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Does autograft choice determine intermediate-term outcome of ACL reconstruction?

ABSTRACT: Many clinical studies and systematic reviews have compared the short-term (2 years) outcomes of ACL reconstruction with hamstring and patellar tendon autograft. Few differences have been observed, with the exception of increased kneeling pain with patellar tendon grafts. The goal of this systematic review is to determine whether there are differences in clinical, patient-reported, or radiographic outcomes based on graft choice at a minimum of 5 years after ACL reconstruction.A systematic review was performed to identify all prospective outcome studies comparing patellar tendon and hamstring autograft ACL reconstruction with minimum follow-up of at least 5 years. Seven studies were identified and meta-analysis of select data determined to be sufficiently homogenous was performed (failure and laxity).Five randomized controlled trials and two prospective cohorts comparing hamstring and patellar tendon autografts were identified. Clinical assessment [failure rate, International Knee Documentation Committee (IKDC) class, Lachman, pivot shift, and KT 1000 testing] showed no difference between grafts. Patient-reported outcomes (Lysholm, Cincinnati, and IKDC) showed no difference. Both anterior knee pain (3/3 studies) and kneeling pain (4/4 studies) were more frequent in the patellar tendon group. However, the patient-reported outcomes in these studies were not different. Radiographic evidence of osteoarthritis was inconsistent between autograft choices.This level II systematic review demonstrates no difference in major clinical results between graft types with the exception of increased anterior knee and kneeling pain. There exists a potential for increased incidence of osteoarthritis in the patellar tendon group but increased sample size is required. These longer-term outcomes are similar to results of prior systematic reviews with two-year follow-up.

SUBMITTER: Magnussen RA

PROVIDER: S-EPMC3745218 | biostudies-literature | 2011 Mar

REPOSITORIES: biostudies-literature

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Does autograft choice determine intermediate-term outcome of ACL reconstruction?

Magnussen Robert A RA Carey James L JL Spindler Kurt P KP

Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA 20101015 3

<h4>Purpose</h4>Many clinical studies and systematic reviews have compared the short-term (2 years) outcomes of ACL reconstruction with hamstring and patellar tendon autograft. Few differences have been observed, with the exception of increased kneeling pain with patellar tendon grafts. The goal of this systematic review is to determine whether there are differences in clinical, patient-reported, or radiographic outcomes based on graft choice at a minimum of 5 years after ACL reconstruction.<h4> ...[more]

PMID: 20953764

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Project description:BackgroundBone-patellar tendon-bone (bone-tendon-bone) and four-strand hamstring tendon grafts (hamstring) are the most commonly utilized autografts for primary anterior cruciate ligament (ACL) reconstruction. Existing clinical trials, registry studies, and meta-analyses offer conflicting opinions regarding the most favorable graft choice.Questions/purposesWhich graft type for ACL reconstruction (bone-tendon-bone or hamstring) has a higher risk of (1) graft rupture and/or (2) graft laxity?MethodsWe performed a meta-analysis of randomized controlled trials (RCTs), prospective cohort studies, and high-quality national registry studies to compare the outcomes of primary ACL reconstruction with bone-tendon-bone autograft or hamstring autograft. Studies that compared these graft types were identified through a comprehensive search of electronic databases (PubMed, MEDLINE, EMBASE, and the Cochrane Library). Two independent reviewers utilized the Jadad scale for RCT study quality and the Modified Coleman Methodology Score for prospective comparative and registry study quality. The included studies were analyzed for the primary outcome measure of graft rupture with or without revision ACL surgery. In surviving grafts, secondary outcomes of graft laxity were quantified by KT1000/2000™ testing, a positive pivot shift test, and a positive Lachman test. Meta-analysis was performed with Review Manager. A total of 47,613 ACL reconstructions (39,768 bone-tendon-bone and 7845 hamstring) from 14 RCTs, 10 prospective comparative studies, and one high-quality national registry study were included in this meta-analysis. Mean age was 28 years in both groups. Sixty-three percent of patients in the bone-tendon-bone cohort were men versus 57% of patients in the hamstring cohort. Mean followup was 68 ± 55 months.ResultsTwo hundred twelve of 7560 (2.80%) bone-tendon-bone grafts ruptured compared with 1123 of 39,510 (2.84%) in the hamstring group (odds ratio = 0.83, 95% confidence interval, 0.72-0.96; p = 0.01). The number needed to treat analysis found that 235 patients would need to be treated with a bone-tendon-bone graft over a hamstring tendon graft to prevent one graft rupture. Instrumented laxity analysis showed that 22% (318 of 1433) of patients in the bone-tendon-bone group had laxity compared with 18% (869 of 4783) in the hamstring tendon group (odds ratio = 0.86; p = 0.16). Pivot shift analysis showed a positive pivot shift in 19% (291 of 1508) of the bone-tendon-bone group compared with 17% (844 of 5062) in the hamstring group (odds ratio = 0.89; p = 0.51). Lachman testing showed a positive Lachman in 25% (71 of 280) of patients receiving bone-tendon-bone grafts compared with 25% (73 of 288) in the hamstring group (odds ratio = 0.96; p = 0.84).ConclusionsIn this meta-analysis of short- to mid-term followup after primary ACL reconstruction, hamstring autografts failed at a higher rate than bone-tendon-bone autografts. However, failure rates were low in each group, the difference observed was small, and we observed few differences between graft types in terms of laxity. Both graft types remain viable options for primary ACL reconstruction, and the difference in failure rate should be one part of a larger conversation with each individual patient about graft selection that should also include potential differences in donor site morbidity, complication rates, and patient-reported outcome measures. Continued prospective collection of patient data will be important going forward as we attempt to further characterize the potential differences in outcomes attributable to graft selection.Level of evidenceLevel III, therapeutic study.

Project description:Objectives: Preclinical studies and an early clinical cohort study have suggested that for complete midsubstance ACL injuries, the technique of suture repair of the anterior cruciate ligament (ACL) augmented with a protein implant placed in the gap between the torn ends (bridge-enhanced ACL repair) may be a viable alternative to ACL reconstruction. We hypothesized that patients treated with bridge-enhanced ACL repair would have non-inferior patient reported outcomes and anteroposterior (AP) laxity, and superior hamstring strength at 2 years after surgery when compared with subjects who had ACL reconstruction with autograft. Study Design: Prospective Randomized Control Trial (NCT02664545). Methods: One hundred patients, ages 13 to 35, with complete mid-substance ACL injuries, were enrolled and underwent surgery within 45 days of injury. Sixty-five patients were randomized to receive a bridge-enhanced ACL repair (BEAR group) and 35 were randomized to receive autograft ACL reconstruction (ACLR group). Outcomes, including the International Knee Documentation Committee (IKDC) Subjective score, instrumented AP laxity and muscle strength were assessed at 2 years post-operatively. Both patients and assessors were blinded as to surgical assignment until after the 2-year assessment. Results: Ninety-six percent of the subjects returned for follow-up at 2 years. The median age of the subjects in both groups at enrollment was 17 years and the median pre-operative Marx score in both groups was 16 points. Non-inferiority criteria were met for both the IKDC subjective score and AP laxity. The BEAR group had significantly better recovery of hamstring strength than the ACLR group (p<0.001). The number of subjects who were reinjured and required a second ACL surgery was not statistically different between the two groups. Subjects who converted from BEAR to ACLR in the study period had outcomes at the 2-year point that were similar to those for subjects who had only a single ipsiateral ACL procedure (BEAR or ACLR). Conclusion: Bridge-enhanced ACL repair using a specific protein-based implant led to non-inferior outcomes to that of ACL reconstruction for patient reported and instrumented knee laxity measures at 2 years after surgery in a young and active cohort of patients with acute mid-substance ACL tears.

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Does autograft choice determine intermediate-term outcome of ACL reconstruction?

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Does autograft choice determine intermediate-term outcome of ACL reconstruction?

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