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Clinical and arthroscopic outcomes of single-bundle anterior cruciate ligament reconstruction using autologous hamstrings augmented with ligament augmentation and reconstruction systems compared with four-strand hamstring tendon grafts alone
Abstract and Figures
PurposeTo compare the clinical, radiological, and second-look arthroscopic outcomes in patients who underwent anterior cruciate ligament (ACL) reconstruction using a four-strand hamstring tendon graft (hamstring group) either without augmentation or with ligament augmentation and reconstruction system (LARS) augmentation (LARS augmentation group).Methods
From January 2018 to December 2019, patients who underwent ACL reconstruction were included. Patient-reported outcome measures (PROMs) were undertaken pre-operatively and at three, six, 12, and 24 months post-operatively. Arthroscopic evaluation was performed focusing on the morphology of the graft based on graft tension, graft tear, and synovial coverage.ResultsA total of 178 consecutive patients received single-bundle ACL reconstruction, 89 patients in each group, and 20 patients were lost to follow-up in the first two years. At the three month follow-up, the LARS augmentation group had significantly higher Lysholm scores, IKDC scores, and KOS-ADLS scores than the hamstring group (P < 0.001). At the three, six and 12-month follow-ups, there were significantly higher Tegner scores and ACL-RSI scores in the LARS augmentation group than in the hamstring group (P < 0.05). At the three and six month follow-ups, the LARS augmentation group had significantly higher rates of return to sports and return to sports at their preinjury level (P < 0.05). There were no between-group differences in other outcomes, including arthroscopic outcomes, graft signal intensity, post-operative complications or rerupture rates.Conclusions
Autologous hamstring augmented with the LARS augmentation technique provides good and realistic clinical and functional results during the early post-operative period with high levels of satisfaction of patients, including participation in sports and physical activity, and high rates of return to sports at the preinjury level, without any apparent complications compared with hamstring ACL reconstruction alone. No increases in complication, reinjury rates, or increased lateral laxity were observed at the 12-month or 24-month follow-up.
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Background
Few studies have reported the return-to-sports (RTS) rate in patients after augmentation of autologous anterior cruciate ligament reconstruction (ACLR) with the Ligament Augmentation and Reconstruction System (LARS).
Purpose/Hypothesis
The purpose of this study was to compare postoperative outcomes in patients who underwent ACLR with single-bundle 4-strand hamstring autograft either without augmentation (HA-ACLR group) or with LARS augmentation (AUG-ACLR group). It was hypothesized that clinical outcomes and RTS rates would be better in the AUG-ACLR group at the 1-year follow-up, with similar outcomes in both cohorts by 2 years.
Study Design
Cohort study; Level of evidence, 3.
Methods
Patients who underwent ACLR between April 2014 and December 2017 were included in the current comparative study if they were skeletally mature and had 1- and 2-year follow-up outcomes; patients with concomitant meniscal surgery were also included. Included were 66 patients with AUG-ACLR (mean age, 26.8 years; 67% male) and 130 patients with HA-ACLR (mean age, 27.5 years; 61% male). Subjective outcome measures included the International Knee Documentation Committee Subjective Knee Evaluation Form, Knee injury and Osteoarthritis Outcome Score, Lysholm scale, Tegner activity scale, and the Noyes sports activity rating scale. Objective measures included knee laxity, maximal isokinetic knee flexion and extension strength, and the results of 4 functional hop tests.
Results
There were no significant differences between the study groups in age, sex distribution, body mass index, time to surgery, or number of concurrent meniscal surgeries. At the 1-year follow-up, the AUG-ACLR group had a significantly higher Tegner score ( P = .001) and rates of RTS ( P = .029) and return to preinjury level of sport ( P = .003) compared with the HA-ACLR group. At the 2-year follow-up, there were no differences in these measures between groups. There were no between-group differences in other subjective outcomes, knee laxity, or strength and hop test results at either postoperative time point. There were also no differences in rerupture rates or other complications between the groups.
Conclusion
Patients with AUG-ACLR had higher 1-year postoperative Tegner scores and rates of RTS and preoperative sport level compared with the HA-ACLR group. The 2-year rerupture rate for the AUG-ACLR group was low, and no intra-articular inflammatory complications were noted.
Background
There is a lack of research on the effects of a postoperative rehabilitation program on anterior cruciate ligament (ACL) graft rupture.
Hypothesis
We hypothesized that a hip-focused rehabilitation protocol with graft rupture education and avoidance training (HIP-GREAT program) would demonstrate lower ACL graft rupture rates compared with a traditional physical therapy (PT) program.
Study Design
Cohort study; Level of evidence, 3.
Methods
This study consisted of young athletes who had undergone ACL reconstruction at a single institution. Postoperatively, 136 participants (mean age, 16.9 ± 2.4 years) were enrolled in a traditional PT protocol between 2006 and 2010, and 153 participants (mean age, 17.0 ± 2.3 years) were enrolled in the HIP-GREAT protocol between 2011 and 2015. Follow-up rates were 31% (42/136) and 27% (41/153) in the traditional PT and HIP-GREAT groups, respectively, at 3 years postoperatively. The hazard ratio was calculated, and absolute risk reduction (ARR) and number-needed-to-treat (NNT) analyses were performed to compare the 2 protocols.
Results
ACL graft rupture occurred in 10 patients (7.4%) in the traditional PT group and 5 patients (3.3%) in the HIP-GREAT group. This difference was not statistically significant (hazard ratio, 0.39; 95% CI, 0.14 to 1.16; P = .09). The ARR was 0.041 (95% CI, –0.011 to 0.093), and the NNT was 24.5.
Conclusion
This study did not demonstrate a statistically significant reduction of ACL graft rupture in patients in the HIP-GREAT group. However, high ARR values and low NNT values were found, which suggests the possible effectiveness of the HIP-GREAT protocol to reduce ACL graft ruptures in young athletes.
Purpose of Review
Anterior cruciate ligament reconstruction is one of the most common orthopedic procedures performed, accounting for over 200,000 cases annually. Despite the high prevalence, there is still much debate as to the optimal graft choice. The purpose of this review is to evaluate the current literature and discuss the reported outcomes for the most common graft choices.
Recent Findings
The most common autografts being used include bone-patellar tendon-bone (BPTB), hamstring tendon (HT), and quadriceps tendon (QT). Hamstring tendon might have a slightly higher re-tear rate when compared with BPTB (2.84 versus 2.80). However, BPTB has a higher rate of anterior knee and kneeling pain in the short- and mid-term follow-up. This has not been shown to be the case in long-term follow-up. Allograft is a viable option for revisions and primaries in patients greater than 35 years old; however, re-tear rate increases significantly in younger patients.
Summary
ACL reconstruction graft choice is a highly studied and yet still exceedingly debated topic. Most large studies report either no significant difference or a small difference in failure rate and outcome scores between the different autograft choices. Allografts have been demonstrated to have an increased risk of failure in younger athletes and should be reserved for revision cases and those aged 35 years and older. Graft choice should ultimately be decided upon based on surgeon comfort and experience and individual patient characteristics.
Background
There are a number of surgical methods for undertaking anterior cruciate ligament (ACL) reconstruction (ACLR), although relatively high rates of ipsilateral retears and contralateral tears exist, with only 65% of patients returning to their preinjury level of sport. ACLR techniques adopting synthetic augmentation have been proposed in an attempt to improve clinical outcomes and reduce reinjury rates.
Purpose
To determine the efficacy of ACLR using autologous hamstrings augmented with the Ligament Augmentation and Reconstruction System (LARS).
Study Design
Case series; Level of evidence, 4.
Methods
A total of 65 patients were prospectively treated with arthroscopically assisted single-bundle ACLR using hamstrings augmented with the LARS, of whom 50 were available for 1- and 2-year reviews. Patient-reported outcome measures (PROMs), KT-1000 arthrometer testing, knee range of motion, peak isokinetic knee strength testing, and a battery of 4 hop tests were employed. Limb symmetry indices (LSIs) were calculated. Analysis of variance was used to evaluate differences over time and between limbs. Data on return to the preinjury level of sport, retears, and reoperations were collected.
Results
High PROM scores were demonstrated at 1 and 2 years. Before the injury, 47 patients (94%) were actively participating in level 1 or 2 sports, with 38 (76%) and 43 (86%) patients having returned at 1 and 2 years, respectively. Normal (<3 mm; 90%) or nearly normal (3-5 mm; 10%) KT-1000 arthrometer side-to-side differences were observed at 2 years. Apart from knee flexion ( P < .0001), extension ( P = .001), and the 6-m timed hop ( P = .039), there were no between-limb differences at 1 year, and there were no differences on any objective measures at 2 years (all P > .05). Mean LSIs across all measures were ≥90%. At 2 years, 84% to 90% of patients were ≥90% on the hop tests, with 72% and 76% of patients having ≥90% for extension and flexion strength, respectively. Two reoperations were undertaken for meniscal tears (7 and 8.5 months), 1 patient (2%) suffered a retear at 7 months, and 2 patients (3%) suffered a contralateral tear (8 and 12 months).
Conclusion
This augmented ACLR technique demonstrated good clinical scores, a high rate of return to sport, and low rates of secondary ruptures and contralateral ACL tears at 2 years. Some caution should be noted in interpreting these results, as 15 of 65 patients (23%) were not included in the 2-year follow-up.
Anterior cruciate ligament (ACL) injuries are common among adolescent athletes and are rising with increased participation in higher level athletics at earlier ages. In these young patients, often with open physes, soft tissue grafts continue to be the primary graft choice for ACL reconstruction. Reinjury continues to be a concern in this high-risk age group, with failure rates 2 to 3 times higher than in adults. Recently, primary ACL reconstruction with suture tape augmentation/reinforcement has been described in both hamstring autografts and allografts. Purported advantages include protection of the graft during the revascularization and remodeling phase of incorporation. This Technical Note details a surgical technique of independent suture tape reinforcement during primary all soft tissue quadriceps tendon autograft ACL reconstruction using an all-inside technique.
Context
Anterior cruciate ligament (ACL) reconstruction (ACLR) is frequently performed in patients younger than 20 years whose goal is to return to sport (RTS). Varying reinjury rates have been reported, and the factors responsible are unclear. Studies differ with regard to age, graft type, surgical techniques, postoperative rehabilitation, RTS guidelines, and methods used to determine ACL failures.
Objective
To determine RTS rates; the effect of participation in high-risk sports, sex, and graft type on ACL reinjury rates; and whether objective test criteria before RTS correlate with lower reinjury rates.
Data Sources
A systematic review of the literature from inception to May 31, 2019, was conducted using the PubMed and Cochrane databases.
Study Selection
Studies on transphyseal ACLR in athletes <20 years old with a minimum mean follow-up of 2 years that reported reinjury rates, the number that RTS, and detailed the type of sport were included.
Study Design
Systematic review.
Level of Evidence
Level 4.
Results
A total of 1239 patients in 8 studies were included; 87% returned to sport and 80% resumed high-risk activities. Of the patients, 18% reinjured the ACL graft and/or the contralateral ACL. Nine percent of patellar tendon autografts and 15% of hamstring autografts failed (odds ratio [OR], 0.52; P = 0.002). Of reinjuries, 90% occurred during high-risk sports. Male patients had a significantly higher rate of ACL graft failure than female patients (OR, 1.64; P = 0.01). There was no sex-based effect on contralateral ACL injuries. Only 1 study cited objective criteria for RTS.
Conclusion
A high percentage of athletes returned to sport, but 1 in 5 suffered reinjuries to either knee. Male patients were more likely to reinjure the ACL graft. Objective criteria for RTS were rarely mentioned or not detailed. The need for testing of knee stability, strength, neuromuscular control, agility, and psychological measures before RTS remains paramount in young athletes.
The purpose of this study was to retrospectively compare clinical results, including proprioceptive function, after anterior cruciate ligament (ACL) reconstruction between 2 groups using techniques that preserve and eliminate the tibial remnant. Forty-eight patients who were followed for at least 24 months after ACL reconstruction with 4-strand hamstring tendon autografts were enrolled in this study. They were then divided into 2 groups: the remnant-preserving group (group A, 26 patients), in whom more than 7 mm of the remnant tibial stump (approximately 20% of the mean length of the ACL) was preserved; and the remnant-eliminating group (group B, 22 patients), in whom the tibial remnant was eliminated during ACL reconstruction. The average duration of follow-up was 25.5 months. At last follow-up, patients were evaluated using the International Knee Documentation Committee scale, Hospital for Special Surgery score, Lachman test, arthrometer, reproduction of passive positioning (RPP) test, threshold to detection of passive motion (TTDPM) test, one-leg hop test, and single-limb standing test. The clinical results between the 2 groups were statistically compared. Group A showed significantly better results on the RPP test at 15° (P=.040) and 30° (P=.010), one-leg hop test (P=.017), and single-limb standing test (P=.007) compared with group B. The other results showed no significant differences. The remnant-preserving technique in ACL reconstruction yields better proprioceptive and functional outcomes and may help achieve postoperative patient satisfaction. [Orthopedics. 2020;43(x):xx-xx.].
Background::
Psychological responses after anterior cruciate ligament (ACL) injury and ACL reconstruction (ACLR) have been identified as predictors of return to sport but have not been investigated in relation to further injury.
Purpose/hypothesis::
To determine whether psychological readiness to return to sport is associated with second ACL injury. It was hypothesized a priori that at both preoperative and 12-month postoperative time points, patients who sustained a second ACL injury would have lower psychological readiness than patients who did not have a second injury.
Study design::
Cohort study; Level of evidence, 2.
Methods::
Patients who had a primary ACLR procedure between June 2014 and June 2016 completed the ACL-Return to Sport after Injury (ACL-RSI) (short version) scale before their ACLR and repeated the scale at 12 months after surgery to assess psychological readiness to return to sport. Patients were followed for a minimum of 2 years (range, 2-4 years) after surgery to determine further injury. The primary outcome was the relationship between ACL-RSI scores and the incidence of second ACL injury.
Results::
In 329 patients who returned to sport after ACLR, 52 (16%) sustained a second ACL injury. No difference in psychological readiness was observed at the preoperative time point, but patients who sustained a second injury trended toward lower psychological readiness at 12 months compared with noninjured patients (60.9 vs 67.2 points; P = .11). Younger (≤20 years) patients with injury had significantly lower psychological readiness to return to sport than young noninjured patients (60.8 vs 71.5 points; P = .02), but no difference was found in older patients (60.9 vs 64.6 points; P = .58). In younger patients, receiver operating characteristic curve analysis revealed a cutoff score of 76.7 points with 90% sensitivity to identify younger patients who sustained a second ACL injury.
Conclusion::
Younger patients with lower psychological readiness are at higher risk for a second ACL injury after return to sport.
Background::
There is limited information about patient expectations regarding return to sport after anterior cruciate ligament reconstruction (ACLR). While it has generally been assumed that patients expect to return, it has also been acknowledged that expectations may change after surgery.
Purpose::
To investigate return-to-sport expectations before and after ACLR and determine factors associated with changed expectations.
Study design::
Cohort study; Level of evidence, 2.
Methods::
The study sample consisted of 675 eligible patients (437 male, 238 female). Return-to-sport expectations were recorded preoperatively. Primary ACLR was performed in 595 patients (of whom 81 had a prior contralateral ACLR) and revision ACLR in 80 patients. At 12 months after surgery, the return to preinjury sport status was assessed along with patients' current sport expectations. The proportion of patients who expected to return to their preinjury level of sport was determined along with actual return rates. Logistic regression was performed to determine the factors associated with the decision to cease sport participation in patients who had expected to be able to return to their preinjury level of sport.
Results::
Overall, 84% of patients expected to be able to return to their preinjury level of sport. Expectations were higher for patients about to undergo their first ACLR, with 88% expecting to return, than for those about to undergo revision surgery or second primary ACLR (63% and 80% expected to return, respectively; P < .001 and P = .08, respectively). At 12 months after surgery, 24% of patients who expected to return to their preinjury level of sport had actually returned, and 15% of all patients had already decided to give up sport. In the regression models, being female ( P = .02) and having undergone previous ACLR ( P < .0001) were factors significantly associated with the decision to give up sport participation.
Conclusion::
Patients had high expectations for returning to their preinjury level of sport at the time of undergoing initial ACLR. Expectations were lower for those who had undergone previous ACLR. Female patients and patients who had undergone previous ACLR were more likely to change their expectations and cease sport participation. These data can be used to provide patients with realistic return-to-sport expectations in the first postoperative year and highlight the challenge for patients who aim to return from multiple ACL injuries.
Background: The decision to return to sport following anterior cruciate ligament (ACL) reconstruction should not only be based on time since surgery. This study aimed to assess, using isokinetic and neuromuscular (hops) testing in a large group, postoperative objective
functional recovery of the knee. The secondary objective was to determine the relationship between psychological, functional scores, and these postoperative tests.
Methods: This prospective study included athletes who underwent surgery between 2013 and 2016 for an isolated full-thickness ACL tear. They received a complete evaluation of functional performance of the knee by isokinetic tests performed on a dynamometer to
measure quadriceps and hamstring strength, and neuromuscular assessment based on single-leg hop tests. The main judgment criterion was satisfactory functional recovery (yes/no) defined as a difference of ≤10% both in the quadriceps 60°/s and the single hop at a minimum of four months of follow-up.
Results: A total of 234 athletes were analyzed. The mean age was 28.4 ± 8.6 years. At 6.5 ± 1.7 months mean follow-up, 44 (18.5%) patients had satisfactory functional recovery of the knee. The correlations between isokinetic/hop tests and the different scores were variable. During follow-up, two patients presented with a graft tear and two with a contralateral ACL tear, all in the group with unsatisfactory functional recovery.
Conclusion: At a mean of six months after ACL reconstruction, objective functional recovery of the knee was generally unsatisfactory and this seemed to be a risk factor for recurrent tears.