RESUMO
PURPOSE: Quadriceps dysfunction is ubiquitous after anterior cruciate ligament reconstruction, especially when using bone-patellar tendon-bone (BPTB) autografts. The role of patellar tendon hypertrophy after graft harvest on knee extensor strength is unknown. The purpose of this study was to determine the predictive ability of patellar tendon (PT) and quadriceps muscle (Quad) cross-sectional area (CSA) on knee extensor strength 1-2 months after ACLR using BPTB autografts. METHODS: This is a cross-sectional analysis of a cohort 1-2 months after ACLR using BPTB autograft. Peak knee extensor torque, and PT and Quad CSA measured using ultrasound imaging, were collected in 13 males and 14 females. Simple linear regressions compared quadriceps strength index (QI) against limb symmetry index (LSI) in PT and Quad CSA. Multiple linear regressions with sequential model comparisons predicting peak knee extensor torque were performed for each limb. The base model included demographics. Quad CSA was added in the first model, then PT CSA was added in the second model. RESULTS: Both PT (p < 0.001, R2 = 0.693) and Quadriceps CSA (p = 0.013, R2 = 0.223) LSI had a positive linear relationship with QI. In the involved limb, addition of PT CSA significantly improved the model (R2 = 0.781, ΔR2 = 0.211, p for ΔR2 < 0.001). In the uninvolved limb, the addition of Quad CSA improved the model, but the addition of PT CSA did not. CONCLUSION: PT LSI was more predictive of QI than Quad CSA LSI. Involved limb PT CSA mattered more in predicting peak knee extensor torque than did Quad CSA, but in the uninvolved limb, Quad CSA was the most important predictor of peak knee extensor torque. Graft site patellar tendon hypertrophy is key for strong quadriceps early after ACLR. Early targeted loading via exercise to promote healing of the graft site patellar tendon may bring patients a step closer to winning their battle against quadriceps dysfunction. LEVEL OF EVIDENCE: Level I.
Assuntos
Lesões do Ligamento Cruzado Anterior , Ligamento Patelar , Traumatismos dos Tendões , Masculino , Feminino , Humanos , Ligamento Patelar/cirurgia , Autoenxertos/cirurgia , Músculo Quadríceps/cirurgia , Lesões do Ligamento Cruzado Anterior/cirurgia , Traumatismos dos Tendões/cirurgia , Hipertrofia/etiologia , Hipertrofia/cirurgia , Enxerto Osso-Tendão Patelar-Osso/efeitos adversosRESUMO
PURPOSE: To perform a meta-analysis of RCTs evaluating donor site morbidity after bone-patellar tendon-bone (BTB), hamstring tendon (HT) and quadriceps tendon (QT) autograft harvest for anterior cruciate ligament reconstruction (ACLR). METHODS: PubMed, OVID/Medline and Cochrane databases were queried in July 2022. All level one articles reporting the frequency of specific donor-site morbidity were included. Frequentist model network meta-analyses with P-scores were conducted to compare the prevalence of donor-site morbidity, complications, all-cause reoperations and revision ACLR among the three treatment groups. RESULTS: Twenty-one RCTs comprising the outcomes of 1726 patients were included. The overall pooled rate of donor-site morbidity (defined as anterior knee pain, difficulty/impossibility kneeling, or combination) was 47.3% (range, 3.8-86.7%). A 69% (95% confidence interval [95% CI]: 0.18-0.56) and 88% (95% CI: 0.04-0.33) lower odds of incurring donor-site morbidity was observed with HT and QT autografts, respectively (p < 0.0001, both), when compared to BTB autograft. QT autograft was associated with a non-statistically significant reduction in donor-site morbidity compared with HT autograft (OR: 0.37, 95% CI: 0.14-1.03, n.s.). Treatment rankings (ordered from best-to-worst autograft choice with respect to donor-site morbidity) were as follows: (1) QT (P-score = 0.99), (2) HT (P-score = 0.51) and (3) BTB (P-score = 0.00). No statistically significant associations were observed between autograft and complications (n.s.), reoperations (n.s.) or revision ACLR (n.s.). CONCLUSION: ACLR using HT and QT autograft tissue was associated with a significant reduction in donor-site morbidity compared to BTB autograft. Autograft selection was not associated with complications, all-cause reoperations, or revision ACLR. Based on the current data, there is sufficient evidence to recommend that autograft selection should be personalized through considering differential rates of donor-site morbidity in the context of patient expectations and activity level without concern for a clinically important change in the rate of adverse events. LEVEL OF EVIDENCE: Level I.
Assuntos
Lesões do Ligamento Cruzado Anterior , Reconstrução do Ligamento Cruzado Anterior , Tendões dos Músculos Isquiotibiais , Ligamento Patelar , Humanos , Autoenxertos/cirurgia , Ligamento Patelar/cirurgia , Metanálise em Rede , Lesões do Ligamento Cruzado Anterior/cirurgia , Ensaios Clínicos Controlados Aleatórios como Assunto , Tendões/transplante , Reconstrução do Ligamento Cruzado Anterior/métodos , Transplante Autólogo , Tendões dos Músculos Isquiotibiais/transplante , Morbidade , Enxerto Osso-Tendão Patelar-Osso/efeitos adversos , Enxerto Osso-Tendão Patelar-Osso/métodosRESUMO
BACKGROUND: Clinical outcomes and potential complications associated with Bone-Patellar Tendon-Bone (BPTB) graft in skeletally immature ACL reconstruction (ACLR) are poorly defined. Considering that in Tanner 1-2 patients this kind of graft is not recommended, we focused our systematic review on the evaluation of all the studies in the literature that reported clinical outcomes and rate of complications of the ACLR using BPTB graft in Tanner 3-4 patients. METHODS: This review was conducted in accordance with the PRISMA statement. PubMed, Cochrane Library, EMBASE and Scopus were examined from 1965 to 2020 using different combinations of the following keywords: "ACL reconstruction", "skeletally immature", "young", "patellar tendon" and "BPTB". The database search yielded 742 studies, on which we performed a primary evaluation. After carrying out a full-text evaluation for the inclusion criteria, 4 studies were included in the final review and assessed using the Newcastle-Ottawa scale. Ninety-six cases with mean age of 14.2 years were reported. RESULTS: Good stability and functional outcomes were reported with a mean follow-up of 49.5 months. Return to sport rate ranged from 91.7% to 100%. A KT-1000 side-to-side difference higher than 5 mm was observed in five patients (5.2%). No lower limb length discrepancy and angulation were reported. Graft rupture rate was 5.2%. CONCLUSION: According to these results, BTPB graft could be a good choice in Tanner 3-4 patients who want to achieve their preinjury sport level with a low risk of growth disturbances and graft failure. Further investigations in a wider population are needed.
Assuntos
Lesões do Ligamento Cruzado Anterior , Reconstrução do Ligamento Cruzado Anterior , Ligamento Patelar , Humanos , Adolescente , Enxerto Osso-Tendão Patelar-Osso/efeitos adversos , Enxerto Osso-Tendão Patelar-Osso/métodos , Reconstrução do Ligamento Cruzado Anterior/efeitos adversos , Reconstrução do Ligamento Cruzado Anterior/métodos , Ligamento Patelar/transplante , Ligamento Cruzado Anterior/cirurgia , Lesões do Ligamento Cruzado Anterior/cirurgia , Transplante AutólogoRESUMO
Infection after anterior cruciate ligament reconstruction is a rare but devastating complication resulting in a deleterious impact on knee function as well as an increased related cost for treatment and rehabilitation for the patients. There are conflicting reports regarding the rate of infection between bone patellar tendon bone (BPTB) and hamstrings tendon (HT) autografts for anterior cruciate ligament reconstruction. Therefore, we performed this review to summarize all the available data regarding the risk of infection after ACL reconstruction, to provide insight on the infection risk between BPTB and HT autografts, and to discuss current recommendations for the diagnosis and treatment of these infections. The incidence and risk of infection after ACL reconstruction with HT graft is higher compared with BPTB grafts. The most commonly subacute and late infections, quadruple type, need for cannulated instruments for harvesting, size and shape and fixation of the extra-tunnel material of the HT are important risk factors for infection. Combined antibiotics administration and adequate arthroscopic lavage and debridement are the optimal treatments for ACL reconstruction infection. Early diagnosis and treatment is the most important predictor for graft retention, which accounts more commonly for BPTB grafts. The treating physicians should be aware of the higher incidence of infection after ACL reconstruction with HT graft, as well as for the need for a high clinical suspicion for early diagnosis of the infection. These will increase the possibility of eradication of the infection and retention of the graft.
Assuntos
Reconstrução do Ligamento Cruzado Anterior , Enxerto Osso-Tendão Patelar-Osso , Reconstrução do Ligamento Cruzado Anterior/efeitos adversos , Reconstrução do Ligamento Cruzado Anterior/métodos , Autoenxertos/cirurgia , Enxerto Osso-Tendão Patelar-Osso/efeitos adversos , Enxerto Osso-Tendão Patelar-Osso/métodos , Humanos , Patela , Tendões/cirurgia , Transplante Autólogo/efeitos adversosRESUMO
PURPOSE: To evaluate the impact of local soaking of the autografts with vancomycin during anterior cruciate ligament (ACL) reconstruction on postoperative infection rates. METHODS: Between 2003 and 2014 (first study period), 1,242 patients underwent ACL reconstruction using autografts, without soaking them in vancomycin solution, while between 2014 and 2019 (second study period) all ACL autografts in 593 patients were soaked in a 5-mg/ml vancomycin solution, in a territory University Hospital. The same standard treatment of perioperative IV antibiotics was applied in both groups. RESULTS: Postoperative septic arthritis occurred in seven out of 1,242 patients (0.56%) during the first study period. Bone patellar tendon bone autograft was used in 311 (25%) patients, and hamstring tendon autograft was used in the rest 931 (75%) of the study population during this period. All infected cases were male and had a hamstrings graft implanted. There were no postoperative infections (0%) in 593 ACL reconstructions during the second study period. Bone patellar tendon bone autograft was used in 178 (30%) patients while hamstring tendon autograft was used in the rest 415 (70%) of the study population, during this period. Statistical analysis revealed a significantly reduced postoperative infection rate (p = 0.018) between the two reported periods, with the main impact referring to the use of hamstrings autograft (p = 0.031) for the first study period. CONCLUSIONS: Septic arthritis following ACL reconstruction can be significantly reduced (or even eliminated) by soaking ACL autografts in a 5 mg/ml vancomycin solution. Of note, this strategy seems to be more effective in the setting of hamstring tendon autograft use, since the risk of postoperative knee infection is significantly higher when this type of graft is used.
Assuntos
Reconstrução do Ligamento Cruzado Anterior/efeitos adversos , Reconstrução do Ligamento Cruzado Anterior/métodos , Antibacterianos/administração & dosagem , Artrite Infecciosa/prevenção & controle , Autoenxertos , Tendões dos Músculos Isquiotibiais/transplante , Vancomicina/administração & dosagem , Adulto , Lesões do Ligamento Cruzado Anterior/cirurgia , Enxerto Osso-Tendão Patelar-Osso/efeitos adversos , Feminino , Humanos , Masculino , Complicações Pós-Operatórias/prevenção & controle , Transplante AutólogoRESUMO
PURPOSE: Comparing scar cosmesis and regional hypoesthesia at the incision site between quadriceps tendon (QT), bone-patellar tendon-bone (BPTB), and hamstring tendon (HT) for anterior cruciate ligament (ACL) reconstruction. METHODS: Ninety patients undergoing ACL reconstruction with QT, HT or BPTB were evaluated at 1-year post-op. Scar cosmesis was assessed using the patient and observer scar assessment scale (POSAS) and length of the incision. Sensory outcome was analyzed by calculating the area of hypoesthesia around the scar. The classical ACL reconstruction functional follow-up was measured using the Lysholm score and KOOS. RESULTS: Concerning QT versus BPTB group, QT patients have a significantly lower mean POSAS (24.8 ± 6.3 vs. 39.6 ± 5.8; p < 0.0001), shorter mean incision (2.8 ± 0.4 cm vs. 6.4 ± 1.3 cm; p < 0.0001), lower extent of hypoesthesia (8.7 ± 5.1 cm2 vs. 88.2 ± 57 cm2; p < 0.0001), and better Lysholm score (90.1 ± 10.1 vs. 82.6 ± 13.5; n.s.). No significant difference was seen in KOOS (90.7 ± 7.2 vs. 88.4 ± 7.0; n.s.). Concerning QT versus HT group, no significant difference was found regarding mean POSAS score (24.8 ± 6.3 vs. 31.8 ± 6.2; n.s.), mean length of the incision (2.8 ± 0.4 cm vs. 2.5 ± 0.6 cm; n.s.), KOOS (90.7 ± 7.2 vs. 89.8 ± 8.2; n.s.) and mean Lysholm score (90.1 ± 10.1 vs. 87.8 ± 0.6; n.s.). The mean measured area of hypoesthesia was significantly higher in the HT group (70.3 ± 77.1 cm2 vs. 8.7 ± 5.1 cm2; p < 0.0001). CONCLUSION: Quadriceps tendon harvesting technique has the safest incision by causing less sensory loss compared to BPTB and HT. It also has the advantage of a short incision with more cosmetic scar compared to BPTB, with no difference compared to HT. However, no significant difference in terms of functional outcome was shown between the three autografts. These findings provide surgeons evidence about their clinical practice and help with graft choice decisions. LEVEL OF EVIDENCE: III.
Assuntos
Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/métodos , Tendões/transplante , Adulto , Reconstrução do Ligamento Cruzado Anterior/efeitos adversos , Enxerto Osso-Tendão Patelar-Osso/efeitos adversos , Enxerto Osso-Tendão Patelar-Osso/métodos , Cicatriz/patologia , Feminino , Seguimentos , Tendões dos Músculos Isquiotibiais/transplante , Humanos , Masculino , Complicações Pós-Operatórias/patologia , Músculo Quadríceps/cirurgia , Transplante Autólogo , Adulto JovemRESUMO
PURPOSE: The purpose of this study was to report the long-term outcomes of a continuous series of patients who underwent simultaneous anterior cruciate ligament (ACL) reconstruction and opening wedge high tibial osteotomy (HTO) for varus-related early medial tibio-femoral osteoarthritis. It was hypothesized that this combined surgery sustainably allowed return to sport with efficient clinical and radiological results. METHODS: From 1995 to 2015, all combined ACL reconstruction (bone-patellar tendon-bone graft) and opening wedge HTO for anterior laxity and early medial arthritis were included. Clinical evaluation at final follow-up used Tegner activity score, Lysholm score, subjective and objective IKDC scores. Radiologic evaluation consisted in full-length, standing, hip-to-ankle X-rays, monopodal weight-bearing X-rays and skyline views. AP laxity assessment used Telos™ at 150 N load. Student's t test was performed for matched parametric data, Wilcoxon for nonparametric variables and Friedman test was used to compare small cohorts, with p < 0.05. RESULTS: 35 Patients (36 knees) were reviewed with a mean follow-up of 10 ± 5.2 years. The mean age at surgery was 39 ± 9. At final follow-up 28 patients (80%) returned to sport (IKDC ≥ B): 11 patients (31%) returned to sport at the same level and 6 (17%) to competitive sports. Mean subjective IKDC and Lysholm scores were 71.8 ± 14.9 and 82 ± 14.1, respectively. The mean decrease of the Tegner activity level from preinjury state to follow-up was 0.8 (p < 0.01). Mean side-to-side difference in anterior tibial translation was 5.1 ± 3.8 mm. Three patients were considered as failures. The mean preoperative mechanical axis was 4.2° ± 2.6° varus and 0.8° ± 2.7° valgus at follow-up. Osteoarthritis progression for medial, lateral, and femoro-patellar compartments was recorded for 12 (33%, p < 0.05), 6 (17%, p < 0.001), and 8 (22%, p < 0.05) knees, respectively. No femoro-tibial osteoarthritis progression was observed in 22 knees (61%). CONCLUSIONS: Combined ACL reconstruction and opening wedge HTO allowed sustainable stabilization of the knee at 10-year follow-up. However, return to sport at the same level was possible just for one-third of patients, with femoro-tibial osteoarthritis progression in 39% of cases. LEVEL OF EVIDENCE: III.
Assuntos
Lesões do Ligamento Cruzado Anterior/cirurgia , Traumatismos em Atletas/cirurgia , Enxerto Osso-Tendão Patelar-Osso/métodos , Instabilidade Articular/cirurgia , Osteoartrite do Joelho/cirurgia , Osteotomia/métodos , Adulto , Lesões do Ligamento Cruzado Anterior/diagnóstico por imagem , Traumatismos em Atletas/diagnóstico por imagem , Enxerto Osso-Tendão Patelar-Osso/efeitos adversos , Progressão da Doença , Feminino , Seguimentos , Humanos , Instabilidade Articular/diagnóstico por imagem , Escore de Lysholm para Joelho , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/diagnóstico por imagem , Osteotomia/efeitos adversos , Complicações Pós-Operatórias , Radiografia , Estudos Retrospectivos , Volta ao Esporte , Resultado do TratamentoRESUMO
Patellar bone-tendon-bone (pBTB) autografts are often considered the "gold standard" for complete anterior cruciate ligament (ACL) reconstruction and are also associated with significant complications and early-onset knee osteoarthritis (OA). A novel quadriceps tendon allograft with synthetic augmentation, or "internal brace" (QTIB), has been reported to have potential advantages for ACL reconstruction based on animal model data. In this preclinical canine comparison study, we hypothesized that QTIB allograft compared with pBTB autograft would provide superior durability for knee stability, function, and prevention of OA. Under approval from our Institutional Animal Care and Use Committee, adult purpose-bred research hounds (n = 10) underwent arthroscopic complete transection of the ACL followed by either an arthroscopic-assisted all-inside ACL reconstruction using the QTIB allograft (n = 5) or pBTB autograft (n = 5). Contralateral knees were used as nonoperated controls (n = 10). Radiographic and arthroscopic assessments were performed at 2 and 6 months, respectively, after surgery. Anterior drawer, internal rotation, lameness, kinetics, pain, effusion, and comfortable range of knee motion were measured at 2, 3, and 6 months. Biomechanical and histologic assessments were performed at 6 months. All reconstructed knees were stable and had intact ACL grafts 6 months after surgery. At 6 months, QTIB reconstructed knees had significantly less lameness, lower pain, less effusion, and increased range of motion when compared with BTB knees (p < 0.05). BTB knees had significantly higher radiographic OA scores than QTIB knees at 6 months (p < 0.05). Superior outcomes associated with QTIB allograft may be due to the lack of donor site morbidity, the use of a robust tendon graft, and/or protection of the graft from the synthetic augmentation. Robust tendon grafts combined with a synthetic internal brace and platelet-rich plasma (PRP) may allow for more rapid and robust tendon-bone healing and graft "ligamentization," which protects the graft from early failure and rapid OA development that can plague commonly-used allografts.
Assuntos
Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/métodos , Enxerto Osso-Tendão Patelar-Osso , Fixadores Internos , Músculo Quadríceps/transplante , Tendões/transplante , Adulto , Aloenxertos , Animais , Reconstrução do Ligamento Cruzado Anterior/instrumentação , Artroscopia , Autoenxertos , Fenômenos Biomecânicos , Enxerto Osso-Tendão Patelar-Osso/efeitos adversos , Enxerto Osso-Tendão Patelar-Osso/métodos , Materiais Revestidos Biocompatíveis , Colágeno , Cães , Humanos , Instabilidade Articular/etiologia , Instabilidade Articular/prevenção & controle , Instabilidade Articular/cirurgia , Articulação do Joelho/cirurgia , Osteoartrite do Joelho/etiologia , Osteoartrite do Joelho/prevenção & controle , Amplitude de Movimento Articular , Suturas , Transplante Autólogo , Transplante HomólogoRESUMO
BACKGROUND: Female athletes are 2 to 8 times more prone to anterior cruciate ligament (ACL) rupture than males. Furthermore, reinjury to the ipsilateral or contralateral knee can occur in >20% of athletes. Female sex and younger age are known risk factors for graft failure. The optimal graft choice for young females remains unknown and poorly studied. PURPOSE/HYPOTHESIS: The authors aimed to compare clinical outcomes in young females who underwent ACL reconstruction (ACLR) with bone-patellar tendon-bone (BTB) and quadrupled hamstring (HS) autografts. It was hypothesized that no significant differences in outcomes exist between graft choices. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Female patients aged 15 to 25 years who underwent primary ACLR with BTB or HS autograft were included for review. Patients were subdivided into 2 age groups: 15 to 20 years and 21 to 25 years. The occurrence of chondral, meniscal, or ligamentous injury to either knee was recorded for comparison. RESULTS: A total of 256 females were included (BTB, n = 175; HS, n = 81). The majority of patients were between the ages of 15 and 20 years (BTB, 80%; HS, 77.8%). Overall, graft rupture occurred in 23 patients (9%) and contralateral ACL tear occurred in 18 (7%). Subgroup analysis showed that 75% of BTB and 100% of HS graft retears occurred in females aged 15 to 20 years. Within this age group, there was a significantly lower rate of graft ruptures in the BTB group (6.4%) as compared with the HS group (17.5%, P = .02). Allograft augmentation was used in 4 of the 11 HS grafts that retore. When allograft-augmented grafts were excluded, there was no significant difference in graft failure rate between graft choices. Fifteen patients in the BTB group (12%) as opposed to 1 in the HS group (2%) reported extreme difficulty or the inability to kneel on the front of the knee (P = .04). CONCLUSION: In females aged 15 to 20 years undergoing ACLR, BTB autograft may lead to fewer graft ruptures than HS autograft. While this difference was not observed in females aged 21 to 25 years, a larger sample may be required to accept the null hypothesis in this age group. BTB autograft significantly increased the risk of kneeling pain as compared with HS regardless of age.
Assuntos
Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/métodos , Traumatismos em Atletas/cirurgia , Enxerto Osso-Tendão Patelar-Osso/métodos , Tendões dos Músculos Isquiotibiais/transplante , Ligamento Patelar/transplante , Adolescente , Adulto , Fatores Etários , Reconstrução do Ligamento Cruzado Anterior/efeitos adversos , Autoenxertos , Enxerto Osso-Tendão Patelar-Osso/efeitos adversos , Feminino , Humanos , Complicações Pós-Operatórias , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Transplante Autólogo , Transplante Homólogo , Adulto JovemRESUMO
BACKGROUND: The anterior cruciate ligament (ACL) repair technique avoids graft harvest and therefore the risk of donor site morbidity. However, early failure rates after ACL repair with suture ligament augmentation (SLA) remain high. PURPOSE: To compare surgical failure, functional outcomes, return to sport, and joint laxity between adolescents who underwent ACL repair with SLA and those who underwent ACL reconstruction with quadriceps tendon-patellar bone autograft (QPA). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Adolescent patients (7-18 years old) underwent ACL repair with SLA or ACL reconstruction with QPA. The authors collected data from those who had postoperative information pertaining to repaired ligament or graft failure, range of motion, complications, and return to sport at a minimum of 6 months after surgery. Participants were contacted after surgery to complete study questionnaires. RESULTS: The cohort included 22 consecutive patients in the SLA group and 157 in the QPA group. The median duration of follow-up was 2.7 years (interquartile range, 2.0-3.6 years) in the QPA group and 3.2 years (2.2-3.4 years) in the SLA group. After adjustment for sex, age, body mass index, and time from injury to surgery, the hazard of graft failure in the SLA group was 10.66 times (95% CI, 3.41-32.92; P < .0001) that of the QPA group. The cumulative incidence of graft failure in the first 3 years after surgery was 48.8% (95% CI, 28.9%-73.1%) in the SLA group, as opposed to 4.7% (2.1%-10.3%) in the QPA group. There was no difference in return to sport between the groups. Among individuals who did not rerupture their ACL, International Knee Documentation Committee and Lysholm scores were comparable between the groups, as well as range of motion. CONCLUSION: The risk of failure was significantly increased in the SLA group relative to the QPA group. The high risk of failure for the SLA group in this short-term follow-up should be considered when selecting the treatment for adolescent patients with an ACL injury.
Assuntos
Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/métodos , Enxerto Osso-Tendão Patelar-Osso/métodos , Técnicas de Sutura , Adolescente , Fatores Etários , Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/efeitos adversos , Traumatismos em Atletas/cirurgia , Enxerto Osso-Tendão Patelar-Osso/efeitos adversos , Criança , Feminino , Seguimentos , Humanos , Instabilidade Articular/etiologia , Masculino , Amplitude de Movimento Articular , Volta ao Esporte , Inquéritos e Questionários , Falha de TratamentoRESUMO
PURPOSE: The purpose of this study was to evaluate the influence of patellar tendinopathy on primary anterior cruciate ligament (ACL) reconstruction graft failure when using bone-patellar tendon-bone (BPTB) autograft. METHODS: All patients undergoing primary ACL reconstruction using ipsilateral BPTB with preoperative magnetic resonance imaging (MRI) available for review were approached for eligibility. The medical charts of included patients were reviewed to obtain demographic information, anatomical characteristics, injury characteristics, treatment characteristics, length of follow-up, and presence of graft failure. A single, fellowship-trained, knee-specialist and blinded researcher performed preoperative MRI interpretation of patellar tendinopathy. The presence/absence of patellar tendinopathy (none, mild, moderate, or severe changes) was compared between patients with (cases) and without (controls) failure of ACL reconstruction. There were 559 cases with a median (range) clinical follow-up was 8 (4-30) months and an average age of 21.5 years (82% males). RESULTS: Of the 559 cases, there were 182 (32.6%) with and 377 (67.4%) without patellar tendinopathy. A total of 32 (5.7%) graft failures occurred. There were a significantly higher failure rate in patients with compared to without patellar tendinopathy (p < 0.001), and in patients with compared to without partial tendon tear (p < 0.001). The odds ratio (95% confidence interval) for graft failure was 5.9 (2.7-13.1), 20.8 (6.8-63.9) and 54.4 (5.5-539.4) in patients with patellar tendinopathy (compared to absence of patellar tendinopathy), moderate or severe patellar tendinopathy (compared to none or mild patellar tendinopathy), or partial tendon tear (compared to absence of tendon tear), respectively. CONCLUSION: The presence of patellar tendinopathy increases the risk of BPTB graft failure when used for ACL reconstruction. The use of BPTB autograft is not recommended if patellar tendinopathy is obvious or there are suspicious of partial tendon tear on MRI. In such cases, the surgeon should consider using a different graft. LEVEL OF EVIDENCE: Retrospective cohort analysis, Level III.
Assuntos
Reconstrução do Ligamento Cruzado Anterior , Enxerto Osso-Tendão Patelar-Osso/efeitos adversos , Ligamento Patelar/fisiopatologia , Tendinopatia/fisiopatologia , Lesões do Ligamento Cruzado Anterior/cirurgia , Autoenxertos , Estudos de Casos e Controles , Estudos de Coortes , Feminino , Humanos , Masculino , Estudos Retrospectivos , Risco , Falha de Tratamento , Adulto JovemRESUMO
The frequency of anterior cruciate ligament (ACL) reconstruction performed worldwide has been significantly increasing per year. Despite the common nature of the procedure, controversy remains regarding the natural history of ACL injuries, surgical technique, graft choice, and long-term outcomes. We present a case report of a 33-year-old male who had a history of an ACL reconstruction that was performed 12 years ago using bone patella tendon bone (BPTB) graft, by using a press-fit femoral technique. He was referred to our outpatient department due to a re-rupture of his ACL following a football injury. Radiographs of the knee joint that were taken revealed a rectangular prominence of bone projected over the femoral notch extending intra-articularly. The patient also had a magnetic resonance imaging (MRI) scan, which revealed a rerupture of the previously reconstructed ACL and evidence of an intra-articular bony prominence. The patient had arthroscopic revision of his ACL reconstruction by using Semitendinosus allograft, which confirmed the complete tear of previously reconstructed ACL graft. Moreover, a bony prominence was well demonstrated intra-articularly close to the femoral intercondylar notch. We hypothesized that this was a part of the BPTB graft that was reconstructed 12 years ago and had either migrated inside the joint or was never positioned appropriately (not adequately fitted in the femoral tunnel). The bony prominence was shaved by using an arthroscopic bony burr, the ACL was revised, and the patient had a good recovery. Intra-articular migration of the femoral bony ends of the BPTB is a rare complication following ACL reconstruction. The patient may be asymptomatic; however, evidence of the bony prominence is usually revealed on postoperative X-rays and magnetic resonance imaging scans.
Assuntos
Lesões do Ligamento Cruzado Anterior/diagnóstico por imagem , Lesões do Ligamento Cruzado Anterior/cirurgia , Enxerto Osso-Tendão Patelar-Osso/efeitos adversos , Adulto , Enxerto Osso-Tendão Patelar-Osso/métodos , Humanos , Masculino , Recidiva , ReoperaçãoRESUMO
PURPOSE: Complications related to anterior cruciate ligament (ACL) graft are common. Change in height, especially patella baja, can be a cause of anterior knee pain. Several studies have related ACL reconstruction with bone-tendon-bone graft to patella baja. METHODS: Forty-three patients with ACL reconstruction using a with bone-tendon-bone graft were included in this study. All patients underwent the same surgery, with closure of the paratenon of the patellar tendon. A radiological study was performed before surgery and 2 years after surgery. The Insall-Salvati index, axial view and patellar tilt were analyzed in all patients. The healthy contralateral knees were used as the control group. RESULTS: No significant differences were observed from the preoperative measurements or at the 2-year follow-up. CONCLUSIONS: The use of patellar tendon with closure of the paratenon in ACL reconstruction was not shown to modify patellar height within the radiological follow-up of two years.
Assuntos
Lesões do Ligamento Cruzado Anterior/cirurgia , Enxerto Osso-Tendão Patelar-Osso/efeitos adversos , Patela/patologia , Complicações Pós-Operatórias/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Patela/diagnóstico por imagem , Patela/cirurgia , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/patologia , Estudos Prospectivos , Radiografia , Resultado do TratamentoRESUMO
PURPOSE: To compare the results of bone-patellar tendon-bone graft (BPTB), semitendinosus-gracilis graft with preserved insertions (STGPI) and semitendinosus-gracilis-free graft (STGF) in terms of graft failure, objective mechanical stability, functional outcome, and return to sports in elite and recreational sports persons. It was hypothesized that the STGPI graft provided superior outcome as compared to the other two grafts. METHODS: Two hundred and forty-nine elite and recreational players who underwent ACL reconstruction surgery, with BPTB graft (N = 80), STGPI graft (N = 85), and STGF graft (N = 84) with a minimum follow-up of 2 years, were assessed using clinical tests, knee arthrometer (KT 1000™), single-leg hop test, Lysholm knee score, Tegner's activity scale, and return to sports. Groups were matched in terms of age, gender, mode of injury, side involved, the level of sports, associated injuries, and mean follow-up. RESULTS: The median age of the patients was 24 years (range 16-46 years), with 227 males and 22 females, with a mean follow-up of 61.8 ± 25.9 months. At the final follow-up, the mean side-to-side difference by KT 1000™ was significantly superior in BPTB group (1.4 ± 2.1 mm) as compared to STGPI (1.9 ± 2.0 mm) and STGF group (2.5 ± 2.0 mm) (p = 0.002). The mean Lysholm knee score, Limb symmetry index (LSI) using single-leg hop test and the mean difference in pre-injury and post-surgery level of Tegner's activity scale were not significantly different. The rate of graft failure was significantly higher in STGF group (7.1%) as compared to BPTB (1.2%) and STGPI (1.2%) groups (p = 0.043). CONCLUSION: BPTB graft is a better graft in terms of mechanical stability than STGPI and STGF grafts. STGPI graft and BPTB graft are superior to STGF graft in terms of graft failure rate. However, there is no statistically significant difference amongst the three grafts in terms of return to sports and clinical tests of instability. STGPI graft is another option in the clinical setting with low graft failure rate like that of BPTB graft and with the added advantage of not having significant donor site morbidity. LEVEL OF EVIDENCE: III.
Assuntos
Lesões do Ligamento Cruzado Anterior/cirurgia , Traumatismos em Atletas/cirurgia , Enxerto Osso-Tendão Patelar-Osso/métodos , Músculo Grácil/transplante , Tendões/transplante , Adolescente , Adulto , Enxerto Osso-Tendão Patelar-Osso/efeitos adversos , Feminino , Sobrevivência de Enxerto , Humanos , Instabilidade Articular/diagnóstico , Escore de Lysholm para Joelho , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Recidiva , Volta ao Esporte , Ruptura/prevenção & controle , Transplante Autólogo , Adulto JovemRESUMO
BACKGROUND: Anterior cruciate ligament (ACL) reconstruction failure is relatively common in young high-risk athletes. The purpose of this study was to examine a single center's 10-year experience with ACL reconstructions in pediatric and adolescent patients to better define short-term failure rates and risk factors for revision ACL surgery. METHODS: This institutional review board-approved retrospective study included all patients who underwent a primary ACL reconstruction between 2002 and 2013. Chart and radiographic review was performed to assess patient demographic, injury, and surgical data including growth plate status, concomitant ligament/meniscus/cartilage injury, surgical procedures, femoral drilling technique, graft source and type, femoral and tibial fixation devices, and graft size. Graft failures had to be confirmed both with clinical examination and magnetic resonance imaging or the patient had to undergo a revision ACL reconstruction. Potential factors associated with failure were evaluated using either parametric or nonparametric analysis as appropriate. RESULTS: A total of 561 ACL reconstructions were performed that met our inclusion criteria. The average patient age was 15.4 years (range, 5 to 19 y) and 53% of the patients were male. In all, 54 failures were identified for a 9.6% failure rate. Soft tissue grafts were twice as likely to fail compared with patellar tendon grafts (13% vs. 6%; P<0.001). Multivariate analysis revealed that graft choice (soft tissue vs. patellar tendon) was the primary variable predictive of failure (P<0.05), with interactions/mediating effects contributed by maturity (growth plate status) and ACL technique (P<0.05). The average time to failure was 13.6 months and hamstring grafts and anatomic femoral tunnels were both found to fail earlier (P<0.05). During the study period, approximately 8% of patients sustained a contralateral ACL injury. CONCLUSIONS: ACL failure rates in adolescent and pediatric patients vary based on patient age, graft selection, and surgical technique. Bone patellar tendon bone autografts had the lowest failure rate in this high-risk population. LEVEL OF EVIDENCE: Level IV-retrospective case series.
Assuntos
Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/métodos , Enxerto Osso-Tendão Patelar-Osso/métodos , Adolescente , Fatores Etários , Reconstrução do Ligamento Cruzado Anterior/estatística & dados numéricos , Traumatismos em Atletas/cirurgia , Enxerto Osso-Tendão Patelar-Osso/efeitos adversos , Enxerto Osso-Tendão Patelar-Osso/estatística & dados numéricos , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Reoperação , Estudos Retrospectivos , Fatores de Risco , Falha de Tratamento , Adulto JovemRESUMO
PURPOSE OF THE STUDY A retrospective evaluation of the success rate of revision ACL reconstruction performed using BTB allograft in terms of the life expectancy of the procedure up to and over five years from surgery. MATERIAL AND METHODS Over a ten-year period, from 2003 to 2013, we performed 47 revision ACL reconstruction surgeries. The majority of the primary ACL reconstructions using BTB autografts were not performed at our site. The group observed included 16 women (34%) and 31 men (66%). The women were aged between 25 and 48 years, the median age being 32.5, and the men were aged between 25 and 46 years with the median age of 35. We were able to make a full pre- and post-operative evaluation of 22 out of 47 patients who underwent secondary ACL reconstruction surgery using a cadaverous BTB graft. This evaluation included an objective clinical testing and a subjective evaluation of the function and stability of the knee joint using the Tegner activity score, Lysholm score, and a modified Cincinatti score. The set of 22 patients was split into two groups: up to five years from revision surgery and over five years from the procedure. RESULTS In the group of patients who were fully evaluated within five years of revision reconstruction there was an average improvement of 16.4 points on the Cincinatti score, 19.9 points on the Lysholm score, and an upward movement averaging 1.5 levels on the Tegner activity score. In the over five years from surgery category the average improvement was 15.5, 15.9, and 1.2 levels upward movement, respectively. We were unable to prove a significantly increased level of failure in BTB allografts after five and more years from revision ACL reconstruction. DISCUSSION The two strongest factors affecting the life expectancy of ACL replacements are the age of the patient and the type of the graft used, allograft or autograft. The most at risk, in terms of how long the graft will last, is the age group of 10 - 19 years old. With each ten-year increase in age the risk of rupture is reduced more-or-less by half. Patients with ACL allograft replacement show a fourfold increased risk of the graft rupturing. The younger and more active the patient requiring revision ACL reconstruction is, the greater the need for an autograft. If an allograft has been used in revision reconstruction on an athlete, a great emphasis must be placed on the necessity of delaying the return to previous sporting activities for at least nine months. CONCLUSIONS The mid-term results of revision ACL reconstruction show that, subject to reasonable levels of stress, a correctly performed procedure using cadaverous BTB grafts is a good option to restore the stability of the knee joint over a period of five years and more from surgery. An increased incidence of reruptures or greater insufficiency of the cadaverous graft were not evident in our group after five and more years. The risk of cadaverous grafts failure is just like in the autologous replacement directly linked to the return to sport interval, frequency and intensity of stress to which the graft is subjected over a long period of time. The risk of rerupture is always higher in allograft reconstructions that have already stood in need of restructuring for a longer period of time. For this reason, a delay in returning to sports activity must be emphasized. As a rule, we recommend a return to full athletic training only after nine months to a year after surgery. Key words: anterior cruciate ligament, revision ACL reconstruction, tendon graft insufficiency, BTB autograft insufficiency, BTB allograft of the ACL, cadaverous BTB graft, ACL graft rerupture.
Assuntos
Enxerto Osso-Tendão Patelar-Osso/métodos , Satisfação do Paciente , Adulto , Enxerto Osso-Tendão Patelar-Osso/efeitos adversos , Enxerto Osso-Tendão Patelar-Osso/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reoperação/estatística & dados numéricos , Falha de Tratamento , Resultado do TratamentoRESUMO
PURPOSE: Subsartorial saphenous nerve blockade (SSNB) is an effective analgesic alternative to femoral nerve blockade after anterior cruciate ligament (ACL) reconstruction with bone-tendon-bone (BTB) autograft. It was hypothesized that dexamethasone in a SSNB will prolong analgesia, improve pain and satisfaction, and reduce postoperative opioid requirements and side effects. METHODS: One hundred ninety-five patients undergoing ACL reconstruction with BTB autograft (ages 16-65) were enrolled. Subjects received SSNB with 13 ml of 0.5 % bupivacaine (control group), 1 mg preservative-free dexamethasone +0.5 % bupivacaine (treatment group I), or 4 mg preservative-free dexamethasone +0.5 % bupivacaine (treatment group II). Subjects received identical perioperative management. On postoperative days 1 and 2, subjects reported perceived block duration, pain scores, satisfaction, opioid use, and side effects. Cox-proportional hazards modelling was used to compare block duration, adjusting for body mass index, age, sex, tourniquet time, American Society of Anesthesiologists classification, and intravenous dexamethasone dose. RESULTS: Patient-perceived block duration was significantly increased in treatment group I [hazard ratio (95 % confidence interval [CI]) 0.48 (0.31-0.75); P = 0.001] and treatment group II (hazard ratio (95 % CI): 0.52 (0.33-0.81); P = 0.004) compared to control. The block was extended from a median (95 % CI) of 33.1 (28.4-37.3) to 41.2 (32.4-50.9) and 46.5 (35.8-48.9) hours, respectively. Additionally, patients in treatment group II reported increased time that block provided pain relief, higher patient satisfaction, lower pain scores at rest, and decreased drowsiness and confusion. CONCLUSION: The addition of 1 and 4 mg of dexamethasone to the block injectate significantly increased SSNB duration by 8-13 h compared to control. LEVEL OF EVIDENCE: Therapeutic study, level 1.
Assuntos
Enxerto Osso-Tendão Patelar-Osso/efeitos adversos , Dexametasona/administração & dosagem , Bloqueio Nervoso/métodos , Dor Pós-Operatória/prevenção & controle , Adulto , Analgésicos Opioides/uso terapêutico , Anestésicos Locais/administração & dosagem , Bupivacaína/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/efeitos adversos , Medição da Dor , Satisfação do Paciente , Adulto JovemRESUMO
Nowadays, bone tunnel enlargement (BTE) after anterior cruciate ligament reconstruction is a well-known phenomenon. It has been identified, investigated and described by many authors during the last thirty years. Nevertheless, the etiology of bone tunnel enlargement still remains unclear. It is known that the causes are multifactorial and may include the surgical technique, the method of fixation, materials used, type of graft as well as biological factors. Due to the recent popularization of the use of hamstring grafts in anterior cruciate ligament reconstruction, the bone tunnel enlargement phenomenon is becoming increasingly common. In this review article, the authors focus on compiling current knowledge about the etiology, diagnosis, and the possibility of reducing the occurrence of this phenomenon by using the latest methods of supporting reconstruction surgery.
Assuntos
Lesões do Ligamento Cruzado Anterior/cirurgia , Enxerto Osso-Tendão Patelar-Osso/efeitos adversos , Fêmur/patologia , Tendões dos Músculos Isquiotibiais/transplante , Complicações Pós-Operatórias/patologia , Tíbia/patologia , Fêmur/diagnóstico por imagem , Fêmur/cirurgia , Humanos , Tíbia/diagnóstico por imagem , Tíbia/cirurgiaRESUMO
Fractures occurring with anterior cruciate ligament (ACL) reconstruction are rare and those that do occur take place on the patellar side of a bone-patellar tendon-bone (BPTB) autograft. Here we discuss a far more infrequent occurrence, fracture of the tibial tubercle aspect of the BPTB autograft. This fracture type occurs even more infrequently than tibial plateau fractures after ACL reconstruction based on the published literature. In this article we discuss the third published episode of a tibial tubercle fracture after BPTB allograft. We also discuss the fracture types seen with this method of ACL reconstruction and provide insights into prevention of this occurrence.
Assuntos
Reconstrução do Ligamento Cruzado Anterior/efeitos adversos , Enxerto Osso-Tendão Patelar-Osso/efeitos adversos , Tíbia/cirurgia , Fraturas da Tíbia/etiologia , Transplante Autólogo/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Tíbia/diagnóstico por imagem , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/cirurgia , Tomografia Computadorizada por Raios XRESUMO
PURPOSE: To describe the outcomes of bone-patellar tendon-bone (BPTB) and soft-tissue allografts in anterior cruciate ligament (ACL) reconstruction with respect to graft failure risk, physical examination findings, instrumented laxity, and patient-reported outcomes. METHODS: A search of the PubMed, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Complete, Cochrane Collaboration, and SPORTDiscus databases was performed. English-language studies with outcome data on primary ACL reconstruction with nonirradiated BPTB and soft-tissue allografts were identified. Outcome data included failure risk, physical examination findings, instrumented laxity measurements, and patient-reported outcome scores. RESULTS: Seventeen studies met the inclusion criteria. Of these studies, 11 reported on BPTB allografts exclusively, 5 reported on soft-tissue allografts exclusively, and 1 compared both types. The comparative study showed no difference in failure risk, Lachman grade, pivot-shift grade, instrumented laxity, or overall International Knee Documentation Committee score between the 2 allograft types. Data from all studies yielded a failure risk of 10.3% (95% confidence interval [CI], 4.5% to 18.1%) in the soft-tissue group and 15.2% (95% CI, 11.3% to 19.6%) in the BPTB group. The risk of a Lachman grade greater than 5 mm was 6.4% (95% CI, 1.7% to 13.7%) in the soft-tissue group and 8.6% (95% CI, 6.3% to 11.2%) in the BPTB group. The risk of a grade 2 or 3 pivot shift was 1.4% (95% CI, 0.3% to 3.3%) in the soft-tissue group and 4.1% (95% CI, 1.9% to 7.2%) in the BPTB group. CONCLUSIONS: One comparative study showed no difference in results after ACL reconstruction with nonirradiated BPTB and soft-tissue allografts. Inclusion of case series in the analysis showed qualitatively similar outcomes with the 2 graft types.