Bone-patellar Tendon-bone Group Research Articles

“Comparative study on the Outcome Of Anatomical Anterior Cruciate Ligament Reconstruction Using Bone Patellar Tendon Bone Vs Hamstring Tendon Autograft At A Mean Follow Up Of 8 Years”

Aim :This study aims to analyse the outcome of anatomical anterior cruciate ligament reconstruction (ACLR) using bone patellar tendon bone (BPTB)autograft and hamstring (HT) tendon autograft at mean follow up of 8 years.Methods: 150 Patients who underwent primary ACLR using either BPTB or HT autograft evaluated using plain radiography to differentiate anatomical and nonanatomical reconstruction.80 patients( BPTB -36 and HT -44)with anatomical reconstruction were then compared for their clinico-radiological outcome at mean followup of 8 years. Results:BPTB group shown better outcome over HT group in terms of increased rotational and anteroposterior(AP) stability at long term follow up[Pivot shift test (p-0.001),Anterior drawer test(p- 0.001),Manual Lachman test(p-0.001) and Radiological Lachman test(p-0.001)] .There was no difference between the groups in terms of IKDC objective and subjective(p-0.363 and p-0.154), LYSHLOM score (p-0.894) , Anterior Knee Pain (p-0.678),single leg hop test ( p-0.248) and osteoarthritic (OA) change( p- 0.550) at mean followup of 8 years.Conclusion:BPTB autograft resulted in superior clinical outcome over HT autograft in terms of increased knee stability.No difference between the grafts in other clinical outcomes and OA change at mean followup of 8 years.

Bone-Patellar Tendon-Bone Versus Quadriceps Tendon-Bone Autografts in Anatomic Rectangular Tunnel Anterior Cruciate Ligament Reconstruction.

Anatomic rectangular tunnel anterior cruciate ligament reconstruction (ART-ACLR) can mimic the fiber arrangement of the native ACL and restore normal knee biomechanics, compared with the conventional round tunnel ACLR. ART-ACLR using a bone-patellar tendon-bone (BPTB) graft can provide satisfactory clinical outcomes; however, some issues such as secondary ACL injury and donor-site morbidity, including postoperative anterior knee pain (AKP), remain to be solved. Due to these issues, quadriceps tendon-bone (QTB) grafts have recently become more popular. To compare the 2-year clinical outcomes of ART-ACLR with BPTB and QTB autografts. Cohort study; Level of evidence, 3. A total of 134 patients underwent primary ART-ACLR with BPTB (n = 70) or QTB (n = 64). All patients had a minimum follow-up period of 2 years postoperatively. Outcome evaluations included the International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), side-to-side differences (SSDs) with the KT-1000 knee arthrometer, rate of secondary ACL injury, and incidence of AKP. Regarding age, sex, height, weight,and concomitant procedures, there were no significant differences between the 2 groups. All clinical scores significantly improved from preoperatively to 6 months postoperatively and further increased throughout the 2-year postoperative period in both groups. The IKDC and all subscales of the KOOS, except Sport and Recreation, were equivalent between the BPTB and QTB groups at each postoperative time point. There were no significant differences in the SSD value of KT-1000 arthrometer between the 2 groups. The rates of secondary ACL injury were 10.0% on the ipsilateral side and 2.9% on the contralateral side in the BPTB group and 3.1% on the ipsilateral side and 4.7% on the contralateral side in the QTB group, with no significant difference between both groups. The incidence of AKP was 17.1% and 4.9% in the BPTB group and QTB group, respectively, with significance of P = .02). The clinical scores, SSD value of the KT-1000 arthrometer, and secondary ACL injury rates were equivalent between the BPTB and QTB groups. However, the incidence of AKP was significantly lower in the QTB group, suggesting that QTB could be a favorable graft for ACLR.

Evaluating Gait with Force Sensing Insoles 6 Months after Anterior Cruciate Ligament Reconstruction: An Autograft Comparison.

Aberrant knee mechanics during gait 6 months after anterior cruciate ligament reconstruction (ACLR) are associated with markers of knee cartilage degeneration. The purpose of this study was to compare loading during walking gait in QT, bone-patellar tendon-bone (BPTB), and hamstring tendon (HT) autograft patients 6 months post-ACLR using loadsol single sensor insoles, and to evaluate associations between loading and patient reported outcomes. 72 patients (13-40 years) who underwent unilateral, primary ACLR with BPTB, QT, or HT autograft completed treadmill gait assessment, the International Knee Documentation Committee (IKDC) survey and the ACL-Return to Sport after Injury (ACL-RSI) survey 6 ± 1 months post-ACLR. Ground reaction forces were collected using loadsols. Limb symmetry indices (LSI) for peak impact force (PIF), loading response instantaneous loading rate (ILR), and loading response average loading rate (ALR) were compared between groups using separate ANCOVAs. Survey scores were compared between groups using one-way ANOVAs. The relationships between IKDC, ACL-RSI, and LSIs were compared using Pearson's product moment correlation coefficients. There were no significant differences between graft sources for LSI in PIF, ILR, ALR, nor impulse. Patient-reported knee function was significantly different between graft source groups with the BPTB group reporting the highest IKDC scores; however, there was no significant difference between groups for ACL-RSI score. There were no significant associations between IKDC score, ACL-RSI score, and biomechanical symmetry among any of the graft source groups. Autograft type does not influence PIF, ILR, ALR, or impulse during walking 6 months post-ACLR. Limb symmetry during gait is not strongly associated with patient reported outcomes regardless of graft source. Loadsols appear to be a suitable tool for use in the clinical rehabilitation setting.

Comparison of Time Needed to Meet Common Rehabilitation Milestones After Anterior Cruciate Ligament Reconstruction According to Graft Type

Background: The use of bone–patellar tendon–bone (BPTB) and hamstring tendon (HT) autografts is common in anterior cruciate ligament reconstruction (ACLR). After ACLR, patients typically progress through specific rehabilitation milestones, and graft type may play a role in patient progression. Purpose: To compare the time to meet rehabilitation milestones between BPTB and HT autografts after ACLR. Design: Cohort study; Level of evidence, 3. Methods: This was a single-institution study on patients who underwent ACLR with either BPTB or HT autograft between June 2018 and July 2021. The primary outcomes were time to meet return-to-sport criteria, including >90% limb symmetry index (LSI) for isokinetic quadriceps and hamstring strength, horizontal hop, 4-crossover hop, and single-hop height. The time to satisfaction of each criterion was compared between graft groups using Wilcoxon tests and Cox proportional hazards models. Results: Included in the analysis were 410 participants who underwent ACLR with either BPTB (n = 232) or HT (n = 178). The BPTB group took longer to achieve >90% LSI for knee extension than HT (11.1 ± 4.1 vs 7.63 ± 2.8 months; P < .001). Similarly, the BPTB group took longer than the HT group to achieve >90% LSI for horizontal hop (11.4 ± 3.5 vs 9.82 ± 2.8 months; P < .001), 4-crossover hop (11.8 ± 3.6 vs 10.4 ± 2.8 months; P = .002), and single-hop height testing (11 ± 3.7 vs 8.81 ± 3.2 months; P < .001). The median time to achieve >90% LSI for hamstring strength was similar between groups (7.18 ± 3 vs 7.56 ± 3.1 months; P = .2). Conclusion: Patients that underwent ACLR with BPTB autograft took longer than patients with HT to meet commonly used postoperative rehabilitation milestones. Clinicians should consider these differences when guiding patients regarding graft choice, postoperative expectations, and rehabilitation.

Reduced Knee Flexion Strength 18 Years After ACL Reconstruction With Hamstring Tendon Versus Patellar Tendon

Background: Bone–patellar tendon–bone (BPTB) and double-looped semitendinosus and gracilis (hamstring) grafts are commonly used for anterior cruciate ligament (ACL) reconstruction. Short-term and midterm studies show little or no differences between the 2 grafts; however, there are only a few long-term studies to compare results between the 2 grafts. Purpose: To compare the results after using either BPTB grafts or hamstring tendon grafts 18 years after ACL reconstruction. Study Design: Randomized controlled trial; Level of evidence 2. Methods: A total of 114 patients with ACL rupture between 2001 and 2004 were randomized to reconstruction with either a BPTB graft or a hamstring tendon graft. Patients were operated on at 4 major hospitals. The 18-year follow-up evaluation included anterior knee laxity measured with a KT-1000 arthrometer, defined as the primary outcome, while clinical examination (Lachman and pivot-shift tests), isokinetic testing of muscle strength, patient-reported outcome measures, and an assessment of radiographic osteoarthritis using the Kellgren-Lawrence classification were defined as secondary outcomes. Results: A total of 96 patients (84%, 47 BPTB and 49 hamstring grafts) were available for follow-up, 71 of these for clinical examination. Seven of 96 patients were excluded for ACL revision (n = 5) or knee replacement (n = 2) surgery. In total, 25 patients (10 BPTB and 15 hamstring grafts) had undergone additional surgery other than ACL revision or total knee arthroplasty. There were no significant differences between the groups in terms of anterior laxity test with KT-1000 arthrometer (primary outcome). In secondary outcomes, no significant differences between groups were reported regarding clinical examination, patient-reported outcome scores, or radiographic osteoarthritis (Kellgren-Lawrence grade 2-4 for patellofemoral joint [18 hamstring and 14 BPTB] or tibiofemoral joint [20 hamstring and 19 BPTB]), while isokinetic testing revealed that the hamstring group had a 10.7% reduction in mean peak flexion torque compared with the BPTB group at 60 deg/s (df = 59; P = .011). At 60 deg/s the mean total flexion work in the hamstring group was reduced by 17.2% compared with the BPTB group (df = 59; P = .002). Conclusion: The flexion strength in the hamstring group was significantly reduced in the operated knee after 18 years. There were no significant differences between the groups regarding subjective outcomes, patient-reported outcomes, range of motion, clinical and instrumented knee laxity, and the development of osteoarthritis. Registration: NCT05876013 (ClinicalTrials.gov identifier).

No Clinically Significant Differences in Outcomes After Anterior Cruciate Ligament Reconstruction When Comparing Quadriceps, Bone–Patellar Tendon–Bone, and Hamstring Autografts of 9 mm or Greater

To determine whether there are patient-reported outcome differences in bone-patellar tendon-bone (BPTB), quadriceps tendon (QT), and hamstring (HS) grafts of comparable size. We performed a retrospective analysis of global registry data to include all patients who had an anterior cruciate ligament reconstruction with BPTB, QT, or HS autograft of at least 9 mm in diameter between 2010 and 2021 with complete 1- and 2-year outcome scores. We compared 1- and 2-year postoperative outcome scores (visual analog scale [VAS], Knee Injury and Osteoarthritis Outcome Score [KOOS] pain, Marx Activity Rating Scale [MARS], Veterans RAND 12-Item Health Survey [VR-12]) between BPTB, QT, and HS of the same size graft. In total, 2,318 subjects were included in the analysis, and all graft types showed improved patient-reported outcome measures at 1 and 2 years postoperatively when compared with baseline. The KOOS pain score for the BPTB group was significantly better than the HS (between-group difference= 2.71, P < .01) and QT (between-group difference= 2.51, P < .01) groups at 1 year, and the BPTB group was better than HS (between-group difference= 1.88, P < .01) at 2 years. However, the differences were small and not clinically meaningful. When we compared graft type, there were no differences in the percentage of patients who reached Minimal clinically important difference, or clinical scores VAS or MARS at 2-year follow-up. There is no clinically meaningful difference in KOOS-pain, VR-12, VAS, and MARS at 1 and 2 years postoperatively in patients having anterior cruciate ligament reconstruction with BPTB, HS, or QT if graft size is at least 9 mm in diameter. Level III, retrospective comparative study.

Hamstring autografts demonstrate either similar or inferior outcomes to quadriceps or bone-patellar tendon-bone autografts in revision anterior cruciate ligament reconstruction: A systematic review of comparative studies.

To evaluate the clinical outcomes in patients undergoing revision anterior cruciate ligament reconstruction (r-ACLR) using hamstring tendon (HT) autografts with those using either quadriceps tendon (QT) or bone-patellar tendon-bone (BPTB) autografts or allografts. Three databases were searched on 8 August 2023. The authors adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, surgical details, patient-reported outcome measures (PROMs), rates of instability, failure and return to sport (RTS) were extracted. Eleven studies comprising 859 patients were included in this review. Five studies compared HT and QT autografts. One study each reported greater IKDC scores (p = 0.04) and Tegner scores (p = 0.04) in the QT group, while one study each reported higher anterior translation (p = 0.04), rates of positive pivot shift (p = 0.03) and rates of failure (p = 0.03) in the HT group. Six studies compared HT and BPTB autografts with one study each reporting greater Lysholm scores (p = 0.02) and less side-to-side anterior laxity (p < 0.01) in the BPTB group. Two studies compared HT autografts with allografts with only one study reporting a faster time to RTS in the HT group than the allograft group (p < 0.001). All other comparisons were not significant. HT autografts result in either similar or inferior outcomes in r-ACLR when compared to QT or BPTB autograft options. Allografts resulted in similar outcomes to HT autografts apart from greater time to RTS for r-ACLR. Level III.

Eighteen-year outcome of anterior cruciate ligament reconstruction with patellar tendon or hamstring autograft.

To evaluate patient reported outcomes and radiographic arthritic changes of transtibial anterior cruciate ligament reconstruction (ACLR) with either bone-patellar tendon-bone (BPTB) or hamstrings (HS) auto-grafts at a minimum of 15-year follow-up. Ninety-four patients (51 of the HS group, 43 of BPTB group) who were operated between the years 2000 to 2005 in two tertiary referral hospitals were contacted and invited to a retrospective evaluation. The interview included subjective outcomes using the Lysholm knee scoring questionnaire, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Tegner activity level scale, Visual Analogue Scale (VAS) for pain and patients' satisfaction scale. Knee examination included measurements of motion and stability. Knee radiographs were evaluated for osteoarthritic changes according to the Kellgren-Lawrence (KL) score. The average evaluation time from surgery was 18.6 years. Subjectively, there was no significant difference between groups except for a better post-operative level of activity and satisfaction in the HS group. Objectively, there was no significant difference between groups in knee stability and range of motion. Most patients had grade KL ≤ 1 radiographic osteoarthritits changes and there was no significant difference between groups. Recurrent complete tear of the reconstructed graft occurred in 3 patients of each group. In both groups 84% had no further surgery while the indications for further surgery were mostly a meniscal tear or tibial hardware removal. Very long-term outcomes and clinical stability of transtibial HS or BPTB graft ACL reconstruction are good with low rate of graft failure and radiographic osteoarthritis.

Young men undergoing anterior cruciate ligament reconstruction with patellar tendon autograft and anteromedial drilling outperform at 5- to 10-year follow-up in terms of graft stability and activity levels compared to those undergoing reconstruction with hamstring autograft and transtibial drilling

ObjectiveTo compare 5- to 10-year outcomes of anterior cruciate ligament (ACL) reconstruction in young men performed with bone-patellar tendon bone (BPTB) autograft and anteromedial portal to reconstruction with hamstring autograft and transtibial technique. It was hypothesised that in young adult men, at 5- to 10-year follow-up, superior restoration of knee laxity and activity levels would be demonstrated using BPTB autograft and anteromedial portal technique. MethodsNinety-four men who had ACL reconstruction with BPTB autograft and anteromedial portal were eligible for comparison to 106 men who had reconstruction with hamstring autograft and transtibial technique. Inclusion criteria were: (1) age 18–35 years, (2) ACL tear caused by sports trauma only, (3) no concomitant ligament reconstruction and (4) 5- to 10-year follow-up. Outcome measures compared between the two groups included Lachman and pivot shift tests, KT side-to-side difference, Tegner and Marx scores, International Knee Documentation Committee (IKDC)-subjective score, Knee Osteoarthritis Outcome Scale (KOOS), Short Form (SF)-36, and single hop test for distance. P value ​< ​0.05 indicated statistical significance. ResultsForty-five patients with BPTB and 55 patients with hamstring ACL reconstruction were available for in-person assessment at 5–10 years after surgery. Outcomes in the BPTB group compared to the hamstring group showed KT difference 1.4 ​± ​1.9 mm vs. 2.8 ​± ​2.3 mm (p ​< ​0.01), pivot shift grade 2–3 in 4% vs. 34% (p ​< ​0.01), return to preinjury Tegner level in 51% vs. 36% (p ​= 0.1) and to preinjury Marx score in 29% vs. 11% (p ​= 0.02), and IKDC-subjective 88 ​± ​10 vs. 82 ​± ​13 vs (p ​< ​0.01), respectively. Statistically significant inter-relationships were found between KT side-to-side difference and the Tegner, Marx and IKDC-subjective scores at follow-up (r ​= ​−0.314, p ​< ​0.01; r ​= ​−0.263, p ​< ​0.01; r ​= ​−0.218, p ​= ​0.03, respectively). ConclusionYoung men undergoing ACL reconstruction with patellar tendon autograft and anteromedial drilling outperform at 5- to 10-year follow-up in terms of graft stability and activity levels compared to young men undergoing reconstruction with hamstring autograft and transtibial drilling. Level of EvidenceIII (Retrospective cross-sectional comparative study).

Patellar Fracture Forces Are Not Affected by Proximal Versus Distal Bone Block Anterior Cruciate Ligament Reconstruction Harvest Sites in a Cadaveric Model

To quantify the maximum load to fracture in patellae from which bone-patellar tendon-bone (BPTB) and bone-quadriceps tendon (BQT) autografts have been harvested for anterior cruciate ligament reconstruction in a cadaveric model. Forty-six fresh-frozen patellae were isolated and divided into the BPTB harvest and BQT harvest groups with matching based on donor age and sex. Computed tomography scans were obtained to calculate bone mineral density (BMD) and patellar height, width, and thickness. BPTB and BQT grafts were harvested from the inferior patella and superior patella, respectively, and then ramped to failure in a 3-point bend test configuration to simulate a postoperative fracture produced by a direct impact after a fall. The presence of fracture, fracture pattern, and maximum load to fracture were recorded. Donor demographic characteristics; patellar height, width, and thickness; and maximum load were compared by the Student t test. Pearson correlations were used to determine whether maximum load was affected by BMD or patellar morphology. The level of significance was set at P < .05. Maximum load to fracture was not significantly different (P= .91) between the BPTB (5.0 ± 2.3 kN) and BQT (5.1 ± 2.6 kN) groups. Maximum loadto fracture in the BPTB group did not correlate with BMD (P= .57) or patellar measurements (P= .57 for thickness, P= .43 for width, and P= .45 for height). Maximum load to fracture in the BQT group positively correlated with BMD and negatively correlated with patellar height. Maximum load to fracture in the BQT group did not correlate with patellar thickness or width. Fracture through the harvest site was observed in 87% of BPTB specimens and 78% of BQT specimens. The location of the BPTB or BQT autograft harvest site did not significantly affect patellar load to fracture in a cadaveric model. It is important to understand patellar morphology and the effect of BPTB and BQT graft harvest-site locations on the biomechanical strength of the patella after anterior cruciate ligament reconstruction.

ACL Reconstruction With Quadriceps Soft Tissue Autograft Versus Bone-Patellar Tendon-Bone Autograft in Cutting and Pivoting Athletes: Outcomes at Minimum 2-Year Follow-up.

The optimal graft choice for anterior cruciate ligament (ACL) reconstruction (ACLR) in the high-level cutting and pivoting athlete remains controversial. Studies have shown similar outcomes when directly comparing bone-patellar tendon-bone (BPTB) autograft versus quadriceps soft tissue (QST) autograft in the general population. However, no studies have directly compared these 2 grafts in athletes participating in cutting and pivoting sports. It was hypothesized that, compared with BPTB autograft, the QST autograft would result in similar patient-reported outcomes and rates of retear, return to sport, and complications. Cohort study; Level of evidence, 3. A retrospective review was performed on athletes participating in cutting and pivoting sports (soccer, American football, lacrosse, and basketball) who underwent primary ACLR with either BPTB autograft or QST autograft chosen by the athlete between January 2015 and January 2019. The International Knee Documentation Committee (IKDC) subjective knee evaluation and Lysholm Knee Scoring Scale were used to evaluate patient-reported outcomes. Return-to-sport and complication rates were identified. Descriptive statistics were expressed using Mann-Whitney test or Student t test for continuous variables and the chi-square test for categorical variables. A total of 68 athletes (32 QST, 36 BPTB) were included for analysis. The percentage follow-up was 89% (32/36) for the QST autograft group and 86% (36/42) for the BPTB autograft group. The 2-year IKDC score (QST, 90.5 ± 6.6 vs BPTB, 89.7 ± 7.8) and 2-year Lysholm score (QST, 91.3 ± 7.5 vs BPTB, 90.5 ± 8.6) were similar between groups. The percentage of athletes able to return to sport within the follow-up period was also similar (88% vs 83%; P = .63). There were 2 retears requiring revision in the BPTB group (6%) and no retears in the QST group (P = .18). One contralateral ACL rupture occurred in the QST group (3%) and 4 in the BPTB group (11%) (P = .21). The QST and BPTB autografts demonstrated similar patient-reported outcomes, return-to-sport rates, and complication rates after primary ACLR at 2-year follow-up. Both autografts appear to be reliable and consistent options for ACLR in the cutting and pivoting athlete.

Comparison of “ligamentization” process between preserved insertion hamstring tendon autograft and bone-patellar tendon-bone autograft

BackgroundLigamentization is a complex process and effect of preservation of hamstring tendon graft insertion on this process is not well studied. Present study was conducted to analyze and compare the ligamentization of semitendinosus gracilis graft with preserved tibial insertion (STGPI) and bone-patellar tendon-bone (BPTB) autografts. MethodsA total of 50 sportspeople who underwent ACL reconstruction using either BPTB (group A; n = 25) or STGPI (group B; n = 25) autografts were included in the study. Contrast enhanced MRI was done at 8 months and 14 months post-ACL reconstruction to evaluate the ligamentization using Signal noise quotient (SNQ), graft intensity and enhancement index. Clinical outcomes (Lysholm score) and knee laxity were also assessed at 8 months and 14 months. Results18/23 (78%) patients in group A and 14/23 (61%) patients in group B had hyperintense graft signal at 8 months (n.s.) and at 14 months, 1/23 patients in group A and none of the patients in group B had hyperintense graft. SNQ at 8 months was 3.6 ± 2 and 3.7 ± 2 in group A and B respectively (n.s.) and at 14 months, SNQ was 2.5 ± 1.5 in group A and 2.4 ± 1.3 in group B (n.s.). Enhancement index at 8 months was 1.5 ± 0.3 and 1.2 ± 0.3 in group A and B respectively (p = 0.0001). Enhancement index at 14 months was 1.21 ± 0.2 in group A and 1.07 ± 0.2 in group B (p = 0.003). Functional outcomes and knee laxity were comparable in both the groups at 8 and 14 months (n.s.). ConclusionBoth the grafts i.e. BPTB and STGPI are similar in terms of rate and extent of ligamentization. Clinical outcomes and knee laxity are also comparable between two grafts.

Minimally Invasive Bone-Patellar Tendon-Bone Graft Harvest Is Associated With Less Frequent Anterior Knee Pain at Rest Than Hamstring Graft Harvest After Anterior Cruciate Ligament Reconstruction at the 1-Year Follow-Up

To compare the incidence of postoperative anterior knee pain at rest and during "knee walking" in patients who had anterior cruciate ligament reconstruction (ACLR) surgery with hamstring tendon (HT) grafts versus bone-patellar tendon-bone (BPTB) grafts harvested using a minimally invasive double-incision technique with autografting of the bone harvest defects. Adult patients who had undergone an ACLR and had completed a questionnaire enquiring about anterior knee symptoms at a minimum of 1 year postoperatively were identified. Two groups were compared: 1) patients who had received a BPTB graft harvested using a minimally invasive double-incision technique with autografting of the bone harvest defects, and 2) patients who had received a HT graft. A total of 142 adult patients were included: 88 had a BPTB graft and 54 had a HT graft. The prevalence of anterior knee pain at rest was 10% in the BPTB group and 28% in the HT group (P= .006). Overall, knee walking scores were worse in the BPTB group when compared to the HG group, but the difference in the proportions of patients who found it impossible to knee-walk was not statistically significant (17% vs 6%; P= .069). Our results showed that pain at rest was less in the BTPB group compared to the HT group contradicting historic literature. In addition, there was no statistically significant difference between the 2 grafts when comparing the proportion of patients who found it "impossible" to knee-walk. Level III, retrospective comparative study.

Poster 330: Quadriceps Autograft Leads to Improved Psychological Readiness for Return to Play Compared to Hamstring and Bone-Patellar Tendon-Bone Autografts Following ACL Reconstruction

Poster 330: Quadriceps Autograft Leads to Improved Psychological Readiness for Return to Play Compared to Hamstring and Bone-Patellar Tendon-Bone Autografts Following ACL Reconstruction

Paper 26: Clinical Outcomes of Combined ACL and Anterolateral Ligament Reconstruction Versus Isolated ACL Reconstruction With Bone-Patellar Tendon-Bone Autograft As The Gold Standard: A Matched-Pair Analysis of 2018 Patients

Objectives: The aims of this study were to compare the clinical outcomes following “gold standard” ACL reconstruction (ACLR) with a Bone-Patellar Tendon-Bone (BPTB) autograft versus ACLR combined with an anterolateral ligament reconstruction (ALLR) using hamstring tendon autografts (HT), in a large series of propensity matched patients. The hypothesis was that combined ACLR+ALLR would confer better graft rupture rates and lower non-graft rupture related re-operation rates than isolated ACLR with BPTB Methods: A retrospective analysis of prospectively collected data was performed. Patients undergoing ACLR+ALLR using HT between January 2003 and December 2019 were propensity matched in a 1:1 ratio to patients undergoing isolated ACLR using BPTB. At the end of the study period rates of graft rupture and any other re-operations or complications that occurred following the index procedure were identified by database interrogation, review of medical records and standardized telephone interview. Kaplan Meier survivorship analyses and Cox-proportional hazards models were used to evaluate graft survivorship, re-operation free survivorship and the significance of potentially important risk factors. Results: A total of 2018 patients (1009 matched pairs) were included. The mean duration of follow-up was 101.3 months. Kaplan Meier Analysis demonstrated a significantly better graft survivorship in the ACLR+ALLR group when compared to the BPTB group at every time point (Fig 1 and Table 1). The Cox model demonstrated that patients in the BPTB group were &gt; 3-fold more likely to experience graft failure (Hazard Ratio (HR) = 3.554 [1.744;7.243], p = 0.0005). Patients aged less than 20 years were at particularly high risk of graft rupture (HR = 5.65 [1.834;17.241], p = 0.0002) and further analysis of this subgroup demonstrated that isolated ACLR with BPTB also conferred a &gt; 3 fold increased risk of graft rupture in young patients when compared to ACLR+ALLR. Multivariate analysis did not identify any other significant risk factors for graft rupture. Overall, there was a significantly higher reoperation rate following isolated ACLR (BPTB group 20.5%, ACLR+ALLR group 8.9%, p &lt; 0.0001). This finding was accounted for by significantly higher rates of graft rupture (9.9% vs 3.5%, p &lt;0.0001), cyclops syndrome (3.3% vs 1.5%, p &lt;0.0001), and secondary meniscectomy (5% vs 2.9%, p=0.0196) in the BPTB group. Conclusions: Patients who underwent isolated ACLR with BPTB autografts experienced significantly worse ACL graft survivorship and overall re-operation free survivorship when compared to those who underwent combined ACLR+ALLR with hamstring autografts. The risk of graft rupture was more than 3-fold higher in patients who underwent isolated ACLR using BPTB. [Table: see text]

The reverse fragility index: RCTs reporting non-significant differences in failure rates between hamstring and bone-patellar tendon-bone autografts have fragile results.

The reverse fragility index (RFI) is a novel metric to appraise the results of studies reporting statistically non-significant results. The purpose of this study was to determine the statistical robustness of randomized controlled trials (RCTs) reporting non-significant differences in anterior cruciate ligament reconstruction (ACLR) graft failure rates, defined as re-rupture/revision ACLR rate, between hamstring tendon (HT) and bone-patellar tendon-bone (BTB) autografts by calculating RFIs. A systematic review was performed to identify RCTs that compared HT to BTB grafts for ACLR through January 2022. Studies reporting non-significant differences in graft re-rupture and revision ACLR rate (n.s.) were included. The RFI, defined as the fewest number of event reversals needed to change the non-significant graft re-rupture/revision outcome to statistically significant (P < 0.05), was recorded for each study. In addition, the number of studies in which the loss to follow-up exceeded the RFI was recorded. Among the 16 included RCTs, the median (interquartile range [IQR]) sample size was 71 (64-114), and the median (IQR) total number of graft re-rupture/revision ACLR events was 4 (4-6). The median (IQR) graft re-rupture/revision ACLR rate was 4.3% (3.0-6.4) overall, 4.1% (2.6-6.7) in the BTB group, and 5.4% (3.0-6.3) in the HT group. The median (IQR) RFI was 3 (3-4), signifying that a reversal of the outcome in 3 patients in one arm was needed to flip the studies' result from non-significant to statistically significant (P < 0.05). The median (IQR) number of participants lost to follow-up was 11 (3-13), and 13 (81.3%) of the included studies had a loss to follow-up greater than the studies' RFI. The results of RCTs reporting statistically non-significant re-rupture/revision ACLR rates between HT and BTB autografts would become significant if the outcome were reversed in a small number of patients-a number that was less than the loss to follow-up in the majority of studies. Thus, the neutrality of these studies is fragile, and a true statistically significant difference in re-rupture/revision rates may have been undetected. Level I.

Efficacy comparison between a new generation of artificial ligaments and bone-patellar tendon-bone autograft for anterior cruciate ligament revision

Objective: To compare the clinical efficacy of a new generation of ligaments (LARS artificial ligament) and bone-patellar tendon-bone (BPTB) autograft as grafts in anterior cruciate ligament (ACL) revision. Methods: A retrospective cohort study. The clinical data of 54 patients who underwent ACL revision from January 2018 to June 2020 in the First Hospital Affiliated to Army Medical University were retrospectively analyzed. There were 44 males and 10 females with a mean age of (28.5±7.7) years (15-45 years). Among them, 24 cases underwent ACL revision with LARS artificial ligament (LARS group), the other 30 cases underwent ACL revision with BPTB (BPTB group). The subjective and objective knee joint evaluation indexes were compared between the two groups to evaluate the clinical efficacy. The subjective evaluation indexes included Tegner score, Lysholm score and the International Knee Documentation Committee (IKDC) score. The objective evaluation indexes included the Lachman test, pivot-shift test, the anterior tibial translation (ATT) measurement at the weight-bearing position and the rate of patients returned to pre-injury sports. Results: The follow-up period was (32.8±5.3) months (24-42 months). At the last follow-up, the IKDC score, Tegner score and Lysholm score in the two groups significantly increased when compared with those before surgery (all P<0.05), and there was no significant difference in those indexes between the two groups (all P>0.05). The ATT measurement in the weight-bearing position was (3.1±0.7) mm in the LARS group and it was (4.1±0.9) mm in the BPTB group, which were significantly improved when compared with those before surgery (both P<0.05), and it was better in the LARS group than in the BPTB group (P<0.05). Postoperative Lachman test and pivot-shift test results in the LARS group were better than those in the BPTB group with statistically significant difference (both P<0.05). The rate of patients returned to pre-injury sports one year after surgery was 79.2%(19/24) in the LARS group and it was 50.0%(15/30) in the BPTB group, and the difference was statistically significant (P=0.029). Conclusions: Both LARS artificial ligament and BPTB autograft can achieve good short-term clinical efficacy in ACL revision, but LARS artificial ligament group has more advantages than BPTB autograft group in knee stability and early return to sports.

Revision ACL reconstruction using quadriceps, hamstring and patellar tendon autografts leads to similar functional outcomes but hamstring graft has a higher tendency of graft failure

PurposeThe purpose of this study was to evaluate the differences in the patient-reported functional outcomes, and graft failure in revision ACL reconstruction using quadriceps tendon (QT), Hamstring tendon (HT) and bone-patellar tendon-bone (BPTB) autografts.MethodsBetween 2010 and 2020, 97 patients who underwent revision ACL reconstruction (40 patients received a QT, 26 an HT and 31 a BPTB graft) met the inclusion criteria. Pre-injury and at 2-year postoperatively patients were evaluated for patient-reported functional outcomes; Lysholm knee score, Tegner activity level and VAS (visual analogue scale) for pain; and graft failure. Patient-reported outcomes and graft failure were compared between the QT, HT and BPTB groups. The patients with graft failure were not included for outcome analysis at 2-years of follow-up.ResultsAll three revision groups with QT, HT and BPTB autograft did not differ significantly in terms of age, sex, time from injury to surgery, concomitant injuries and single-stage or double-stage procedures (n.s.). No significant difference was found in the pre-injury patient-reported outcome; Lysholm knee score, Tegner activity and VAS for pain (n.s.) between the three groups. At the 2-year follow-up functional outcomes improved in all three groups and all the patients returned to pre-injury activity level; however, no significant difference was found in functional outcomes at the 2-year follow-up between the three groups (n.s.). Graft failure occurred in 4 (10%), 5 (19%) and 3 (10%) patients of QT, HT and BPTB groups, respectively. However, the rate of failure did not differ significantly between groups.ConclusionAll three autografts (QT, HT and BPTB) demonstrated satisfactory patient-reported outcomes in revision ACL reconstruction. Compared with QT and BPTB grafts, HT graft showed a higher tendency for failure rates. With the increasing incidence of revision ACL reconstruction, surgeons should be aware of all the available graft options. The findings of this study will assist the surgeons in the graft selection for revision ACL reconstruction.Level of evidenceLevel III.

Influence of Graft Type on Lower Extremity Functional Test Performance and Failure Rate After Anterior Cruciate Ligament Reconstruction.

Both autografts and allografts are used to reconstruct the anterior cruciate ligament (ACL) after injury; however, it is unclear whether graft source affects lower extremity functional test performance or failure rate in an active military population. To compare lower extremity functional test performance and graft failure rates between ACL grafts [allograft, hamstring, bone-patellar tendon-bone (BTB)]. Cross-sectional. Level 2. Ninety-eight cadets entering a US Service Academy with a history of unilateral ACL reconstruction (ACLR) agreed to participate. Before basic training, participants completed 4 lower extremity functional tests. Active injury surveillance was conducted within the study cohort to identify all subsequent graft failures. Cadets with hamstring autografts outperformed the BTB and allograft groups on the Lower Quarter Y-Balance Test-Posteromedial direction and single-leg hop test, respectively. No differences were detected by graft type for the other functional tests. The incidence of subsequent ipsilateral graft failures in patients with autograft was 8.11%. No failures were observed in the allograft group during the follow-up period. After controlling for sex, joint hypermobility, and time since injury and surgery, the risk of graft failure was 9.8 times higher for patients with a hamstring autograft than with a BTB (P = 0.045). After ACLR, graft type appears to influence some single-limb measures of lower extremity function and the risk of subsequent failure. Hamstring autografts demonstrated better functional performance but increased risk of graft failure. Surgeons need to weigh the pros and cons of all graft options in relation to the patient's lifestyle. Regardless of graft type, individuals with an ACLR may require additional rehabilitation to regain neuromuscular control during dynamic single-limb tasks and mitigate graft failure.

Paper 02: ACL Reconstruction in Cutting and Pivoting Athletes: Soft Tissue Quadriceps Tendon Autograft vs. Bone-Patellar Tendon-Bone Autograft

Objectives:ACL reconstruction is one of the most common knee procedures performed annually in the United States. Athletes participating in cutting and pivoting sports are at high risk for ACL injury. In the general population, most graft choices including allograft, bone-patellar tendon-bone (BTB) autograft, hamstring autograft and quadriceps autograft have all been shown to excellent results following reconstruction. However, in the high-level cutting and pivoting athlete, the optimal graft for reconstruction remains controversial. Most consider BTB autograft to be the gold standard for such athletes. However, BTB autografts have drawbacks including anterior knee pain, difficulty kneeling and possible patellar fracture and patellar tendon rupture. Quadriceps autograft has increased in popularity since it offers a thicker graft with more favorable tensile properties compared to BTB and hamstring autografts. The quadriceps autograft has nearly twice the cross sectional area, higher load to failure and greater stiffness than the BTB autograft. Studies have shown equivalent outcomes when directly comparing BTB autograft vs. soft tissue quadriceps autograft in the general population. No studies have directly compared these two grafts in athletes participating in cutting and pivoting sports. We hypothesized that the quadriceps autograft would lead to similar patient outcomes, re-tear rates, return to sport and complications as BTB autografts in the cutting and pivoting athlete.Methods:A retrospective review of cutting and pivoting athletes with ACL tears treated with BTB autograft or soft tissue quadriceps autograft with at least 2 years of follow up was performed. Only athletes participating in cutting and pivoting sports were included in the study. Four sports were considered to be cutting and pivoting including soccer, football, lacrosse and basketball. The decision on which graft to use was based on the athlete’s choice after discussing the pros and cons of each graft. Exclusion criteria included those athletes with recurrent ACL tears, multiligamentous injuries, previous meniscal surgery and those requiring osteotomies. International Knee Documentation Committee Subjective Knee Evaluation (IKDC) and Lysholm knee scoring scale were used to evaluate patient reported outcomes. Through chart review, ability to return to sport, time to return to sport and complications were identified. The postoperative rehabilitation protocol for both grafts was identical.Results:There were 32 athletes in the soft tissue quadriceps autograft group and 36 in the BTB autograft group. The average age was 18.6 years for the quad group and 19.7 years for the BTB autograft group (p=0.63). Females made up 62.5% of the quadriceps group and 44.4% of the BTB group (p=0.14). The quad group was made up of 56.3% high school and 43.7% college athletes compared to 61.1% high school and 38.9% college athletes in the BTB autograft group (p=0.53). Soccer was the most common sport with 16 in the quad group and 14 in the BTB group. The rest of the quad group included 8 football players, 4 lacrosse and 4 basketball players. The remaining BTB group consisted of 12 football players, 8 lacrosse and 2 basketball players. Meniscal surgery was performed in combination with the ACL reconstruction in 17 (53.1%) of the quad group and 22 (61.1%) of the BTB autograft group (p=0.37). Average graft size was 9.5mm for the quad autograft group and 10 for the BTB autograft group. The 2-year IKDC score was 93.6 for the quad group and 95.1 for the BTB group (p=0.45). The 2 year Lysholm scores were 95.7 and 96.1 for the quad and BTB groups respectively. Return to play at the same or higher level was 90.6% in the quad group and 86.1% in the BTB autograft group (p=0.82). Time to return was also similar between the groups with 7.1 months for the quad group and 7.6 months for the BTB autograft group. There was 1 re-tear which required revision in the BTB group and no re-tears in the quad group (p=0.34). Arthrofibrosis requiring MUA and lysis of adhesions occurred in 2 quad autografts and 4 BTB autografts (p=0.49). One contralateral ACL rupture occurred in the quad autograft group and 4 in the BTB autograft group (p=0.21).Conclusions:The optimal ACL graft in high level athletes participating in cutting and pivoting sports remains in question. In our comparison of quadriceps autograft compared to BTB autograft in this athletic population, no difference in patient reported outcomes, return to sport or re-tear rates was identified. Based on these findings, quadriceps autograft is as effective as BTB autografts in cutting and pivoting athletes and should be part of the graft choice discussion with the athlete.