Revision Risk of Soft Tissue Allograft Versus Hybrid Graft After Anterior Cruciate Ligament Reconstruction

2020 ◽  
Vol 48 (4) ◽  
pp. 799-805 ◽  
Author(s):  
Raffy Mirzayan ◽  
Heather A. Prentice ◽  
Anthony Essilfie ◽  
William E. Burfeind ◽  
David Y. Ding ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Ligament Reconstruction ◽  
Cruciate Ligament ◽  
Hamstring Autograft ◽  
Tissue Allograft ◽  
Aseptic Revision ◽  
Revision Risk ◽  
Anterior Cruciate ◽  
Graft Diameter

Background: When a harvested hamstring autograft is deemed by the surgeon to be of inadequate diameter, the options include using the small graft, using another autograft from a different site, augmenting with an allograft (hybrid graft), using a different configuration of the graft (eg, 5- or 6-stranded), or abandoning the autograft and using allograft alone. A small graft diameter is associated with a higher revision risk, and using another autograft site includes added harvest-site morbidity; therefore, use of a hybrid graft or an allograft alone may be appealing alternative options. Revision risk for hybrid graft compared with soft tissue allograft is not known. Purpose: To evaluate the risk for aseptic revision surgery after primary anterior cruciate ligament reconstruction (ACLR) using a soft tissue allograft compared with ACLR using a hybrid graft in patients 25 years and younger. Study Design: Cohort study; Level of evidence, 3. Methods: Data from a health care system’s ACLR registry were used to identify primary isolated unilateral ACLRs between 2009 and 2016 using either a hybrid graft (hamstring autograft with soft tissue allograft) or a soft tissue allograft alone. Multivariable Cox proportional hazards regression was used to evaluate risk for aseptic revision after ACLR according to graft used after adjustment for age, allograft processing, tunnel drilling technique, and region where the primary ACLR was performed. Results: The cohort included 2080 ACLR procedures; a hybrid graft was used for 479 (23.0%) ACLRs. Median follow-up time was 3.4 years (interquartile range, 1.8-5.1 years). The crude 2-year aseptic revision probability was 5.4% (95% CI, 4.3%-6.7%) for soft tissue allograft ACLR and 3.8% (95% CI, 2.3%-6.4%) for hybrid graft ACLR. After adjustment for covariates, soft tissue allograft ACLR had a higher risk of aseptic revision during follow-up compared with hybrid graft ACLR (hazard ratio, 2.00; 95% CI, 1.21-3.31; P = .007). Conclusion: Soft tissue allografts had a 2-fold higher risk of aseptic revision compared with hybrid graft after ACLR. Future studies evaluating the indications for using hybrid grafts and the optimal hybrid graft diameter is needed.

scholarly journals Revision Risk Of Soft Tissue Allograft Versus Hybrid Graft Following Anterior Cruciate Ligament Reconstruction

2020 ◽  
Vol 8 (3_suppl2) ◽  
pp. 2325967120S0012
Author(s):  
Raffy Mirzayan ◽  
Heather A. Prentice ◽  
Anthony Essilfie ◽  
William Burfeind ◽  
David Y. Ding ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Ligament Reconstruction ◽  
Cruciate Ligament ◽  
Hamstring Autograft ◽  
Cruciate Ligament Reconstruction ◽  
Tissue Allograft ◽  
Aseptic Revision ◽  
Revision Risk ◽  
Anterior Cruciate

Objectives: Prior studies have found smaller hamstring autograft diameter to be associated with a higher revision risk following anterior cruciate ligament reconstruction (ACLR). Therefore, when a harvested hamstring autograft is deemed by the surgeon to be of inadequate diameter, the options include: using the small graft, using another autograft from a different site, augmenting with an allograft (hybrid graft), or abandoning the autograft and using allograft alone. Using another autograft site includes added harvest-site morbidity, therefore utilization of an allograft to augment the autograft (hybrid) or allograft alone may be an appealing alternative option. Revision risk for hybrid graft compared to soft tissue allograft in is not known. The purpose of our study was to determine the risk for aseptic revision following soft tissue allograft ACLR compared to hybrid graft ACLR in patients 25 years and younger. Methods: Data from a healthcare system’s ACLR registry was used to conduct a cohort study. Primary isolated unilateral ACLR from 2009-2016 using either a hybrid graft (hamstring autograft + soft tissue allograft) or soft tissue allograft alone were identified. Time-to-aseptic revision surgery following primary ACLR was the primary endpoint. Multivariable Cox proportional hazard regression was used to evaluate risk for aseptic revision according to graft utilization after adjustment for age, allograft processing, tunnel drilling technique, and region where the primary ACLR was performed. Analysis censored patients at the time lost to follow-up (healthcare plan termination or death) or the end of study follow-up. A sandwich covariance matrix estimator was used to account for clustering of ACLR at the surgeon level. Results: The cohort included 2080 ACLR performed by 161 surgeons at 42 healthcare centers. Soft tissue allograft was used for 1601 (77.0%) ACLR and hybrid graft for 478 (23.0%). For the soft tissue allograft ACLR group, mean age was 19.2 (standard deviation [SD]=3.5) years, 79.1% of allografts were irradiated or chemically processed, and 50.4% of femoral tunnels were through the trans-tibial technique. For the hybrid graft ACLR group, mean age was 18.4 (SD=3.3) years, 81.5% were irradiated or chemically processed, and 72.3% of femoral tunnels were through the trans-tibial technique. Median follow-up time was 3.4 years (interquartile range=1.8-5.1 years). The crude 2-year aseptic revision probability was 5.4% (95% confidence interval [CI]=4.3-6.7) for soft tissue allograft ACLR and 3.8% (95% CI=2.3-6.4) for hybrid ACLR. After adjustment for covariates, soft tissue allograft ACLR had a higher risk of aseptic revision during follow-up compared to hybrid graft ACLR (hazard ratio=2.00, 95% CI=1.21-3.31, p=0.007). Conclusion: Soft tissue allograft had twice the risk of aseptic revision compared to hybrid graft following ACLR. Based on our findings, when faced with a hamstring autograft that is deemed to have an inadequate diameter, augmenting it with allograft tendon may be preferred over abandoning it for an allograft alone. Future study evaluating the indications and the optimal hybrid graft diameter is needed.

scholarly journals Influence of graft diameter on patient reported outcomes after hamstring autograft anterior cruciate ligament reconstruction

2019 ◽  
Author(s):  
Robert A. Duerr ◽  
Kirsten D. Garvey ◽  
Jakob Ackermann ◽  
Elizabeth G. Matzkin
Keyword(s):  
Anterior Cruciate Ligament ◽  
Anterior Cruciate Ligament Reconstruction ◽  
Ligament Reconstruction ◽  
Cruciate Ligament ◽  
Hamstring Autograft ◽  
Cruciate Ligament Reconstruction ◽  
Point Increase ◽  
Patient Reported ◽  
Anterior Cruciate ◽  
Graft Diameter

Several studies have identified graft diameter as a risk factor for failure following anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to evaluate the effect of graft diameter on patient reported outcome measures (PROMS) following ACLR. We performed a retrospective review of prospectively collected data using a global surgical registry. 153 of 287 patients (53.3%) had complete data for each timepoint. Effect of graft diameter, graft type, femoral tunnel drilling technique, patient age, sex, and body mass index were evaluated. At 1-year post-operatively, a 1-mm increase in graft diameter was found to correlate with a 5.7-point increase in the Knee Injury and Osteoarthritis Outcome Score (KOOS) activity of daily living score (p = 0.01), a 10.3-point increase in the sport score (p=0.003), and a 9.8-point increase in the quality of life score (p=0.013). At 2-years post-operatively, a 1-mm increase in graft size was found to be marginally correlated with KOOS symptoms and sport scores. Patients undergoing hamstring autograft ACLR, increasing graft diameter can result in improved PROMS, specifically improved KOOS subscale scores at 1 and 2-years post-operative.

Bioabsorbable Versus Titanium Screws in Anterior Cruciate Ligament Reconstruction Using Hamstring Autograft: A Prospective, Randomized Controlled Trial With 13-Year Follow-up

2020 ◽  
Vol 48 (6) ◽  
pp. 1316-1326
Author(s):  
Keran Sundaraj ◽  
Lucy J. Salmon ◽  
Emma L. Heath ◽  
Carl S. Winalski ◽  
Ceylan Colak ◽  
...  
Keyword(s):  
Ligament Reconstruction ◽  
Controlled Trial ◽  
Cruciate Ligament ◽  
Hamstring Autograft ◽  
Cruciate Ligament Reconstruction ◽  
Titanium Screw ◽  
Randomized Controlled ◽  
Titanium Screws ◽  
Anterior Cruciate

Background: Bioabsorbable screws for anterior cruciate ligament reconstruction (ACLR) have been a popular choice, with theoretical advantages in imaging and surgery. Titanium and poly-L-lactic acid with hydroxyapatite (PLLA-HA) screws have been compared, but with less than a decade of follow-up. Purpose/Hypothesis: The purpose was to compare long-term outcomes of hamstring autograft ACLR using either PLLA-HA screws or titanium screws. We hypothesized there would be no difference at 13 years in clinical scores or tunnel widening between PLLA-HA and titanium screw types, along with high-grade resorption and ossification of PLLA-HA screws. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Forty patients undergoing ACLR were randomized to receive either a PLLA-HA screw or a titanium screw for ACL hamstring autograft fixation. Blinded evaluation was performed at 2, 5, and 13 years using the International Knee Documentation Committee score, Lysholm knee score, and KT-1000 arthrometer. Magnetic resonance imaging (MRI) was performed at 2 or 5 years and 13 years to evaluate tunnel volumes, ossification around the screw, graft integration, and cyst formation. Computed tomography (CT) of patients with PLLA-HA was performed at 13 years to evaluate tunnel volumes and intratunnel ossification. Results: No differences were seen in clinical outcomes at 2, 5, or 13 years between the 2 groups. At 13 years, tibial tunnel volumes were smaller for the PLLA-HA group (2.17 cm3) compared with the titanium group (3.33 cm3; P = .004). By 13 years, the PLLA-HA group had complete or nearly complete resorption on MRI or CT scan. Conclusion: Equivalent clinical results were found between PLLA-HA and titanium groups at 2, 5, and 13 years. Although PLLA-HA screws had complete or nearly complete resorption by 13 years, tunnel volumes remained largely unchanged, with minimal ossification.

scholarly journals Failure Rates of 5-Strand and 6-Strand vs Quadrupled Hamstring Autograft ACL Reconstruction: A Comparative Study of 413 Patients With a Minimum 2-Year Follow-up

2020 ◽  
Vol 8 (8) ◽  
pp. 232596712094632
Author(s):  
Ahmed Khalil Attia ◽  
Hazem Nasef ◽  
Kareem Hussein ElSweify ◽  
Mohammed A. Adam ◽  
Faris AbuShaaban ◽  
...  
Keyword(s):  
Cruciate Ligament ◽  
Control Group ◽  
Failure Rates ◽  
Hamstring Autograft ◽  
Level Of Evidence ◽  
Increased Risk ◽  
The Mean ◽  
Anterior Cruciate ◽  
Graft Diameter

Background: Anterior cruciate ligament reconstruction (ACLR) with hamstring autograft has gained popularity. However, an unpredictably small graft diameter has been a drawback of this technique. Smaller graft diameter has been associated with increased risk of revision, and increasing the number of strands has been reported as a successful technique to increase the graft diameter. Purpose: To compare failure rates of 5-strand (5HS) and 6-strand (6HS) hamstring autograft compared with conventional 4-strand (4HS) hamstring autograft. We describe the technique in detail, supplemented by photographs and illustrations, to provide a reproducible technique to avoid the variable and often insufficient 4HS graft diameter reported in the literature. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively reviewed prospectively collected data of all primary hamstring autograft ACLRs performed at our institution with a minimum 2-year follow-up and 8.0-mm graft diameter. A total of 413 consecutive knees met the study inclusion and exclusion criteria. The study population was divided into 5HS and 6HS groups as well as a 4HS control group. The primary outcome was failure of ACLR, defined as persistent or recurrent instability and/or revision ACLR. Results: The analysis included 224, 156, and 33 knees in the 5HS, 6HS, and 4HS groups, respectively. The overall ACLR failure rate in this study was 11 cases (8%): 5 cases for 5HS, 3 cases for 6HS, and 3 cases for 4HS. No statistically significant differences were found among groups ( P = .06). The mean graft diameter was 9 mm, and the mean follow-up was 44.27 months. Conclusion: The 5HS and 6HS constructs have similar failure rates to the conventional 4HS construct of 8.0-mm diameter and are therefore safe and reliable to increase the diameter of relatively smaller hamstring autografts. We strongly recommend using this technique when the length of the tendons permits to avoid failures reportedly associated with inadequate graft size.

Magnetic Resonance Imaging 1 Year After Hamstring Autograft Anterior Cruciate Ligament Reconstruction Can Identify Those at Higher Risk of Graft Failure: An Analysis of 250 Cases

2021 ◽  
Vol 49 (5) ◽  
pp. 1270-1278
Author(s):  
Sven E. Putnis ◽  
Takeshi Oshima ◽  
Antonio Klasan ◽  
Samuel Grasso ◽  
Thomas Neri ◽  
...  
Keyword(s):  
Ligament Reconstruction ◽  
Femoral Tunnel ◽  
Cruciate Ligament ◽  
Signal Intensity Ratio ◽  
Hamstring Autograft ◽  
Resonance Imaging ◽  
Cruciate Ligament Reconstruction ◽  
Graft Rupture ◽  
Anterior Cruciate

Background: There is currently no analysis of 1-year postoperative magnetic resonance imaging (MRI) that reproducibly evaluates the graft of a hamstring autograft anterior cruciate ligament reconstruction (ACLR) and helps to identify who is at a higher risk of graft rupture upon return to pivoting sports. Purpose: To ascertain whether a novel MRI analysis of ACLR at 1 year postoperatively can be used to predict graft rupture, sporting level, and clinical outcome at a 1-year and minimum 2-year follow-up. Study Design: Case-control study; Level of evidence, 3. Methods: Graft healing and integration after hamstring autograft ACLR were evaluated using the MRI signal intensity ratio at multiple areas using oblique reconstructions both parallel and perpendicular to the graft and tunnel apertures. Clinical outcomes were assessment of side-to-side laxity and International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Lysholm, and Tegner activity level scores at 1 year. Repeat outcome measures and detection of graft rupture were evaluated at a minimum of 2 years. Results: A total of 250 patients (42.4% female) underwent MRI analysis at 1 year, and assessment of 211 patients between 1 year and the final follow-up (range, 24-36 months) detected 9 graft ruptures (4.3%; 5 in female patients). A significant predictor for graft rupture was a high signal parallel to the proximal intra-articular graft and perpendicular to the femoral tunnel aperture ( P = .032 and P = .049, respectively), with each proximal graft signal intensity ratio (SIR) increase by 1 corresponding to a 40% increased risk of graft rupture. A cutoff SIR of 4 had a sensitivity and specificity of 66% and 77%, respectively, in the proximal graft and 88% and 60% in the femoral aperture. In all patients, graft signal adjacent to and within the tibial tunnel aperture, and in the mid intra-articular portion, was significantly lower than that for the femoral aperture ( P < .001). A significant correlation was seen between the appearance of higher graft signal on MRI and those patients achieving top sporting levels by 1 year. Conclusion: ACLR graft rupture after 1 year is associated with MRI appearances of high graft signal adjacent to and within the femoral tunnel aperture. Patients with aspirations of quickly returning to a high sporting level may benefit from MRI analysis of graft signal. Graft signal was highest at the femoral tunnel aperture, adding further radiographic evidence that the rate-limiting step to graft healing occurs proximally.

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