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Internal Brace ACL Repair is Associated with High Failure Rate in the First Two Years Post-Surgery

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Abstract

Objectives To compare graft/internal brace survival, self-reported functional outcomes, and joint laxity in adolescents who underwent quadriceps tendon patellar autograft (QPA) reconstruction versus ACL repair with internal brace ligament augmentation. Methods We identified all adolescent and pediatric subjects who underwent primary ACL reconstruction or repair with internal brace augmentation between January 2013 and January 2016. Only subjects with a minimum of 6 months of follow-up were included. Graft failure, range of motion (ROM), complications, and demographic information including age and gender was collected. Failure was defined as the need for revision surgery or MRI-confirmed graft/internal brace failure. Subjects were prospectively contacted by telephone and were invited to either schedule a follow-up appointment or to complete research questionnaires over the phone. Objective joint laxity measures, KT1000, were obtained from a subset of subjects (N=25 QPA and N=6 repair group) that completed the research visit. Wilcoxon rank sum tests were used to compare IKDC and joint laxity measure. Multi-variable Cox proportional hazards regression analyses were used to compare failure-free survival in the two groups during the first 24 months post-surgery. Results The final cohort included 132 patients in the QPA group (52% female) and 19 patients in the repair group (53% female). The repair group tended to be younger (mean: 14.1 yrs, ±2.9 vs 15.5 yrs, ±1.8). Median duration of follow-up was 2.1 years [range: 0.5-4 years] in the repair group compared to 1.2 years [range: 0.5-4 years] in the QPA group. Within the first 24 months post-surgery, the cumulative incidence of failure was 3.8% (5/132) in the QPA group compared to 52.6% (10/19) in the repair group. After adjusting for age, the hazard of failure in the repair group was 22.1 [95% CI: 6.7 to 73.2, p <0.0001] times the hazard of failure in the QPA group. KT-1000 side-to-side joint laxity measures in the repair group [Median: 2.5 mm, range: -1 mm to 7 mm] were significantly [p=0.0212] higher than the joint laxity measures in the QPA group [Median: 1.0 mm, range: -1 mm to 4 mm]. There was no difference [p= 0.3826] in IKDC scores in the repair group [N=53, median: 97, range: 58-100] compared to the QPA group [N=10, median: 94, range: 32-100]. Conclusion Failure rate and joint laxity measures were significantly increased in the internal brace repair group relative to the QPA group. Failure-free survival in the repair group was less than 50% at two years.The high failure rate in the repair group should be considered when selecting the appropriate intervention for the pediatric adolescent athlete with an ACL injury.
2018 AOSSM Annual Meeting
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Internal Brace ACL Repair is Associated with High Failure Rate in the First Two Years Post-
Surgery
Alexia Georgia Gagliardi, BA1, Patrick M. Carry, MS1, Ariel Kiyomi Daoud, BA2, Harin Bhavin Parikh, Medical Student2,
Jay C. Albright, MD1
1Musculoskeletal Research Center, Orthopedics Institute, Children’s Hospital Colorado, Aurora, CO, USA, 2Department of
Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
Objectives: To compare graft/internal brace survival, self-reported functional outcomes, and joint laxity in
adolescents who underwent quadriceps tendon patellar autograft (QPA) reconstruction versus ACL repair with
internal brace ligament augmentation.
Methods: We identified all adolescent and pediatric subjects who underwent primary ACL reconstruction or repair
with internal brace augmentation between January 2013 and January 2016. Only subjects with a minimum of 6
months of follow-up were included. Graft failure, range of motion (ROM), complications, and demographic
information including age and gender was collected. Failure was defined as the need for revision surgery or MRI-
confirmed graft/internal brace failure. Subjects were prospectively contacted by telephone and were invited to either
schedule a follow-up appointment or to complete research questionnaires over the phone. Objective joint laxity
measures, KT1000, were obtained from a subset of subjects (N=25 QPA and N=6 repair group) that completed the
research visit. Wilcoxon rank sum tests were used to compare IKDC and joint laxity measure. Multi-variable Cox
proportional hazards regression analyses were used to compare failure-free survival in the two groups during the
first 24 months post-surgery.
Results: The final cohort included 132 patients in the QPA group (52% female) and 19 patients in the repair group
(53% female). The repair group tended to be younger (mean: 14.1 yrs, ±2.9 vs 15.5 yrs, ±1.8). Median duration of
follow-up was 2.1 years [range: 0.5-4 years] in the repair group compared to 1.2 years [range: 0.5-4 years] in the
QPA group. Within the first 24 months post-surgery, the cumulative incidence of failure was 3.8% (5/132) in the
QPA group compared to 52.6% (10/19) in the repair group. After adjusting for age, the hazard of failure in the repair
group was 22.1 [95% CI: 6.7 to 73.2, p <0.0001] times the hazard of failure in the QPA group. KT-1000 side-to-side
joint laxity measures in the repair group [Median: 2.5mm, range: -1mm to 7mm] were significantly [p=0.0212] higher
than the joint laxity measures in the QPA group [Median: 1.0mm, range: -1mm to 4mm]. There was no difference
[p= 0.3826] in IKDC scores in the repair group [N=53, median: 97, range: 58-100] compared to the QPA group
[N=10, median: 94, range: 32-100].
Conclusion: Failure rate and joint laxity measures were significantly increased in the internal brace repair group
relative to the QPA group. Failure-free survival in the repair group was less than 50% at two years.The high failure
rate in the repair group should be considered when selecting the appropriate intervention for the pediatric
adolescent athlete with an ACL injury.
The Orthopaedic Journal of Sports Medicine, 6(7)(suppl 4)
DOI: 10.1177/2325967118S00068
©The Author(s) 2018
Article
The internal brace (IB) technique is a promising treatment option for repairing the proximal rupture of the anterior cruciate ligament (ACL). This paper presents a biomechanical evaluation of the IB technique. Sixteen cadaveric sheep knees underwent monotonic tensile tests, cyclic loading, and passive flexion-extension testing. Data were compared in a series of eight control specimens with an intact ACL and eight repaired specimens where the ACL was cut and repaired using the IB. In parallel with the mechanical testing, finite element analysis (FEA) was performed to investigate the influence of IB loading on the femur-ACL-tibia complex (FATC). The 3D geometry of the FATC was reconstructed from CT scans of the sheep. The IB 3D model was integrated with the 3D FATC for FEA to obtain the femur-repaired ACL with IB - tibia complex (FRA-IB-TC) group. For the intact specimens, the mean (± SD) failure load in the tensile testing was 937 N (± 192 N), while for the FRA-IB-TC specimens, it was 519 N (± 52 N). The FRA-IB-TC remained biomechanically stable during the cyclic loading testing. The FEA demonstrated an increase in ACL stress to 24.59 MPa and displacement values of 0.391 mm. The IB construct exhibited shear and notch effects at the button-suture-bone fixation site. Testing on this sheep model allowed us a parametric analysis of the impact of the IB repair technique. However, the results will need to be confirmed in a human model. In conclusion, although the IB technique has biomechanical drawbacks, the mechanical properties of the technique are satisfactory.
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