed procedures including meniscal repairs (45%), lateral extra-articular tenodesis (LET; 31%), osteotomies (13%), and meniscal allograft transplantations (11%) was shown. Concurrent LET was associated with intact cartilage and severely abnormal preoperative knee laxity and showed a statistically significant and linear increase over time ( p < 0.05). Intact cartilage (41%, p < 0.05), concurrent medial meniscal repairs (39%, p < 0.05), and LET (35%, non-significant) were most frequently observed in patients aged < 20 years.

Conclusion

Quadriceps tendon autograft and concurrent LET are becoming increasingly popular in revision ACL-R. Intact cartilage and severely abnormal preoperative knee laxity represent indications for LET in revision ACL-R. The high rate of concurrent procedures observed demonstrates the high surgical demands of revision ACL-R.

Level of evidence

Level III.

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Most cited references 59

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When the entire population is the sample: strengths and limitations in register-based epidemiology.

Lau Thygesen, Annette Kjær Ersbøll (2014)

Studies based on databases, medical records and registers are used extensively today in epidemiological research. Despite the increasing use, no developed methodological literature on use and evaluation of population-based registers is available, even though data collection in register-based studies differs from researcher-collected data, all persons in a population are available and traditional statistical analyses focusing on sampling error as the main source of uncertainty may not be relevant. We present the main strengths and limitations of register-based studies, biases especially important in register-based studies and methods for evaluating completeness and validity of registers. The main strengths are that data already exist and valuable time has passed, complete study populations minimizing selection bias and independently collected data. Main limitations are that necessary information may be unavailable, data collection is not done by the researcher, confounder information is lacking, missing information on data quality, truncation at start of follow-up making it difficult to differentiate between prevalent and incident cases and the risk of data dredging. We conclude that epidemiological studies with inclusion of all persons in a population followed for decades available relatively fast are important data sources for modern epidemiology, but it is important to acknowledge the data limitations.

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Lateral Extra-articular Tenodesis Reduces Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-Year Outcomes From the STABILITY Study Randomized Clinical Trial

Alan Getgood, Dianne Bryant, Robert C. Litchfield … (2020)

Persistent anterolateral rotatory laxity after anterior cruciate ligament (ACL) reconstruction (ACLR) has been correlated with poor clinical outcomes and graft failure. We hypothesized that a single-bundle, hamstring ACLR in combination with a lateral extra-articular tenodesis (LET) would reduce the risk of ACLR failure in young, active individuals. Randomized controlled trial; Level of evidence, 1. This is a multicenter, prospective, randomized clinical trial comparing a single-bundle, hamstring tendon ACLR with or without LET performed using a strip of iliotibial band. Patients 25 years or younger with an ACL-deficient knee were included and also had to meet at least 2 of the following 3 criteria: (1) grade 2 pivot shift or greater, (2) a desire to return to high-risk/pivoting sports, (3) and generalized ligamentous laxity (GLL). The primary outcome was ACLR clinical failure, a composite measure of rotatory laxity or a graft rupture. Secondary outcome measures included the P4 pain scale, Marx Activity Rating Scale, Knee injury Osteoarthritis and Outcome Score (KOOS), International Knee Documentation Committee score, and ACL Quality of Life Questionnaire. Patients were reviewed at 3, 6, 12, and 24 months postoperatively. A total of 618 patients (297 males; 48%) with a mean age of 18.9 years (range, 14-25 years) were randomized. A total of 436 (87.9%) patients presented preoperatively with high-grade rotatory laxity (grade 2 pivot shift or greater), and 215 (42.1%) were diagnosed as having GLL. There were 18 patients lost to follow-up and 11 who withdrew (~5%). In the ACLR group, 120/298 (40%) patients sustained the primary outcome of clinical failure, compared with 72/291 (25%) in the ACLR+LET group (relative risk reduction [RRR], 0.38; 95% CI, 0.21-0.52; P < .0001). A total of 45 patients experienced graft rupture, 34/298 (11%) in the ACLR group compared with 11/291 (4%) in the ACL+LET group (RRR, 0.67; 95% CI, 0.36-0.83; P < .001). The number needed to treat with LET to prevent 1 patient from graft rupture was 14.3 over the first 2 postoperative years. At 3 months, patients in the ACLR group had less pain as measured by the P4 ( P = .003) and KOOS ( P = .007), with KOOS pain persisting in favor of the ACLR group to 6 months ( P = .02). No clinically important differences in patient-reported outcome measures were found between groups at other time points. The level of sports activity was similar between groups at 2 years after surgery, as measured by the Marx Activity Rating Scale ( P = .11). The addition of LET to a single-bundle hamstring tendon autograft ACLR in young patients at high risk of failure results in a statistically significant, clinically relevant reduction in graft rupture and persistent rotatory laxity at 2 years after surgery. NCT02018354 ( ClinicalTrials.gov identifier)

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Ipsilateral graft and contralateral ACL rupture at five years or more following ACL reconstruction: a systematic review.

Casey W. Dunn, Robert Magnussen, David Wright … (2011)

Injury to the ipsilateral graft used for reconstruction of the anterior cruciate ligament (ACL) or a new injury to the contralateral ACL is a devastating outcome following successful ACL reconstruction, rehabilitation, and return to sport. Little evidence exists regarding the intermediate to long-term risk of these events. The present study is a systematic review of Level-I and II prospective studies that evaluated the rate of rupture of the ACL graft and the ACL in the contralateral knee following a primary ACL reconstruction with use of a mini-open or arthroscopic bone-tendon-bone or hamstring autograft after a minimum duration of follow-up of five years. Six studies met the inclusion and exclusion criteria. The ipsilateral ACL graft rupture rate ranged from 1.8% to 10.4%, with a pooled percentage of 5.8%. The contralateral injury rate ranged from 8.2% to 16.0%, with a pooled percentage of 11.8%. This systematic review demonstrates that the risk of ACL tear in the contralateral knee (11.8%) is double the risk of ACL graft rupture in the ipsilateral knee (5.8%). Additional studies must be performed to determine predictors for these injuries and to improve our ability to avoid this devastating outcome.

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Author and article information

Contributors

Volker Musahl: musahlv@upmc.edu

Journal

Journal ID (nlm-ta): Knee Surg Sports Traumatol Arthrosc

Journal ID (iso-abbrev): Knee Surg Sports Traumatol Arthrosc

Title: Knee Surgery, Sports Traumatology, Arthroscopy

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 0942-2056

ISSN (Electronic): 1433-7347

Publication date (Electronic): 16 February 2021

Publication date PMC-release: 16 February 2021

Publication date (Print): 2022

Volume: 30

Issue: 1

Pages: 149-160

Affiliations

[1 ]GRID grid.21925.3d, ISNI 0000 0004 1936 9000, Department of Orthopaedic Surgery, , UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, ; 3200 S. Water St., Pittsburgh, PA 15203 USA

[2 ]GRID grid.15474.33, ISNI 0000 0004 0477 2438, Department for Orthopaedic Sports Medicine, , Klinikum rechts der Isar, Technical University of Munich, ; Ismaninger Str. 22, 81675 Munich, Germany

[3 ]GRID grid.39381.30, ISNI 0000 0004 1936 8884, Department of Orthopedic Surgery, , Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, ; 3M Centre, 1151 Richmond Street, London, ON N6A 3K7 Canada

Author information

Philipp W. Winkler http://orcid.org/0000-0002-3997-1010

Article

Publisher ID: 6478

DOI: 10.1007/s00167-021-06478-y

PMC ID: 8800889

PubMed ID: 33591370

SO-VID: 9837f83f-d2ed-45da-9e93-b5e7d117c735

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

History

Date received : 29 December 2020

Date accepted : 25 January 2021

Custom metadata

issue-copyright-statement © The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2022

ScienceOpen disciplines: Surgery

Keywords: acl,anterior cruciate ligament,revision,lateral extra-articular tenodesis,quadriceps tendon,allograft

Data availability:

ScienceOpen disciplines: Surgery

Keywords: acl, anterior cruciate ligament, revision, lateral extra-articular tenodesis, quadriceps tendon, allograft

Quadriceps tendon autograft is becoming increasingly popular in revision ACL reconstruction

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25th European Students' Conference

Most cited references 59

When the entire population is the sample: strengths and limitations in register-based epidemiology.

Lateral Extra-articular Tenodesis Reduces Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-Year Outcomes From the STABILITY Study Randomized Clinical Trial

Ipsilateral graft and contralateral ACL rupture at five years or more following ACL reconstruction: a systematic review.

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